2. TACTICAL FIELD CARE

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1 Tactical Combat Casualty Care in Special Operations Colonel (Dr.) Robert Allen, USAF, MC Lt Colonel John McAtee, USAF, BSC (PA-C) Extracted from the Pararescue Medication and Procedure Handbook Introduction: Care of combat trauma patients is not the same as care of trauma patients in the civilian environment. ATLS, BTLS and PHTLS are worthy programs, but are designed for use on the battlefield. Medical care of the patient must be modified in combat to fit the tactical situation. Combat casualty care is divided into three phases: care under fire, tactical field care, and combat casualty evacuation (CASEVAC). A synopsis of the type of care to be delivered in each phase is given below. 1. CARE UNDER FIRE -Care given at the scene of injury while under effective fire. Highly limited care, with the goal of geting the victim out of the fire zone without creating new casualties. -Procedures: Return fire as directed or required. Try to keep yourself from being injured. Try to keep the casualty from sustaining any further injury -If the casualty is awake and able to function, direct him to take cover and start self-aid. Airway intervention, if needed, is limited to a nasopharyngeal airway. Stop any life-threatening hemorrhage with a tourniquet. Take the casualty with you when you leave. 2. TACTICAL FIELD CARE -Care given once the operator and casualty are no longer under effective fire. This phase is where the majority of Pararescue medical care takes place. -Procedures: Address the ABC s, replace tourniquets with pressure dressings Treat wounds with appropriate dressings/splints. Treat pain and administer antibiotics as required. 3. COMBAT CASUALTY EVACUATION (CASEVAC) -Care given once transport to higher level of medical care has begun. Will usually involve aircraft/boat/vehicle transport, where additional medical equipment may be available. Procedures: Continue treatment from phase 2, monitor the patient Document the care given, prepare to hand-off the casualty to the next echelon of medical care.

2 NOTE: 1.These procedures hold for tactical combat casualty care only. Peacetime rescue assumes that all patients have a chance to survive. However, in peacetime situations where the rescuer s lives are in immediate danger (avalanche chutes, etc), these procedures may be needed. 2. C-Spine precautions are seldom needed in penetrating neck trauma in combat casualty care. 3. Combat casualties (blast and penetrating trauma) who are pulseless and apneic are dead. Attempts to resuscitate these patients are futile. 4. No handbook can anticipate every tactical and or medical situation that might occur during a rescue. When faced with an unusual situation, the SOF medic or team member will have to improvise, adapt and overcome. EVACUATION BY MEDICAL AIR AMBULANCES Extracted from the Expert Field Medical Badge Study Guide January 1993 Introduction: Both helicopter and fixed-wing aircraft are used for aeromedical evacuation. Dedicated aeromedical evacuation assets permit en route patient care, which minimizes further injury to the patient and decreases mortality. Advantages of Aeromedical Evacuation: 1. The speed of air evacuation to an MTF ensures timely treatment, which: (1) Saves lives. (2) Reduces permanent disability. (3) Increases the number of patients returned to duty. 2. The range and speed of aircraft make it possible to evacuate patients rapidly by air over relatively long distances. This requires the less frequent displacement of MTFs. 3. Helicopters can move patients quickly over rough terrain that would make evacuation by other vehicles difficult or impossible. The minimum landing area required for helicopters and other vertical/short takeoff and landing (V/STOL) aircraft permits patients to be picked up close to the front and delivered to the supporting MTFs. 4. Because of the speed, range, flexibility and versatility of aeromedical evacuation, patients can be moved directly to the MTF best equipped to deal with their condition.

3 5. Specialized MTFs are made possible by aeromedical evacuation, which permits economy in the use of these facilities. Fewer specialty treatment teams are required because of the ability to rapidly evacuate patients to a specific hospital with the required specialists. Hospitals are also required to move less often, thereby reducing non-effective periods during movement and reestablishment. Responsibilities for Loading. The commander requesting the patient evacuation is responsible for delivering the patient to the landing site and for loading him aboard the aircraft. The aeromedical evacuation personnel supervise the loading. In airhead operations, patients are usually transported by vehicle or litter bearers to designated evacuation points inside the airhead perimeter. Air Ambulances. Helicopters are rotary-wing aircraft capable of horizontal, vertical, lateral and hovering flight, giving them the ability to circumvent terrain obstacles, and minimal landing/takeoff area requirements. This enables them to operate in areas inaccessible to fixed-wing aircraft or surface vehicles. The helicopter's relatively slow flight speed permits operations during periods of reduced ceiling and visibility. Helicopters are organic to the air ambulance units and aviation units of the division and corps. Military helicopters are designated by a combination of letters and numbers that identify the basic mission and type: attack helicopter (AH), observation helicopter (OH), utility helicopter (UH) and cargo/transport helicopter, (CH). The last two classes of helicopters can be used for air evacuation of litter patients. a. The UH-60A Blackhawk (Figure 1). This helicopter is the primary dedicated air ambulance. The normal configuration for aeromedical evacuation provides for four litter patients and one ambulatory patient. The maximum configuration provides for six litter patients and one ambulatory patient, or seven ambulatory patients. Figure 1. UH-60A Blackhawk b. The UH-1H/V Iroquois (Figure 2). This aircraft is also used as a dedicated air ambulance. The normal evacuation configuration provides for three litter and four ambulatory patients. The maximum patient configuration allows six litter patients or nine ambulatory patients.

4 Figure 2. UH-1H/V Iroquois Helicopter Landing Sites. 1. Responsibility: The unit requesting aeromedical evacuation support is responsible for selecting and properly marking the helicopter LZs. 2. Criteria for Landing Sites: A. The helicopter LZ and approach zones to the area should be free of obstructions. Sufficient space must be provided for hovering and maneuvering the helicopter during landing and takeoff. If possible, select approach zones that permit the helicopter to land and take off into the prevailing wind, and a landing site that affords helicopter pilots the opportunity to make shallow approaches. B. Definite measurements for LZs cannot be prescribed, since they vary with temperature, altitude, wind, terrain, loading conditions, and individual helicopter characteristics. The minimum requirement for light helicopters is a cleared area 30 meters in diameter with approach and departure zones clear of obstructions. C. Remove or Mark Obstructions. Remove any object (paper, cartons, ponchos, blankets, tents, or parachutes) likely to be blown about by the wind from the rotor from the landing area. Clearly mark obstacles (such as cables, wires or antennas) at or near LZs that cannot be removed and may not be readily seen by a pilot. Red lights are normally used at night to mark all obstacles that cannot be removed from an LZ. In most combat situations, it is impractical for security reasons to mark the tops of obstacles at the approach and departure end of an LZ. If obstacles or other hazards cannot be marked, advise pilots of this by radio. D. Identifying the Landing Site (Figures 3 through 6). (1) When the tactical situation permits, mark a landing site with the letter "H" or "Y, using identification panels or other appropriate marking material. Take special care to secure panels to the ground in order to prevent them from being blown about by the rotor wash. Driving stakes through the panels will secure them; rocks piled on the corners are inadequate. (2) If the tactical situation permits, indicate the wind direction with one of the following: (a) Small windsock or rag tied to the end of a stick at the edge the LZ.

