While the focus of the Domestic Preparedness web site is on the first-responder and emergency-management communities, the Global War on Terrorism links events that occur overseas to the defense of the nation’s homeland. The following article, which focuses on the process for evacuating injured soldiers, provides some insights on how those processes and the lessons learned in general from the war in Iraq can be applied within the United States itself. In a truly catastrophic domestic event the nation’s first responders frequently are among the victims, and must therefore be treated compassionately. But the need for their services also requires on many occasions that they be returned to duty as quickly and as efficiently as possible. The medical evacuation process used by the nation’s armed services to handle troops wounded in Iraq may offer some insights into developing a system that would be useful in U.S. domestic emergencies as well.    An Air Force nurse finished strapping the soldier into a jump seat, one in a row of seats for about a dozen ambulatory patients seated along one interior side of the cavernous interior of a C-17 airlift aircraft, the U.S. military’s workhorse logistics airplane. This C-17, specially equipped for medical-evacuation (medevac) purposes and staffed with a number of physicians as well as nurses, had arrived in the darkness in Balad, Iraq, from Germany a couple of hours before.

In the much subdued lighting a nurse gently touched a soldier as a parent would a small child, whispering reassuring words into the soldier’s ear while reading the diagnosis summary paper each of the evacuees had carried with him (or her) onto the aircraft. The nurse moved on to the next soldier down the row of jump seats and, finding her in pain, checked her paperwork and made certain she had pain medications available to her. The nurse moved the second patient to one of the stretchers and tied her down for the flight, wrapping her in a blanket to guard her against the risk of hypothermia (the temperature would quickly drop more than 30 degrees shortly after the C-17 became airborne).

White Bandages and Bold Black Letters

In front of the jump seats were two lines of stretcher bunks running the length of the aircraft. The bunks, stacked three high, were held in place by metal arms mounted on the floor of the C-17’s passenger deck. Some of the mounted stretchers held the forms of those who had been carried on board following the ambulatory patients. A number of other vacant stretcher bunks and blankets were available for the ambulatory patients themselves.   

The Air Force doctors and nurses moved between their patients, checking each one quickly and professionally. Some of the patients were conscious; others were not. Some were hooked to IVs, others were sleeping, or unconscious, or maybe just holding their eyes closed. Among the worst wounded were a number of patients who had survived the most common causes of death among the combat fatalities, but were (or had been) bleeding from arms or legs that had been smashed or explosively amputated; several were bleeding and/or choking from serious facial wounds. Two stretchers, holding bodies almost completely covered by a tangle of plastic tubes and pumps, that had been carried on board were particularly noticeable. The skulls of the soldiers on the two stretchers were covered with thick white bandage caps on which was written, in bold black letters, “no bone.” Each of these two patients was attended by a team of two nurses constantly adjusting and checking their respective patients. One nurse had a small pen light that she flashed into the eye of her patient, then turned and moved her hands in a closing contracting motion and received a thumbs-up in return from the other nurse. These two soldiers, and several of those missing portions of limbs, probably owe their lives to the new training requirements to train certain soldiers as combat life savers (CLSs). 

Every squad that goes “outside the wire” now includes at least one CLS-trained soldier equipped with an innovative and surprisingly comprehensive first-aid kit. The Army’s realistic CLS first-aid training now saves an estimated ten percent of wounded/injured soldiers who otherwise probably would die in the field. In today’s combat operations, a wounded soldier can quickly receive from his fellow soldiers the immediate first-aid care needed to stop profuse bleeding, and/or to open airways, until a combat medic or military doctor or nurse can take over. The lightweight CLS first-aid kit includes, among other emergency necessities, a tube that can be inserted to open an airway, a useful and easy-to-handle tourniquet, and a pressure HemCon bandage.    

Pre-Dawn Takeoff Mandatory 

The rear of the C-17 was open, giving the patients a full view of the darkness beyond – but the sky was now showing the first signs of coming dawn. The murmuring, not demanding in tone, but a whispered beseeching, started somewhere down the line. Each patient in turn found himself or herself repeating the words, almost like a prayer, “time to go.” They all knew that, once dawn had arrived in full force, the massive C-17 would be visible for miles around, and would be an open invitation to enemy mortar fire. The C-17 lifted off the runway just as dawn broke. The six-hour daily medevac flight from Balad to Landstuhl, Germany, carried twenty-five medical evacuees and an almost equal number of medical-team members. AMEDD (the U.S. Army Medical Department, Office of the Surgeon General) keeps close track of the number of Army soldiers evacuated from a combat zone, and the reasons why they had to be evacuated.

In 2005, the U.S. Army averaged 120,000 soldiers in-theater in Iraq on any given day. An average of twenty-three soldiers per day were medically evacuated from the theater, or a total of approximately 8,400 for the entire year. Of those twenty three, three had been wounded in action, seven had received non-battle injuries, and thirteen were suffering from some type of disease. The top three reasons for the wounded-in-action evacuations were: (a) explosions (improvised explosive devices or IEDs, primarily), 66.7 percent; (b) gunshot wounds, 15.3 percent; and (c) wounds caused by RPGs (rocket-propelled grenades), 7.8 percent. The top three reasons for non-battle-injury evacuations were orthopedic problems, 62.6 percent, surgical problems, 37.1 percent, and dental problems, 0.2 percent. The disease evacuations were listed as 44.4 percent medical, 43.8 percent surgical, and 11.4 percent psychiatric. 

