Medical Evacuation is central to any military medical support system. This Topic is the discussion of the principles of medical evacuation planning and execution with specific consideration of the command and control arrangements for forwarding medical evacuation. Helicopter evacuation as the central element of the pre-hospital military medical care system rather than a ground ambulance. There are times when the tactical situation prevents helicopters from reaching the casualty, and thus the victim will have to be moved by ground ambulance to a safe location for a helicopter landing site. Furthermore, ground medical evacuation is essential for running significant numbers of injuries in a large-scale warfighting scenario.
NATO medical doctrine defines some medical evacuation terms. Medical evacuation is the movement of patients under medical supervision.
The term CASEVAC has been used to describe casualty evacuation in a non-assigned vehicle/aircraft and may not include in-transit care.
Forward Aeromedical Evacuation (FAME or more commonly MEDEVAC) provides for transfer from the point of wounding to the initial medical treatment facility.
Tactical Aeromedical Evacuation (TACEVAC) is the evacuation of casualties between medical facilities within the theatre of operations.
In current operations, MEDEVAC is almost invariably undertaken by helicopters. The assignment of aircraft to the aeromedical mission may be ‘dedicated’ in which the particular airframe is role specific and cannot be used for other general tasks.
This might include the display of the Red Cross, modifications to take stretchers and medical equipment and fitting of specific capabilities such as a winch. This is likely to result in an aircraft most suitable for the medical mission but with a risk of non-availability. An alternative is to have designated aircraft in which a general support aircraft is assigned to the task but may be re-assigned to other tasks. This gives more flexibility as the capability can be transferred to another aircraft if the designated aircraft becomes unavailable. The difference between ‘dedicated’ and ‘designated’ has been a contentious issue in the UK but needs to be considered in the context of managing aircraft fleets rather than single aircraft capabilities.
The exact type of aircraft for rotary wing (RW) aeromedical evacuation varies by nation according to the performance, volume and protection requirements. As an example, the UK has used the Puma and Sea King helicopter for this role in the Balkans, the Merlin helicopter in Iraq and the Chinook in Afghanistan. The US Army invariably uses the UH-60A which is marked with the Red Cross but has limited protective firepower. The US Air Force has a specialist aircraft the HH-60 which has substantial night operations and protective firepower capability but does not display the Red Cross. This capability has a priority task for ‘personnel recovery’ but is primarily employed within Afghanistan to support MEDEVAC. There is also significant variation in the number and training of the medical escorts between these capabilities. The UK standard is now the Medical Emergency Response Team comprising a paramedic and a flight nurse or the enhanced MERT [MERT-E) when a doctor trained in pre-hospital care is added to the team. The recent experience of opposition anti-helicopter tactics in Afghanistan has led to the requirement for a ‘gun-ship’ escort for MEDEVAC aircraft. Thus the MEDEVAC mission should be considered as aviation ‘task line’ of a minimum of two aircraft rather than just the aircraft assigned to the MEDEVAC function.
Planning Medical Evacuation
The goal of ‘right patient, right platform, right escort, right time, right place’ requires a detailed understanding of the inter-relationship between MEDEVAC, TACEVAC and deployed hospital capability and capacity in warzones.
Time is an important factor in patient survival. The term ‘clinical timelines’ is used to describe the target times for each element of the casualty evacuation chain from the point of wounding to primary surgery. Although there is a dispute about the appropriate target for an acceptable time from wounding to initial resuscitation for medical planning purposes, there is widespread agreement that this should be as short as possible. There are four critical timelines described in NATO policy and doctrine.
The planning for the location of MEDEVAC helicopters is based upon the cumulative time between initiation of the request for evacuation – the ‘9 liner’ and the ‘wheels down’ of the MEDEVAC helicopter at the receiving hospital. This includes the time taken for the ‘9 liners’ to be initiated and passed through the communications system to the controlling headquarters, the time required to process the information and issue the launch authority, and the ‘notice to move’ time for the helicopter and crew. Thus the actual total flight time is likely to be much less than the cumulative two hours to surgery, and therefore the maximum range of the MEDEVAC mission loop is not usually more than 40-60 nautical miles.