5 (b) Man standing at the upwind edge of the site with his back to the wind and his arm extended forward. (c) Smoke grenades emitting colored smoke as soon as the helicopter is sighted. Smoke color should be identified by the aircrew and confirmed by ground personnel. (3) Consider the following factors in night operations: (a) One of the many ways to mark a landing site is to place a light, such as a chemical light, at each of the four corners of the usable area of the LZ. Use colored lights to distinguish them from other lights in the vicinity. A particular color can also serve as one element used to identify the LZ. Use flare pots or other types of open lights only as a last resort. They usually are blown out by the rotor downwash and often create a hazardous glare or reflection on the aircraft windshield. Use a coded signal flash to the pilot from a ground operator to further identify the site. This signal can be the directed beam of a signal lamp, flashlight, vehicle lights or other means. When using open flames, ground personnel should advise the pilot before he lands. Secure burning material in such a way that it will not blow over and start a fire on the LZ. Take precautions to ensure that open flames are not placed where the pilot must hover over or be within 3 meters of them. Flash the coded signal to the aircraft repeatedly until recognition is assured. After recognition, the signal operator, from his position on the upwind side of the LZ, directs the beam of light downwind along the ground to bisect the landing area. The pilot makes his approach for landing in line with the beam of light and toward its source, landing at the center of the marked area. Display all lights for as short a time as possible before arrival of the helicopter. Turn the lights off immediately after the aircraft lands. (b) If standard lighting methods are not possible, pocket-sized white (for day) or blue (for night) strobe lights are excellent means to help the pilot in identify the LZ. (c) During takeoff, display only those lights requested by the pilot. Turn them off immediately after the aircraft departs. (4) When the helicopter approaches the LZ, the ground contact team can ask the pilot to turn on his rotating beacon briefly. This enables the ground personnel to identify the aircraft and confirm its position in relation to the LZ (north, south, east, or west). The rotating beacon can be turned off as soon as the ground contact team locates and identifies the aircraft. The ground contact team should help the pilot by informing him of his location in relation to the LZ, observing the aircraft's silhouette and guiding the aircraft toward the LZ. Maintain two-way radio contact while the aircraft is maneuvering toward the LZ. Have the pilot describe the type of lighting or signal being displayed and have ground personnel verify by radio. Continue the signal until the aircraft touches down in the LZ. (5) FM homing procedures can be a valuable asset, especially to troops in the field under adverse conditions. The pilot can more accurately locate ground personnel with FM homing. The success of a homing operation depends upon the actions of the ground personnel. First, ground personnel must be operating an FM radio that is capable of transmitting in the frequency range of 30.0 to megahertz; then they must be able to gain maximum performance from the radio (refer to appropriate technical manual for procedure). The range of FM radio communications is limited to

6 line of sight; therefore, personnel should remain as clear as possible of obstructions and obstacles that could interfere with the radio signals. Ground personnel must have knowledge of the FM homing procedures. For example, when the pilot asks the radio operator to "key the microphone," he is simply asking that the transmit button be depressed for a period of seconds. This gives the pilot an opportunity to determine the direction to the person using the radio. NOTE Enemy detection of your LZ site by means of electronic triangulation when using FM homing presents a serious threat that must be considered. Figure 3. Semi-Fixed Base Operations (Day).

7 Figure 4. Semi-Fixed Base Operations (Night).

8 Figure 5. Field Expedient Landing Zone (Day).

9 Figure 6. Field Expedient (Y) LZ (Night). Figure 7. Field Expedient (T) LZ (Night).

10 6. Loading Patients aboard Rotary-Wing Aircraft. a. Responsibility for loading and securing. The pilot is responsible for ensuring that the litter squad follows the prescribed methods for loading and securing litters and related equipment. The pilot must also make the final decision regarding how many patients can be loaded safely. b. Safety Measures. When loading and unloading a rotary-wing aircraft, certain precautionary measures must be taken. Litter bearers must present as low a silhouette as possible and must keep clear of the rotors at all times. Do not approach the helicopter until a crewmember signals to do so. The litter bearers should approach the aircraft at a 45 angle from the front of the helicopter. If the helicopter is on a slope and conditions permit, loading personnel should approach the aircraft from the downhill side. Follow all directions given by the crew, and carry litters parallel to the ground. Smoking is not permitted within 50 feet of the aircraft. 7. Loading Patients Aboard the UH-60A Blackhawk Helicopter. a. Interior of the UH-60A Blackhawk Helicopter. This helicopter, like the UH-1H/V, has a number of possible seating and cargo configurations. A major difference in preparing the UH-60A to carry litters is that a medical evacuation kit must be installed. This kit consists of a seat/converter assembly unit and a litter support unit. The seat/converter assembly provides for three rear-facing seats that allow the medical attendant and crew chief to monitor patients. The litter support unit consists of a center pedestal that can be rotated 90 about the vertical axis to load and unload patients. The litter support unit has a capacity of four to six litter patients. The patients can be loaded from either side of the aircraft. Only the upper litter supports in the four-litter configuration can be tilted for loading and unloading patients. If no litter patients are being evacuated, a maximum of six ambulatory patients can be seated on the litter support unit (three on each side). A seventh ambulatory patient can be seated on a troop seat. NOTE When the six-litter modification kit is installed, the center pedestal can no longer be rotated. NOTE Only three litters can be loaded when using the internal rescue hoist.