Traumas, Triage, and Reevaluations 

The climate, the overall physical environment, and the unique combat conditions in Iraq have generated a broad range of medical-assistance needs for U.S. soldiers serving in-theater in Iraq. The U.S. Army’s evacuation policy for Iraq postulates that an evacuation decision must be made within a seven-day window when a soldier requires medical aid. The primary goal at every stage of the process, though, is to return the soldier to duty as soon as possible. And, in fact, the overwhelming majority of soldiers who require medical aid are treated in-theater and returned to duty within three days. There is at least a clinic available at all of the U.S. Army’s principal operating bases in Iraq, and three Level 3 trauma centers in-theater as well. 

All soldiers are treated thoroughly, professionally, and with compassion. Initially, a good-faith effort is made to address the medical condition in-theater. If the medical resources needed are not available in-theater to treat the condition, the soldier is eligible for evacuation. Prominent among the more important factors used to determine if a soldier should be evacuated are medical/military judgments as to whether he or she is able to continue to contribute to the mission in his/her condition and/or if he or she might be dangerous to himself/herself or to others. The soldiers who have to be evacuated are triaged first and rated urgent, priority, or routine – the patients are reevaluated, though, at each step of the evacuation process.   

It takes time and considerable resources to evacuate a soldier from Iraq. The risk of travel itself elevates the danger of an attack or accident for everyone involved. The most seriously wounded, injured, or ill soldiers are evaluated for evacuation at one of the trauma Level 3 hospitals in-theater (including one in the so-called “Green Zone” in Baghdad).  Some are brought in by ground convoy, but most are carried by Black Hawk medevac helicopters. Those who are certified for evacuation are stabilized and transported via Black Hawk helicopter to Camp Anaconda, a massive Saddam-era airbase near Balad, which is about a 45-minute flight north of Baghdad. Apache gunships cover the flight of the medevac helicopters. In addition, the flights are launched in darkness, whenever possible. The insurgents target U.S. and allied medical personnel and equipment every chance they get. 

The Balad Air Force Theater Hospital includes three intensive-care wards and is capable of dealing with a wide scope of medical problems, including brain, spinal, ear, and eye injuries. On the hospital’s staff are a number of trauma and orthopedic surgeons as well as mental-health and physical-therapy specialists, all of them serving in an H-shaped warren of air-conditioned tents pitched on a concrete pad on the tarmac of the airfield.   

Ready for Duty – Or “Not Fixable” 

Many soldiers treated in Balad are returned to duty in-theater. Of those evacuated to Germany, many are treated at Landstuhl and returned to duty with their units in Iraq. Those evaluated as suffering chronic conditions – or, as the troops say, are “not fixable” – are evacuated to the United States. The Walter Reed Army Medical Center in Washington, D.C., receives and treats many of the soldiers who are missing limbs – most in this category, however, are returned to the military base from which they were mobilized. For example, Womack Army Hospital at Fort Bragg, N.C., has a Medical Hold Company assigned to manage the care of a constantly changing group of approximately one hundred soldiers. 

The soldier’s stay in the stateside medical-hold companies is usually not less than two months. After that, the soldier is either returned to duty or referred to a medical board system for consideration for discharge from the active service. The stateside applications of the lessons learned from the U.S. military’s experience in evacuating injured personnel from Iraq already are being used in some domestic medical-emergency and disaster situations. 

Other applications are being considered – e.g., the practice of ensuring the availability of a CLS-trained individual, an example that easily could be applied to first-responder teams working in high-risk situations. The medical and logistics techniques acquired and refined in transporting severely injured soldiers also could readily be used in responding to catastrophic or near-catastrophic disasters and emergencies involving large numbers of traumatic injuries.

 An important footnote worth mentioning: Many of the military medical personnel serving in Iraq are members of National Guard or Reserve units. In their civilian lives, as well as in their military careers, they serve as medical professionals. Hence the skills, knowledge, and training that they learn from their experience in the combat theater will be applied in various ways when they are carrying out their civilian first-responder duties. Decision makers at all levels of government should take comfort from the fact that a broad spectrum of combat-tested medical skills will quickly be available when the U.S. military is again called upon to provide support to civilian agencies during a major domestic disaster that injures and/or incapacitates scores and perhaps hundreds of people.

Peter D. Menk

Peter D. Menk entered the Army in 1968 and has served in all three components of the Army, Regular, Reserve and National Guard. He is presently a Colonel, JAGC in the Individual Ready Reserve, USAR. His military experience includes service in the artillery, Judge Advocate General's Corps, as a strategist, as an international law expert and as an expert in homeland security. He has served in assignments within the United States and overseas including missions in Asia, Africa, Latin America, and Kosovo. He has a BA from the University of Miami, FL, an MA in International Relations from Salve Regina University, a JD from the University of Virginia School of Law and a post-graduate certificate in International Security Studies from the Fletcher School of Law and Diplomacy, Tufts University. He is a graduate of the Air War College and was a Fellow, United States Army War College. He is a consultant with Resource Consultants Inc.

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