Care In The Air
by Joseph Eddins, Airman Magazine
June 5, 2018
At 1420, Jan 29, 2018, the situation aboard a C-130H, configured for Aeromedical Evacuation and cruising at 20,000 feet was uneventful. The two teams, each comprised of two flight nurses and three technicians, attended to their six patients varying needs in the dim green glow of the aircraft’s cargo bay.
Some patients requested to be moved to a more comfortable position on their litters, which were stacked on supports in the middle of the cargo bay, while others had their vital signs monitored as needed and pain medication was administered through their IV lines. Two of the patients, returning home for treatment of psychological issues, simply needed some softly worded assurances that all was well as they sat in their jump seats.
Then, at 1430, all hell broke loose.
One of the psych patients jumped from his seat, screaming above the engine noise, “I can’t do this! I don’t want to do this any more!” and lunged for the rear paratroop door. Two of the nurses grabbed him as they pleaded into their headsets for help from the other crewmembers.
As they struggled to subdue the six-foot, two-inch, 220-pound Airman before he could open the door and depressurize the aircraft, another patient with a musculoskeletal arm wound became frightened and tried to get to his feet while still attached to heart and blood pressure monitors and with an intravenous line in his arm.
As all the nurses and technicians’ attention was on the combative patient, trying to restrain him so he could be administered a sedative, the unnerved patient on the litter fell to the bay floor yelling for help, but he could not be heard above the engines and rants of the other patient.
It was minutes before the nurses and technicians had the psych patient restrained and noticed the other patient on the floor. Three of them lifted him back onto his litter, asked where he was hurt, reattached leads to his monitor and were reestablishing an IV line, when, suddenly, the noise from the engines ceased. Then the green lights in the bay turned to white.
The psych patient held up his bound wrists and said, “Ok, you can get these off me now.”
Tech. Sgt. Christina Johnson, Flight Nurse/Aeromedical Evacuation Technician Cadre, at the 711th Human Performance Wing, U.S. Air Force School of Aerospace Medicine (USAFSAM), who had been watching the situation unfold from a perch near the rear ramp, walked over to the paratroop door and raised it. Then turned to the crew and said, “Everybody, alright? Ok, lets go debrief.”
The C-130H did not depressurize and crash when Johnson opened the door because the “aircraft” was, in fact, only inches above ground level. The “patients” on the litters stopped breathing, blinking and bleeding once the lights came on, because they were not actual flesh and bone, but high-fidelity training simulators made of rubber, tubing and motorized actuators controlled by technicians through software on a handheld computer tablet.
The “psych patient” was fictional, portrayed by Tech. Sgt. Donald Ennis, Flight Nurse/Aeromedical Evacuation Technician Cadre, at the 711th Human Performance Wing, U.S. Air Force School of Aerospace Medicine’s (USAFSAM) Flight Nurse/Aeromedical Evacuation Technician Course at the Air Force Research Laboratory at Wright Patterson Air Force Base, Ohio.
The entire mission was part of the hands-on training during which USAFSAM exposes students from around the world to various types of wartime injuries and the realism of flying on Air Force cargo aircraft during an aeromedical evacuation mission, all while safely at ground level in Building 840 at Wright Patterson AFB.
While this training evolution is by no means representative of the typical Aeromedical Evacuation mission, the extreme circumstances of the simulation drive home the importance of crew resource management and communication to mission success. Learning to maintain those tools in an extreme environment will foster their habitual use during less dramatic missions.
“We want to prepare them for the worst day in their career. If they're comfortable with taking care of patients in the back of an aircraft when maybe you might be under hostile fire, patients are bleeding out, but you can't really tell in the poor lighting if it's blood or spit, what have you. We want to make sure that they're not going to freeze and they know exactly what they need to do,” said Tech. Sgt. Johnson. “We have high fidelity manikins that are able to breathe, blink, talk, and bleed. Their tongues can swell and block their airways. You can push medications. It creates a real world environment for us and it's almost like taking care of a real patient.”
The psych patient meltdown scenario is designed in particular to keep the student’s head on a swivel while maintaining awareness of all the patients’ needs and keeping the lines of communication between team members open and flowing.