11 When the medical evacuation kit is installed, a number of cabin configurations are possible. Table 1. Patient Configurations, UH-60A Medical Evacuation Kit Four-Litter (Combat) Configuration 4 litter patients 1 ambulatory patient 2 litter patients 4 ambulatory patients No litter patients 7 ambulatory patients Six-Litter (High Capacity) Configuration 6 litter patients 1 ambulatory patient 3 litter patients 4 ambulatory patients No litter patients 7 ambulatory patients NOTE With each configuration, there is sufficient room to carry a crew chief and a medical aidman. Table 2. Patient Configurations, UH-60A Medical Evacuation Kit with Internal Rescue Hoist Installed Four-Litter (Combat) Six-Litter (High Capacity) Configuration Configuration 3 litter patients 4 litter patients 1 ambulatory patients 1 ambulatory patients No litter patients No litter patients 4 ambulatory patients 4 ambulatory patients NOTE With each configuration, there is sufficient room to carry a crew chief and a medical aidman. b. Guides for Loading Patients. (1) Position litter patients in the helicopter according to the nature of their injuries or condition. Aircraft personnel supervise the loading and positioning of the patients. Normally, the helicopter has a crew of four: a pilot in command, co-pilot, crew chief and medical aidman. (2) The most seriously injured patients are loaded last, on the bottom pans of the litter support unit. A patient's condition, however, can require in-flight emergency medical care (such as cardiopulmonary resuscitation). To facilitate access to the patient, he should be loaded onto either of the top pans.

12 (3) The structure of the litter support unit allows patients to receive IV fluids and oxygen in flight. Patients receiving IV fluids can be placed on any of the litter pans, depending on their injuries or condition. (4) Load patients in traction splints last, on a bottom pan. (5) The UH-60A can be loaded on both sides simultaneously. Load patients so that upon rotating the litter support, the patient's head will be forward in the cabin. To do this, load patients on the left side of the aircraft head first, and load patients on the right side of the aircraft feet first (left and right sides are determined from the position of the PC's seat, looking forward). When the six-litter configuration is used, load the fifth and sixth litter patients with the carousel in the fly position and the patients heads toward the front of the aircraft. c. Installing Litter Pan Supports. Each litter support is attached to the center pedestal by two end pivot shafts and two T-shaped fittings. These fittings and shafts allow the removal, interchange or repositioning of the supports. There are five pivot shaft support holes at both ends on the right and left side of the center console. Behind the holes are support rollers for the pivot shafts. From top to bottom, the top hole is for the upper litter in the six-litter configuration and the second hole is for the upper litter support in a four-litter configuration. These end holes line up with a central pivot hole that accommodates a central pivot shaft on the litter support. Only this litter position allows midposition pivoting for loading or unloading. The third hole is for the center litter of the six-litter configuration. The fourth hole is used to install the litter support as a seat for evacuating ambulatory patients. The fifth hole is used for the lower litter support in the four-litter configuration. The third, fourth, and fifth positions do not have a tilt function. (1) Lower litter support installation. Before installing, each center pivot shaft must be retracted and unlocked. The center pivot shaft handle must be secured in the handle retainer. End pivot handles must be in the tilt position. (a) Engage T-bars on litter support with split retention fittings at the bottom of the pedestal. (b) Line up the end pivot shafts with holes. Disengage the pivot shaft lever locks and move the end pivot shaft lever toward the pedestal. Then fully insert the pivot shaft into the pivot shaft holes on the pedestal and engage the handle lock. (c) Repeat step (b) for the other end of litter support. (2) Upper litter support installation. Before installing, each center pivot pin must be unlocked and retracted. Then disengage the handle is from its retainer. The end pivot handles must be in the tilt position. (a) Tilt the outer edge of litter support slightly down and engage the T-bars into split retention fittings at the second support hold from the top of pedestal. (b) Raise the outer edge of the litter support until the support is level.

13 (c) Insert the end pivot shaft into the pedestal by pulling on the pivot shaft lever lock and moving the lever toward pedestal until end pivot shaft engages partway in end pivot support hole. (d) Turn the center pivot shaft lock handle counterclockwise until it is horizontal. (e) Push the center pivot shaft toward the pedestal until the shaft is fully inserted into the center pivot shaft hole. The opposite end of the litter support should be raised or lowered to align the center shaft on the support with the center hole on pedestal. (f) Turn the center pivot lock lever clockwise to the horizontal positions. (g) Repeat step (c) above for the other end of litter support. Now slide both end pivot shafts in fully by moving the pivot lever lock handle to the engaged position. (3) Upper litter support relocation for six-liter configuration. (a) Remove the litter support from the second support hole from the top of the pedestal. The removal of the litter support is the reverse of its installation. Before relocation, each center pivot pin must be locked and the handles must be secured in the handle retainer. (b) Line up the end pivot shafts with the top support holes. Then fully insert and engage the handle lock. (c) Repeat steps (a) and (b) above for other end of litter support. (4) Middle litter support installation for six-litter configuration. (a) Remove the litter support from the fifth (bottom) support hole. The removal of the litter support is the reverse of its installation. (b) Align the end pivot shafts with third support hole from top of pedestal to relocate it. Then fully insert and engage handle lock. (c) Repeat steps (a) and (b) above for the other end of litter support. (5) Bottom litter support installation for six-litter configuration. To complete the six-litter configuration, the modification kit is required. This kit consists of a tube assembly and a restraint assembly for each side. (a) Insert the restraint assembly using the plate quick disconnect fittings into the proper quick attachment fittings on the cargo floor. Pull up on the restraint assembly to check for secure installation. (b) Attach tube assembly longitudinally to the proper tie down restraint rings on the cargo floor. Ensure that the restraint rings are properly secured to the bracket tube support with the attached pin (Figure 8).

14 (c) Repeat steps (a) and (b) above for the other end of the litter support. Figure 8. Litter Pan in the Load and Unload (Tilt) Position (Same at Other Side of Pedestal) (6) Litter support installation for ambulatory patient seating. (a) Prepare supports as in c (l) above. (b) Engage the T-bar on the litter pan with the split retention brackets below the support tilt stop brackets. (c) Position the litter support at the second from the bottom litter support end pivot hole on pedestal. (d) Line up the end pivot shafts with the holes. Disengage pivot shaft lever lock and move pivot shaft lever toward pedestal. Fully insert the pivot shaft into pivot shaft hole on pedestal and engage handle lock. (e) Repeat step (c) for the other end of litter support (7) Storing litter pans. (a) Lower stowage brackets to the horizontal position and insert the retaining pin through stowage bracket into pedestal. WARNING Improperly positioning the stowage bracket retaining pin reduces the holding capability of the stowage bracket and might cause it to shear the pivot bolt during a crash sequence.