The tactical geometry for the current operating environment is based upon security forces holding areas of ground and securing this space from opposition activity. This converts the battlefield from the conventional force-on-force linear geometry with an identifiable confrontation line to an area battlefield with multiple nodes of contested space. Thus the MEDEVAC mission is converted from a direct flow to area support. Hence MEDEVAC planning is based upon a ‘range ring’ coverage with a radius of 40–60 nautical miles.
Control and co-ordination (Cc) are differentiated from command and control (C2) to emphasize the fact that aviation, not medical commanders command helicopters. The medical services are customers on behalf of the casualties and determine the aeromedical evacuation requirement by capability, capacity, and destination. The final assignment and management of aircraft to meet this requirement is very rarely a medical function. The Cc function should be delivered from within the headquarters most suited to integrate the battlespace picture with the requests for MEDEVAC, the allocation of missions to task lines and the selection of destination medical facility. The choice of the most suitable headquarters is complicated when the MEDEVAC range rings cover ground controlled by more than one battlespace owner and may require the application of the ‘artillery principle’ of command at the highest level and control at the lowest level.
NATO doctrine directs that medical evacuation is controlled by a Patient Evacuation Co-ordination Centre (PECC). Operational experience has demonstrated that this must be located in the headquarters command post or Combined Joint Operations Centre (CJOC) able to both read and respond to the battle. The PECC should be very closely sited to the Aviation and Air staff cells and be readily accessible to the CJOC duty officer. This is the justification for separating the PECC function from the Medical Plans function that may sit in the Medical Director’s central office. The PECC may need to be divided into the Medical Operations cell (Med Ops) providing Cc to MEDEVAC and the Evacuation Co-ordination Cell, managed by the Evacuation Co-ordination Officer (ECO) providing Cc to TACEVAC.
The Cc of MEDEVAC previously summarised was an oversimplification of the process. Medical evacuation is requested by the ‘9 liners’ submitted over the combat/tactical radio net to a sub-unit command post from where it is passed by the unit command net to the CJOC, either by radio or more commonly over a digital ‘chat’ system. This is highlighted by the duty watchkeeper and passed to Med Ops and the Aviation desk; both desks check the grid for the pick-up location. The Med Ops desk confirms the priority for evacuation, recommends the assignment of aircraft and medical escorts, and the destination medical facility. The aviation desk confirms the availability and suitability of the aircraft. The duty officer authorizes the mission. The aviation desk then assigns the task to the aviation commander. The aviation commander has the final launch authority for the aircraft. During the MEDEVAC mission, the Med Ops desk tracks critical information used for monitoring performance.
The MEDEVAC Cc process should enable the MEDEVAC task ‘right patient, right platform, right escort, right time, right destination’ to be achieved by matching the resources described to the clinical needs of the patient and the tactical environment – so-called ‘intelligent tasking.’ The patient’s clinical needs are described by the urgency category for delivery to a hospital facility: A – within 90 minutes; B – within 4 hours and C – within 24 hours and clarified by the MIST (Mechanism of injury, Injury, Symptoms and signs, and Treatment gave) report. This information enables the clinical escort to be matched to the patients’ requirements. Overall, the competencies required of the Med Ops watchkeepers depends on the range of decision options available. It is simple if there are only one aircraft type and medical escort available to deliver casualties to a single facility. More complex options require people in the decision-making process who can assess both the operational and clinical situation before making the MEDEVAC decisions.
Monitoring Performance of a Medevac
The final element of the MEDEVAC system is the monitoring of performance as described by both Hodgetts and Cordell which can be divided into clinical audit, incident reporting, and trend analysis. This is an important element of Healthcare Governance on military operations.
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