Through more than a decade of sustained combat, the men and women of the Air Force Medical Service have answered our nation’s call and maintained a standard of excellence second to none. Since the war began, the innovations and advancements across the Military Health System have enabled the highest combat casualty survival rate in history. As 2012 gets under way, I want you to know that our servicemen and women wounded in battle are receiving the best trauma care America has to offer. We call it “Trusted Care Anywhere.” 

Lt. Gen Charles B. Green, MD Air Force Surgeon General

Achieving such an unprecedented survival rate required a commitment to continuous learning. We leveraged and analyzed a lot of data to determine what really saves lives and makes a difference. I believe we never run out of lessons to learn, and there are even times we re-learn old lessons, such as how to use tourni­quets. Of course, wars always have yielded advances in medicine, and these have been no different. New lessons have been learned, including better ways to use blood and fluids to save lives, based on the amount of time it will take to transport some­one to a higher echelon of care.

Transporting Wounded Troops

The Air Force Medical Service’s signature contribution — aeromedical evacuation (AE) — in conjunction with our Expeditionary Medical Support (EMEDS) hospitals have made huge inroads as a direct result of these wars. On Sept. 12, 2001, we set up our EMEDS at McGuire Air Force Base, NJ. EMEDS are tent-based modular, scalable, rapid-response medical facilities used in humanitarian relief, wartime contingencies and disaster response. Our goal was to provide patient care for New York’s victims. Although we were not called upon to provide assistance, the tragedy enabled us to envision linking our EMEDS to our aeromedical evacuation system in order to move large numbers of patients to higher echelons of care.

Shortly after the invasion of Iraq, our EMEDS hospital at Balad became a key hub for transporting wounded servicemembers to definitive care in Germany and stateside. A similar hub at the Craig Joint Theater Hospital in Afghanistan soon followed. Now, 10 years later, the tireless efforts of hundreds of dedicated Air Force active duty, Reserve and Guard medics and aircrews resulted in the transportation and care of more than 90,000 wounded servicemembers with only four patients not surviving transport. Every war brought advances in medicine that benefit all patients, military and civilian.  This war is no different. 

The enhancement of our aeromedical evacuation system through the addition of critical care, air-transport teams has been and continues to be a huge factor in our unprecedented high  casualty survival rate. These teams have sped up the patient movement process by bringing increasingly advanced care closer to the point of injury than ever before, allowing patients to be moved to definitive care at a much faster rate. This has freed up hospital beds for new battlefield casualties and allowed us to use much smaller hospitals in the theater.

Saving Lives and Limbs

We believe the technologies we have brought into theater have saved limbs and lives. Newer vascu­lar shunts preserve critical blood flow. Automated ventilators get patients off assisted ventilation sooner and require fewer resources. New concussion-management regimens prevent repeated injury to the brain and allow time to heal before warriors return to duty. 

In the med­ical world, you never want to implement something that has risk — and yet, we have to keep moving forward. In our theater hospitals such as Balad, Air Force vascular surgeons have pioneered new methods of hemorrhage control and blood-vessel reconstruction based on combat-casualty experience. These innovations have saved limbs and lives and set new standards for military and civilian trauma surgeons.

These critical efforts are captured through another post 9/11 initiative, the Joint Theater Trauma Registry (JTTR).  This data repository collects all trauma-related data, providing timely information on care and outcomes of trauma patients at follow-on medical facilities. This registry greatly enhances clinical decision-making and measures subsequent outcomes for improving treatment and establishing valuable lessons learned for the future.

Medical Lessons Since 911 Impact Patient Care Aeromedical Evacuation Cont.

Maj. Travis Girlach, MD, installs a central line into a patients chest to relieve pressure from fluid at the Craig Joint Theater Hospital, Bagram Airfield, Afganistan. – U.S. Air Force photo by Sr. Airman Sheila deVera

Make no mistake; we have had lots of help getting to this point. We have partnered with medical schools, federal and private-sector facilities to leverage both our and their skilled work forces to help prepare us for the future. Among them are our Centers for the Sustainment of Trauma and Readiness in Baltimore, Cincinnati and St. Louis that provide our medics state-of-the-art training required to treat combat casualties. New relationships have been formed with Scottsdale and Tampa General Hospitals. We continuously work to incorporate these capabilities and lessons learned into the entire spectrum of care.

In our AE system, we want to improve the ability to move patients with blast-lung injuries. Till now, our ventilators have not been capable enough to move someone for the six hours required in flight, so they must remain in theater longer. Some of the new ventilators are much more capable of enabling us to move these patients sooner. We also have looked at different ways to do heart-lung machine support, such as utilizing oxygenation through the Novalung and through extracorporeal membrane oxygenation (ECMO). We want to see if we can miniaturize that equipment and make it available without having a special team to run it. These types of efforts are geared toward resuscitating patients more quickly in the field and bringing the sickest patients back home quickly and safely. 

Our on-the-ground response has evolved with our new EMEDS Health Response Teams (HRT). These newly tested and proven packages enable us to arrive in a chaotic situation, set up and see the first patient for triage and early emergency care within 30 minutes of arrival and perform the first surgery within three to five hours. The HRT already has been used successfully in a humanitarian mission and will be our standard package in providing rapid battlefield medicine.

Enhancing Care

As we enter 2012, and during my final year as Air Force Surgeon General, I would like to see a lot of things completed that are now in motion. Foremost among them is modernizing our air-evacuation capabilities and EMEDS and completing training modules for these new capabilities. We also are continuing to make great strides in our Patient-Centered Medical Home concept to enhance quality of care.

“The enhancement of our aeromedical evacuation system through the addition of critical care air transport teams has been and continues to be a huge factor in our unprecedented high casualty survival rate.”

The centerpiece of providing patient care and “Trusted Care Anywhere” is our Patient-Centered Medical Home. This program, which has more than 700,000 enrollees, allows better continuity of care for our patients. Previously, provider/patient continuity was about 40%; now, our patients are seeing the same provider 75 to 85% of the time. This patient/provider continuity makes a huge difference in terms of our ability to build a relationship of trust with our patients. We want to enhance this relationship even further over the next six months, when we roll out Secure Messaging, which will allow our patients to talk with their doc­tors by e-mail in a secure forum. Soon, our patients will be able to access a personal-health record. They will be able to view lab tests and X-rays on their home computers. It’s about making the patient a much more active participant in their healthcare.
Medical Homes are about building relationships between providers and patients, establishing trust and making the patient an active participant in their own healthcare. We have been working on this concept for almost 10 years. By this summer, we’ll have 1 million patients enrolled. We link patients and health teams to activate patients to be more involved in decisions regarding their health. This has huge possibility to change medicine.

An aeromedical evacuation crew carries wounded warriors aboard a C-17 Globemaster III aircraft at Ramstein Air Base, Germany, for a flight to Andrews Air Force Base, MD, to receive advanced-level care in the United States. (DoD photo/Donna Miles)

We are linking these capabilities to precision care. If you’re willing, we’ll take your genetic material and study it. Information from this genomic analysis that might pose a risk to your health will be shared with you. De-identified databases will allow us to advance research efforts. Research groups can determine associations or a specific area where they think there may be merit in terms of how we can change clinical practice. This type of research will likely change the way we think of disease. 

Like you, I will never forget Sept. 11, 2001. I could not have foreseen the changes that would occur in combat medicine as a result of that day. As the nation rallied in support of the victims of the tragedies, so too did the men and women of the Air Force Medical Service. As I reflect on the past 10 years, I believe our medics epitomize the best of what America has to offer. They will continue to advance the art and science of medicine as they provide “Trusted Care Anywhere.”

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