15 (b) Place the litter pan in the stowed position against the center pedestal. (c) Secure the litter pan to the center pedestal by routing the opposite web strap around the upper portion of the litter panhandle. Secure the metal clasp to the metal ring. NOTE The use of opposite strap reduces excess litter pan movement. (d) Use opposite web strap to secure the upper side of the litter pan handle as described in step (c) above, while the same side web strap is used to secure the bottom side of the stored litter pan handle. (e) Remove the stowed litter pans by reversing steps (a)-(d) above. d. Loading Upper Litters. For ease of loading, the upper litter pans can be tilted. Upper litter pans are supported by a center pivot shaft and two end pivot shafts, one at each end of the litter pan. To tilt the upper support for the loading and unloading of litter patients, the center shaft remains locked to the pedestal and the end shafts are disengaged for support pivoting. NOTE This system was designed to pivot about the center shaft allowing either end to be tilted downward. Although the supports can be pivoted at either end, more effort is required when a loaded litter is installed. e. Loading and Securing Patients. (1) To load four litter patients with a four-man litter squad, load the litters from the top to bottom. The sequence for loading litters from one side of the aircraft with the carousel turned is upper right, upper left, lower right and then lower left. To load litters from both sides of the aircraft simultaneously, load from top to bottom (Figure 9). (a) The litter support unit is rotated 90 clockwise to receive the litter patients. The flight crew lowers the top pan to accept the litter and stands by to assist as the litter squad approaches the aircraft. (b) The litter squad moves into the semi-overhead carry, lifting the litter just high enough for the litter stirrups of one end to slide on to the litter pan. The litter squad slides the litter forward. The

16 flight crewmember guides and assists the litter squad, until the litter stirrups of both ends are secured on the pan. The litter squad departs as the flight crewmember raises the pan back to its upright position and secures it. The flight crewmember fastens the litter straps attached to the litter support assembly. (c) After the first litter is loaded, the squad leaves the aircraft as a team to obtain another litter patient. The second, third, and fourth litters are loaded in the same manner, except that the bottom pans are not tilted to receive patients. (d) After loading four litter patients, the litter support unit is rotated 90 counterclockwise and locked in the in-flight position. The cargo doors must be closed for flight. Figure 9. Loading Litter into UH-60A. (2) Loading six litter patients requires the repositioning of the litter support prior to loading. The loading procedure remains the same as the four-litter configuration except for the following: (a) The top litter support no longer tilts, necessitating overhead loading and can require additional assistance. (b) After four litters are loaded, the pedestal must be rotated back to the locked position. Then, install the restraint and tube assembly modification kit. The last two litters are side loaded between the restraints, with the patients' heads towards the front of the aircraft. They are secured. (3) When the aircraft is to receive a mixed load of litter and ambulatory patients, one top pan of the litter support is removed and repositioned just above the bottom pan on the same side. The aircraft can now accommodate two or three litter and four ambulatory patients (Figure 10). (a) The litter support unit is rotated clockwise to receive the litter patients, except for the third litter in the six-litter configuration. Load the litters as described in paragraph e (1) above. Upon loading and securing the litter patients, the litter support unit is rotated counterclockwise to the inflight position. The third litter is then loaded when the six-litter configuration is used. (b) Ground personnel escort ambulatory patients to the aircraft, and are assist them into their seats and secure them with the seat belts attached to the litter support unit. (c) Close the cargo doors for flight.

17 WARNING To prevent further injury to patients, all end support pins of the installed litter pans must be in the locked position for flight. Figure 10. Litter Support f. Unloading Patients. Unload the aircraft in the reverse order of the loading procedure. The pans are normally unloaded bottom pan first, then top to ensure that the most seriously injured patients are unloaded first. 8. Loading Patients aboard the UH-1H/V Iroquois Helicopter. a. Interior of the UH-1H/V Iroquois Helicopter. This helicopter has several litter and seating configurations. Changing configurations to meet operational requirements can be done in a few minutes. Facilities for carrying a tier of three litters loaded lengthwise in the aircraft are located on each side of the helicopter cargo compartment (Figure 11), giving the helicopter a maximum litter capacity of six (or nine ambulatory patients). This configuration is normally used in rear areas to move large numbers of stable patients. The normal configuration for the aircraft is three litter patients loaded crosswise and four ambulatory patients. The maximum load the helicopter can lift must be considered capacity varies with the altitude and temperature. The pilot will advise the ground personnel of his load capacity.

18 Figure 11. Interior View of UH-1H/V Iroquois Helicopter, Six-Litter Configuration b. Guides for Loading Patients. Patients are normally loaded from the top tier down to the bottom tier, with the most seriously injured loaded last. (1) Litter patients should be positioned in the helicopter according to the nature of their injuries or condition. Personnel aboard the helicopter supervise the loading of the aircraft. care. (2) The most seriously injured patients are placed in the bottom litter tiers to permit in-flight (3) Litter patients receiving IV fluids should not be positioned on the top row of litter tiers but should be placed as low as possible in the litter rack. (4) Patients in Hare traction splints with splint supports and footrests must be loaded last and placed directly on the floor of the helicopter. c. Loading and Securing Patients. (1) To load six litter patients with a four-man litter squad, load the litters from both sides of the aircraft and from top to bottom. Figures 12 and 13 illustrate procedures for loading the right side. Figure 14 illustrates procedures for loading the left side. (2) When the helicopter is equipped for mixed loading (Figures 15 thru 17), load three litters crosswise and put four ambulatory patients in the side seats. (a) When loading from the left, the litter squad moves to the side of the helicopter with the litter perpendicular to the cargo compartment; then the squad moves into a litter post carry. Bearers 1 and 3 give their litter handles to the crew members, who put the handles in the litter support brackets on the far side of the aircraft. Bearers 2 and 4 secure the foot of the litter.

19 (b) After loading the first litter, the squad leaves the helicopter to pick up another litter patient. The second and third litters are loaded in the same way as the first one. After the three litter patients are loaded, take the ambulatory patients to the aircraft and direct them to their seats. d. Unloading Patients. The aircraft is unloaded in the reverse order of loading. The tiers are unloaded from bottom to top on one side and then on the other side. At the unloading command, the litter squad moves to the helicopter and the bearers take their proper places at the litter. The squad then performs its duties in the reverse order of loading. Figure 12. Loading UH-1H/V From Right Side (Step One) Figure 13. Loading UH-1H/V From Right Side (Step Two)

20 Figure 14. Loading UH-1H/V From Left Side Figure 15. Loading UH-1H/V Litter Crosswise

21 Figure 16. UH-1H/V with Two Litters Loaded Crosswise Figure 17. UH-1H/V with Mixed Load of Litter and Ambulatory Patients Figure 18. CH-47 Chinook Helicopter. a. The CH-47 Chinook helicopter (Figure 18) has a capacity of 24 litter patients, or 31 ambulatory patients or a combination of litter and ambulatory patients. The aircraft's overall size and rotor blade diameter make it unsuitable for use in small or confined areas. b. The CH-47 helicopter should not be brought into a LZ that is smaller than 40 meters in diameter.