“While the rest of the crew is wanting to focus on this one patient, they kind of forget about all the other patients,” said Tech. Sgt. Johnson. “If you have a psych patient that decides, ‘Today's the day that I might just lose it,’ while you're trying to focus on somebody that's bleeding out and you’re trying to direct the rest of your team to control that, it can be a little bit chaotic, but, they get through it as a better nurse and technician.”
Flight Nurse and Aeromedical Evacuation Technician students complete 40 hours of missions on the C-130H mockup as part of their ground training check-rides. The High Bay in Building 840 houses two C-130 mockups as well as a C-17 mockup, to accommodate the Flight Nurse and Aeromedical Evacuation Technician Course and other aeromedical evacuation courses at USAFSAM.
Each “aircraft” can simulate the lighting, sounds (from normal engine noises to explosions and crash landings) and the heating and cooling conditions that can be experienced onboard actual AE missions. Cabin decompression also can be simulated with students having to don supplemental oxygen systems while maintaining care of their patients.
Just two years ago, the course still consisted of mainly PowerPoint presentations and in-class lectures. Now the students work hands-on in the simulator for 50 percent of their time in Dayton, Ohio.
The students come from guard, reserve and active-duty Air Force units as well as sister services, the Department of Defense and partner nations. While the Air Force maintains 31 AE units, only four are active duty, so classes often have a majority of National Guard and Air Force Reserve personnel.
According to Johnson, personnel from sister services and partner nations, often attend as an introduction to aeromedical evacuation, as they may be going to a command and control units and need to understand the capabilities and responsibilities of AE crews. International students from the militaries of Allied Nations have been attending the course since the early 1960s leading to partnerships with more than 100 countries.
The team that Tech. Sgt. Johnson is instructing includes an officer in the South Korean Air Force, Maj. Sun A Lee, who is a chief manager of her country’s aerospace nursing division and is responsible for teaching air evacuation techniques, critical nursing and emergency medicine to junior officers.
“I want to learn about the U.S. Air Force aeromedical evacuation system. It is very different from my country and a very good experience. I am particularly impressed with the education curriculum and how it is organized,” said the Major. “I will propose some developments to the air evacuation system in my country. It is very important to develop aeromedical techniques across agencies, I think.”
Tech. Sgt. Johnson believes that the international students provide a unique opportunity for instructors, as well as the students, to see methods that partner nations use to provide patient care.
“It's called global patient movement for a reason,” she said.
Tech. Sgt. Johnson knows from real-world experience the many facets that must come together to effectively and safely care for patients while airborne. Her 10-year career in AE began with caring for patients in-flight, transitioned to learning the command and control component by organizing and directing AE missions for the entire Pacific Theater as a C2 agent for Pacific Air Forces and has culminated with her four years at the schoolhouse in Dayton, passing on her experience to the next generations of flight nurses and technicians.
Still, her own education must stay up to date to function effectively as an educator.
“In medicine, everything is evolving so we have to train appropriately. I can't teach you the same stuff I was teaching 10 years ago because it's not relevant. So we're constantly evolving our education methods with the information that our consultants provide,” said Johnson. “We have AE consultants at (Air Mobility Command) that direct a lot of our guidance and our instructional methods and if we have any information that's new to the course, they are definitely our first reach back to confirm that this is something that we need to be teaching the next generation. We go through a validation period every so often to make sure we are indeed teaching the right things.”
One of the key evolutions in the Aeromedical Flight Nurse and Aeromedical Evacuation Technician Course is the foundational reality of the simulations. While the patients are not real people, their cases come from the most up to date real-word experiences of AE crews.
The U.S. Transportation Command Regulating and Command and Control Evacuation System, or TRAC2ES, was designed to manage the movement of patients, give commands involved in the missions patient and asset visibility, including while in-transit, as well as management of lift-bed resources and collaborative support for patient movement requests and mission execution within and between theaters.
USAFSAM quickly realized the paperwork generated by the TRAC2ES system to manage patient movement and guide treatment while in-transit could be used as a real-time, real-world, training tool for their students.