22 Loading Patients aboard the CH-47 Chinook Helicopter. a. Interior of the CH-47 Chinook Helicopter. (1) This helicopter's maximum capacity is 24 litter patients or 31 ambulatory patients. The 31 ambulatory patients are seated in the ten three-man seats and the one-man seat as shown in view A of Figure 21. The two one-man seats are used by crewmembers. (2) When carrying 24 litter patients, the seats are replaced with six tiers of litters, four litters high. The two one-man seats in the rear section should remain in place for the crewmembers. The oneman seat at the left front can also be left in place if needed. (3) The combinations of litter and ambulatory patients the CE-47 helicopter is capable of accommodating are provided in Table 3. Table 3. Litter and Ambulatory Configuration of the CH-47 (Chinook) Helicopter Ambulatory Litter b. Litter Support Kits. These kits are available for adapting the helicopter's interior to evacuate litter patients. These kits contain twelve litter poles stored in the front of the cargo compartment and twelve litter straps stored in overhead recesses. The poles contain safety attachments for securing them along the sidewalls of the compartment. The pull-down straps on the aisle side are secured to floor studs. Permanently attached to each litter pole and each strap are four litter support brackets with locking devices for securing litter handles in place. It is not necessary to remove the seats before adapting the compartment for litter patients. The seats can be folded against the wall and strapped in place. c. Loading Litter Patients. Loading litter patients aboard the CH-47 helicopter is similar to loading patients aboard the UH-1H/V air ambulance except the litter squad is not assisted by the crewmembers. In a two-man carry, the litter squad carries each litter patient up the ramp through the lowered rear door and to the litter rack where the litter is to be placed. The squad then moves into a four-man carry and places the litter patient into the appropriate tier. The litter racks should be loaded from front to rear and from top to bottom. Litter patients requiring in-flight medical care should be positioned to facilitate this care. If the helicopter is to be loaded with a combination of litter and ambulatory patients, the litter patients should be positioned to the rear of the ambulatory

23 patients whenever possible. Figure 19. Interior View of CH-47 (Chinook) Helicopter Fixed-Wing Aircraft.

24 Extracted from: the Pararescue medication and Procedure Handbook TABLE 4. 9 LINE MEDEVAC REQUEST LINE ITEM EXPLANATION EXPLANATION Location of Pickup Site 1 Encrypt the grid coordinates of the pickup site. When using the DRYAD Numeral Cipher the same set line will be used to encrypt the grid zone letters and coordinates. To preclude misunderstanding, state that grid zone letters are included in the message unless unit SOP specifies its use at all times. Required so evac vehicle knows where to pickup patient. Also, so the unit coordinating the evacuation mission can plan the route for the evac vehicle or if vehicle must pick up from more than one location 2 3 Radio frequency Call sign and Suffix Number of patients by precedence Encrypt the frequency of the radio at the pickup site, not a relay frequency. The call sign (and suffix if used) of person to be contacted at the pickup site can be transmitted in the clear. Report only applicable information and encrypt the brevity codes. A-URGENT B-URGENT-SURG C-PRIORITY D-ROUTINE E-CONVENIENCE Required so that evac vehicles can contact requesting unit while en route to obtain additional information or change in situation or directions. Required by unit controlling the evac vehicles to assist in prioritizing missions. 4 Special equipment required If 2 or more categories must be reported in the same request, insert the word BREAK between each category. Encrypt the applicable brevity codes A-None B-Hoist C-Extraction equipment D-Ventilator Required so that the necessary equipment can be placed on board the evac vehicle prior to the start of the mission. 5 Number of patients by type Report only applicable information and encrypt the brevity code. If requesting MEDEVAC for both types, insert the word BREAK between litter entry and ambulatory entry. L+# of pts Litter A+# of pts Ambulatory Required so that the appropriate number evac vehicles can be dispatched to the pickup site. They should be configured to carry the patients requiring evac. 6 Security of pickup site (Wartime) N- No enemy troops in area P- Possible enemy troops in area (approach with caution) E- Enemy troops in the area (approach with caution) X- Enemy troops in area (armed escort required) Required to assist the evac crew in assessing the situation and determining if assistance is required. More definitive guidance can be provided to the evac vehicle while en route (specific location of enemy to

25 Number and type of wound, injury or illness (Peacetime) Method of marking pickup site Patient nationality and status NBC contamination (Wartime) Terrain Description (Peacetime) Specific information regarding patient wounds by type Report serious bleeding with patient blood type (if known) Encrypt the brevity codes. A- Panels B- Pyrotechnic signal C- Smoke D-None E-Other The number patients in each category need not be transmitted. Encrypt only the applicable brevity codes. A- US military B- US civilian C- Non-US military D- Non-US civilian E- EPW Include this line only when applicable. Encrypt the applicable brevity codes. N- Nuclear B- Biological C- Chemical Include details of terrain features in and around proposed LZ. If possible, describe relationship of site to prominent terrain features. assist aircraft in planning approach). Required to assist evac personnel in treatment and special equipment needed. Required to assist crew in identifying the pickup site. Note that the color of panels or smoke should not be transmitted until the evac vehicle contacts the unit just prior to its arrival. For security, the crew should identify the color and the unit confirm. Required to assist in planning for destination facilities and need for guards. Unit requesting support should ensure that there is an English-speaking representative at the pickup site. Required to assist in planning for the mission (determines which evac vehicle will perform the mission and when it will be accomplished) Required to allow evac personnel to assess approach into area. CASEVAC with Fixed Winged Aircraft The capability of some fixed-wing aircraft to land or the take off from selected small, unprepared areas permits the evacuation of patients from AOs that would be inaccessible to larger aircraft. These aircraft can fly slowly with a high degree of maneuverability, further enhancing their value in forward areas under combat conditions. Small fixed-wing aircraft are limited in speed and range in comparison to larger transport-type aircraft. When adequate airfields are available (Figures 20 and 21), fixed-wing aircraft might be used in forward areas for patient evacuation. This is a secondary mission for these aircraft that will be used to augment dedicated air ambulance assets.

26 Figure 20. Marking and Lighting of Airplane LZ (Day).

27 Figure 21. Marking and Lighting of Airplane LZ (Night).

28 AEROMEDICAL EVACUATION Colonel Sheila Millette, USAF, NC Captain Pete Sorensen, USAF, NC Colonel (Ret) Robert H. Brannon, USAF, MSC Extracted from: The USAF Aeromedical Evacuation Handbook for Special Operations Forces INTRODUCTION: This information is intended to facilitate the movement of patients from bare base or austere environments to facilities with the appropriate level of care. The Aeromedical Evacuation (AE) system uses fixed wing aircraft to move patients. Air Mobility Command (AMC) is designated lead command for AE. The AE system can be used in conjunction with other evacuation systems (CASEVAC, MEDEVAC) if they are available. The information in this section provides a simplified method for accessing the AE system, and covers some patient and equipment considerations as well. Finally, the updated listing of telephone numbers should facilitate easier worldwide access. ACCESS PROCESS AND TELEPHONE NUMBERS For patient movement assistance in the US or SOUTHCOM, contact the Global Patient Movement Requirements Center (GPMRC) at DSN or commercial (618) or (24-hour number). The GPMRC will obtain patient information and will validate and coordinate the patient movement. If you are unable to contact the GPMRC, contact the Tanker Airlift Control Center (TACC) AE Cell at DSN or commercial (618) (24-hour number). The TACC can also be reached at AIR MOBL (also a 24-hour number). Ask to speak to someone in the AE Cell. The TACC AE Cell is responsible for the tasking, scheduling, execution and recovery of AE missions. Once TACC has been contacted, a coordinated effort will begin, initiating procedures to obtain aircrews, equipment and aircraft. Telephone numbers for the Theater Patient Movement Centers (TPMRC), which are located in Germany and Japan, are listed below. The function of the TPMRC basically mirrors the function of the GPMRC for patient movement within their respective theaters. They coordinate with the GPMRC and TACC for intertheater AE mission coordination and execution. The Theater Patient Movement Requirements Center Europe (TPMRC-E) for USEUCOM (Europe/parts of Africa) and CENTCOM (parts of Asia and Africa) is located at Ramstein AB, Germany: DSN or 8040; commercial or 8040 The TPMRC-E is a 24-hour, one stop shop for integrating patient movement requirements. The primary mission is to coordinate and communicate patient movement requirements to service components that execute the patient movement mission in the USEUCOM and USCENTCOM areas of responsibility and interest.

29 The TPMRC for PACAF (Asia-Pacific) is located at Yokota AB, Japan: DSN or 4857; commercial /4857 In austere conditions, any medical or AE element, AE liaison team (AELT), mobile aeromedical staging facility (MASF) or AE crewmember can be contacted for assistance. EQUIPMENT AND SUPPLY CONSIDERATIONS When moving your patients, several issues need to be taken into consideration. The most important is to ensure that good, clear information is conveyed to the individual arranging the aeromedical evacuation mission. Let the Patient Movement Clinical Coordinator (PMCC) at GPMRC know if: - You feel that a specific piece of equipment might be needed; - You want to swap equipment, or if you want to keep your own equipment; - The patient is on the only litter that you have and you want to retain the litter. Equipment The equipment carried on a routine aeromedical evacuation mission: (Ref AFI ) - Life-Pak 10, Cardiac Monitor and Defibrillator - Life-Pak 10 Battery Support System - Portable suction unit - Pulse oximeter - PT-LOX (10 liters of liquid oxygen per unit, 1 liter = 804 gaseous) - Frequency converter (for aircraft that do not deliver a 115 VAC/60HZ power source) - IV infusion pump - Electrical cable assembly set (extension cords to access electrical power source) - Ambu-bags - Intubation kit - Emergency medications - Advanced cardiac life support (ACLS) medication and equipment NOTE: Air Force AE squadrons only use in-flight medical equipment that has been approved by Armstrong Laboratory for use in the AE system. If you feel other equipment is necessary, let the AE coordinator know. Ventilators, backboards, traction devices or Stryker frame, decompression masks, chest tubes and drainage kits are available if required

30 Supplies Standardized in-flight kits are available on each aeromedical evacuation mission. They include IV supplies, oxygen equipment, irrigation fluids, dressing supplies, Foley catheters, NG tubes and limited splint and immobilization supplies. If you feel that additional supplies are needed, inform the Patient Movement Clinical Coordinator (PMCC) at the GPMRC. Additional supplies can include: burn packs, additional IV fluids, additional immobilization devices, cervical collars and/or expansion of the ACLS/ATLS medications, narcotics and equipment. PATIENT CONSIDERATIONS These are patient considerations and classifications that should be used to inform the PMCC of your patient(s) status. Patient Classifications/Category: 1 - Psychiatric 2 Inpatient Litter 3 Ambulatory Inpatient 4 - Infant 5 - Outpatient 6 - Attendant Note: When contacting the PMCC, use the numerical description. Additional patient description/categorization should not be necessary. Air Force Patient Movement Precedence: (Joint Pub ) Urgent: Immediate movement to save life, limb or eyesight Priority: Patients requiring prompt medical care not available locally, used when the medical condition could deteriorate and the patient cannot wait for routine evacuation, (move within 24 hours) Routine: Patient requires medical evacuation, but their condition is not expected to deteriorate significantly (move within 72 hours) Note: These differ from the Army and Navy patient movement precedences. Ensure that the PMCC understands you are with a SOF unit and your request is not an everyday request. Relay information on any unusual circumstances or needs to send this patient to a particular destination. They will respond accordingly. Patient Information: You should be prepared to provide the follow information to the PMCC:

31 1. Name 2. Rank 3. SSN 4. Unit/Organization 5. Nationality 6. Date of Departure 7. Destination 8. Diagnosis 9. Special equipment needed, including oxygen 10. Special medical considerations 11. Patient classification Note: The PMCC can help you find an accepting physician if needed. Patient Preparation/Documentation: Document on one of the following forms, if available: - DD Form 1380, US Medical Card - DD Form 600, Chronological Record of Medical Care - DD Form 602, Patient Evacuation Tag or AF Form 3899, AE Patient Record - Any other available clinical documentation format It should be noted that there is no intent here to tell you how to take care of your patients. These are simply some considerations for you. When communicating with the PMCC, have as much of the patient information readily available as possible. Be brief: - Why is the patient being aeromedically evacuated, i.e. what is clinically/medically wrong with the patient? - Brief synopsis of current history, if known. - Past significant medical history, including allergies. If none, state so. - Current knowledge of patient medications. If known, send documentation. If none, state so.