“The patient scenarios that we use are pulled straight from TRAC2ES,” said Capt. Sarah Johnson, an instructor for the Flight Nurse and Aeromedical Technician Course. “So the information in the scenarios is all from actual patients that have been moved in the aeromedical evacuation system, whether it's within the last year, or even the last week. So when we tell students that this is an actual patient, if there's a mistake in the paperwork, that's a real mistake, that's not something that we're doing to try to trip them up or confuse them. This is a sick patient that's currently being moved. So we're able to pull real data and expose students to things that they're actually going to be able to see when they go and deploy and fly down range.”
Capt. Johnson believes that these real-world cases can also prepare students for the types and frequency of certain types of injuries indicative of particular areas of operations to which they may deploy, from infections to concussive head wounds to bullet wounds to burns. It also gets them accustomed to using the actual paperwork they will be issued when briefed on each patient they will care for in-flight.
She adds that the USAFSAM Flight Nurse and Aeromedical Technician Course not only enables students to go into a high stress, but low-threat, environment where they are free to make mistakes and learn from them without having to worry about injuring a real patient.
Still, for the new students, the fidelity of the patient scenarios coupled with the realism of the aircraft environment and disease processes at altitude can be bewildering for even the most experienced students.
“Active-duty technicians and nurses are trained the Air Force way and then you have the guard and reserve members who potentially have been working in the emergency room or Intensive Care Unit for 10 or 15 years,” said Capt. Johnson. “They have a wealth of knowledge and are very good at their jobs, but then you bring them here and everyone's kind of on a level playing field.
“You put them in the back of an aircraft with the lights off and the sound going and the person that had the 15 years of ICU experience all of a sudden is stopped; kind of a deer in headlights look because they don't know where anything is or how to necessarily approach the situation. A situation that might be super easy in a hospital is made 20 times harder on the back of an aircraft. You don't have a supply room. If you don't have it in your in-flight kits, you don't have it. There's no calling down to a different department or walking down the hallway and when you realize you forgot to grab something. If you didn't grab it or if you don't already have it with you, it's not an option anymore.”
For 1st Lt. Toya Williams, of the 36th Aeromedical Evacuation Squadron at Keesler AFB, Mississippi, learning in a well-lit, quiet classroom about how a patient’s body changes at altitude affects how she administers treatment takes on a whole new dimension during simulations.
“It's like waking up in the morning and you don't have your glasses on and you still have crust in you're eyes and you are moving around trying to find where things are,” said Williams. “But, I think the scenarios and practicing the way you're really going to do it in the air really helps us adapt. You learn how to work while not having light and not having the ability to hear all the time or not being able to speak like I am now and needing to use a different communication device… we have the exact same process of learning about the patient, the exact same examples of the documentation that we're getting. So the simulations are priceless. They help me way beyond Power Points or verbal teaching.”
Airman 1st Class Travis Chadwick, of the 187th Aeromedical Evacuation Squadron of the Wyoming Air National Guard, is relatively new to the medical career field but is using the experience of not only his instructors, but also his classmates to expand his AE knowledge base.
“My current duties right now is to mainly assist the nurses and also do basic life support like CPR; very basic skills,” said Chadwick. “But I’ve been introduced to so many people that have had tons of experience in different scenarios and different patients. One member of our crew, she worked in the operating room for eight years as a trauma nurse. Another worked on an ambulance and so we've got a lot of emergency experience inside of our crew and I'm just a little sponge trying to soak up everything that they're telling me.”
For Capt. Johnson the Flight Nurse Course and Aeromedical Evacuation Technician Course is a very different experience for her students than when she went through the course just four years ago.
“We use a learning management system online where our students are able to access PowerPoints and information prior to coming to the course as well as during the course,” said Capt. Johnson. “So some of our modules are things the students need to accomplish within the first five days. They are able to learn about crew resource management, aircrew basics. There are videos on how the air medical evacuation equipment operates and preloaded lectures.
“I was at my first AE assignment for only about 60 days before I deployed, so I was upgraded and then out the door right away. I didn't have the luxury of being able to kind of take it slow and figure out the steps out on what might happen or what should be happening. I learned on the job, which was OK, but it would have been nice to ease into it a little bit or have more exposure before I got out the door.”