32 PREFLIGHT CONSIDERATIONS Weapons and Ammunition You must understand that a patient s weapons and ammunition will be a concern for you when trying to get your patients onto the aircraft. The easiest way to avoid controversy with the AE crew and the other aircrew members is to anti-hijack the individual yourself. To anti-hijack the patient, do the following: - Separate the ammunition from the weapon; the loadmaster (if no loadmaster, check with Aircraft Commander, or Medical Crew Director, or Flying Crew Chief) will secure the ammunition. Make sure the weapon has been CLEARED! If time permits, label the weapon CLEARED and identify the owner. - Secure any explosives prior to entry to the plane (aircraft and explosives are a bad combination). Make sure to check the patients uniform pockets for C-4, detonators, grenades, ammunition, etc. - Secure knives with the loadmaster or designated individual in a similar fashion as the ammunition - Search bags and rucksacks for ammunition, knives and explosivesl; take appropriate action as described above. - If possible, leave ammo/explosives with the remaining SOF unit if possible. - Civilian air ambulance companies will not take weapons, ammunitions or explosives. The unit is responsible for securing these or arranging to leave behind. General Principles of Flight Physiology/Gas Laws. The temperature, pressure, volume and relative mass of a gas influence the body s response to barometric pressure changes as the aircraft changes altitude. Barometric/atmospheric pressure is the pressure exerted against an object by the atmosphere. Boyle s Law: The principle of gas expansion. The volume of a gas is inversely proportional to the pressure. Increasing altitude decreases barometric pressure. An example is a balloon expanding at altitude. If there is free air in the chest or cranium, the expanding air pressure will cause increased pressure inside the structure. An altitude restriction is required. Consult the PMCC. Dalton s Law: The law of partial pressure. As altitude increases, barometric pressure decreases. However, oxygen partial pressure/concentration remains 21% of the total air regardless of altitude. Consequently, as altitude increases, the partial pressure of oxygen decreases. The actual available oxygen to the tissues decreases with altitude because oxygen molecules move farther apart. This can result in hypoxia, or lower levels of oxygen to the tissues and cells. Charles Law: When the mass of a gas is kept under constant pressure the pressure will increase or decrease as the temperature of the gas increases or decreases. As an example, the pressure reading in a tire or an oxygen tank decreases as the temperature decreases. Henry s Law: The solubility of gases in liquids. The weight of a gas dissolved in a liquid is directly proportional to the weight of the gas above the liquid. An example is shaking a can of soda and

33 opening it immediately. The balance of pressure is altered, releasing the bubbles of gas in the soda. The release of nitrogen bubbles into the blood after a flight or diving decompression causing the bends is another example. An altitude restriction is required. If the patient has conducted scuba diving operations 24 hours prior to entry into the AE system, inform the AE crew. Graham s Law: The law of gaseous diffusion. Gases flow from higher pressure (or concentration) to a region of lower pressure (or concentration). Simple diffusion or gas exchange at the cellular level is an example. Physiological Stresses of Flight. Patients in the AE environment are more susceptible to the physiologic stresses encountered at altitude. Clinical factors include patency of the respiratory passages, neuromuscular function, rate and depth of respiration, adequate blood flow and diffusion of oxygen at the alveolar and cell level, an adequate hemoglobin level and a functioning respiratory center. Decreased Partial Pressure of Oxygen (pa02). The effects of higher altitudes plus the patient s condition can lead to hypoxia. There are four types of hypoxia requiring in-flight oxygen: 1. Hypoxic hypoxia or altitude hypoxia: If oxygen is required on the ground, it may be necessary to increase the O2 flow rate to maintain oxygen saturation levels at 90%. 2. Histotoxic hypoxia or tissue poisoning: affects the tissues ability to utilize oxygen. Caused by carbon monoxide poisoning, cyanide and alcohol. 3. Hypemic hypoxia or reduced oxygen carrying capacity of the blood: Caused by hemorrhage, anemia, sickle cell anemia, cyanide and carbon monoxide (which has 200% greater bonding affinity to hemoglobin than O2). 4. Stagnant hypoxia or reduced cardiac output: due to pooling of blood and reduced flow to the tissues caused by respiratory failure, shock, PEEP, tourniquets, embolus, and heart failure. Barometric Pressure Changes. On ascent, gas expands and on descent gas contracts. Trapped or partially trapped gases in body cavities (GI tract, lungs, skull, middle ear, sinuses and teeth) expand. Untreated gas expansion in the abdominal cavity can cause diaphragmatic crowding resulting in decreased lung volume and expansion. This can be relieved with a vented NG tube. Additionally, the ear and sinuses must adjust as the cabin pressure changes. Flying with a cold, sinus infection or facial or head injuries can require decongestants or an altitude restriction. Thermal Changes. Aircraft cabin temperature can fluctuate considerably. Temperatures can range from freezing up to 90 while on the ground. In-flight temperatures tend to be cooler. Hyperthermia and hypothermia are seen in burns and frostbite. Both conditions increase the body s oxygen requirements. Decreased Humidity. When air is cooled, it loses its ability to hold moisture. Air at altitude is cold and dry. After two hours of flying time, relative humidity is 5% and after four hours, it is less than 1%. Oxygen needs humidification. Noise. Unprotected exposure to noise can interfere with effective communication, produce temporary threshold shifts (auditory fatigue), permanent threshold shifts (sensorineural hearing loss) and varying levels of fatigue. Wear hearing protection when the aircraft s engines are running.

34 Vibration. The mechanical energy of aircraft vibration is transferred to the tissues and increases muscle activity, especially if in direct contact with the aircraft fuselage. Extra padding of suspected injuries can diminish pain. Fatigue. All of the stresses of flight induce fatigue to some degree. Gravitational Forces (G-Forces). When the aircraft accelerates or decelerates, the body responds by moving in the same direction as the aircraft. Severe head injuries can sustain further damage if the head of the litter is not elevated or if the aircraft produces sudden movement, such as during carrier takeoffs and landings. Special Considerations A thorough primary and secondary preflight assessment, documentation and communication will improve patient outcomes. Airway: Secure with C-Spine precautions as needed. Glasgow Coma Scale (GCS) less than 8 can indicate hypoxia and the patient may need to be intubated prior to flight. Endotracheal or tracheostomy tubes are the best choice. Use sterile water or saline instead of air to inflate the balloons. Document the amount of fluid used. Report tube size to PMRC Breathing: Give humidified oxygen to maintain 90% saturation Rule out tension pneumothorax. Use a Heimlich valve on chest tubes Circulation: Control bleeding Maintain IV fluids; keep track of intake and output. Immobilized fractures. Do not use air splints or MAST trousers in-flight. Disability: Documented baseline GCS and vital signs preflight are essential. Head Injuries: Secure the airway. Use caution with facial fractures Elevate the head and torso to 30, if not contraindicated. Dress wounds Check pupils, verbal response, clear drainage from ears or nasal passages Secure the cervical area, as necessary Thorax: Check breath sounds Check for flail chest Check for a mediastinum shift Rule out hemothorax/pneumothorax or ruptured diaphragm; securely tape Heimlich value on chest tube, (the AE crew can provide one) Report blood loss to TPMRC and AE crew Dress wounds as appropriate Abdomen and Perineum: Check for obvious tenderness and tautness

35 Dress wounds. In the event of exposed bowel, cover with saline dressing and reinforce (if available). Do not insert bowel back into the abdominal cavity. Do not change dressings in-flight. Prior to inserting a Foley catheter, inspect for obvious or suspected abdominal injury. Males: check the rectum/prostate for potential urethral tear. Females: check for obvious vaginal bleeding. Use sterile water or saline instead of air to inflate the balloons. Extremities: Stop hemorrhage, apply pressure dressings, elevate the limb. Dress and splint as appropriate Perform circulation and neuro checks; reapply dressings and splints as needed. Altitude Restrictions: The following injuries will require an altitude restriction to decrease the likelihood of any further injury/complications. (When air is introduced into a cavity, it will expand at altitude, potentially causing further injury): Head injuries Eye injuries Traumatic chest and abdominal injuries Decompression injuries (will require destination field elevation and 100% oxygen) Injuries/complications involving the heart if severely compromised. Note: It is important to note that if there is an altitude restriction, the flight time will be lengthened. Inform the PMCC of the likelihood of an altitude restriction. In the event that you feel there is a requirement to have specialized medical personnel to augment the AE crew, inform the PMCC.

36 AEROMEDICAL EVACUATION ELEMENTS The Theater Aeromedical Evacuation System employs several elements to support AE command, control, communications, patient care and system support. The following sections provide a brief description of the key elements. Aeromedical Evacuation Control Team (AECT) The AECT is the operations center responsible for the overall planning, coordinating and directing of AE operations. The AECT is located in the Air Mobility Division of the Air Operations Center. Aeromedical Evacuation Liaison Team (AELT) The AELT provides a direct communications link and immediate coordination between the user Service requesting aeromedical evacuation and the AECT. AELTs, which generally consist of a Medical Service Corps officer and radio operators, can be augmented with a nurse to provide patient movement coordination interface. AELTs are normally located at the echelon of the user Service that authorizes casualty movements. Depending on the tactical operation being supported, AELTs can be co-located directly with a field medical facility or at any other level of command necessary to ensure a smooth, coordinated casualty flow into the AE system. In addition, the AELT can be used at any AE element as a communications team, as operations dictate. Mobile Aeromedical Staging Facility (MASF) The MASF is a mobile, tented, temporary staging facility deployed to provide supportive casualty nursing care and administration. Each MASF is capable of routinely holding and processing 50 patients at any time. It is not intended to hold casualties overnight or for an extended period. Patients can generally be held from 2-6 hours. Normally, a MASF will be capable of cycling its patient load four times within a 24-hour period. It can, however, surge to six cycles in 24 hours for a limited time. MASFs are located near runways or taxiways of airfields or forward operating bases used by tactical airlift aircraft to resupply combat forces. No physicians are assigned to the MASF. Aeromedical Staging Facility (ASF) An ASF is a fixed medical facility located on or near an enplaning or deplaning air base or airstrip to provide patient reception, administrative processing, ground transportation, feeding, and limited medical care for patients entering, en route in, or leaving the aeromedical evacuation system. ASFs perform all of the functions of an MASF, except that they are not readily mobile, and ASFs have physicians assigned. Aeromedical Evacuation Crews

37 AE crews provide in-flight supportive nursing care aboard the evacuation aircraft. The crews are responsible for ensuring the aircraft are properly configured and loaded. A standard AE crew normally consists of five: two flight nurses and three aeromedical technicians. However, the crew can be tailored as the mission dictates, with double crews often assigned to missions with over 50 casualties. Physicians are not part of a standard AE crew. Critical Care Air Transport Teams (CCATT) CCATTs provide critical care augmentation to aeromedically evacuate injured, ill and/or burn patients requiring advanced care during transportation. They are available to assist the AE crews if a patient s condition dictates. A CCATT is comprised of three personnel: a physician, usually an intensivist (cardiopulmonary), a critical care nurse and a respiratory technician.

38 PRIMARY AEROMEDICAL EVACUATION AIRCRAFT There are a variety aircraft that are capable of performing the AE mission. They include, but are not limited to, the following: C-9A Nightingale Mission: The C-9A is a twin-engine, T-tailed, medium-range jet aircraft specifically designed for aeromedical evacuation. It is used in PACAF and USAFE as well as in the CONUS. Features: The Nightingale is a modified version of the McDonnell Douglas DC-9. It is the only aircraft in the inventory specifically designed for moving litter and ambulatory patients. The C-9A's airlift capability to carry 40 litter patients, or 40 ambulatory and four litter patients, or combinations thereof, and provides the flexibility for Air Mobility Command's worldwide aeromedical evacuation role. A hydraulic folding ramp allows efficient loading and unloading of litter patients and special medical equipment. The plane has: Ceiling receptacles for securing intravenous bags. A special care area with a separate ventilation system for patients requiring isolation or intensive care. Eleven vacuum and therapeutic oxygen outlets, positioned in sidewall service panels at litter tier locations. A 28 VDC outlet in the special care area. Twenty-two 115 VAC-60 hertz electrical outlets located throughout the cabin permit the use of cardiac monitors, respirators, incubators and infusion pumps at any location within the cabin. A medical refrigerator for preserving whole blood and biological drugs. A medical supply work area with sink, medicine storage section and worktable, fore-and-aft galleys and lavatories. Aft-facing commercial airline-type seats for ambulatory patients. A station for a medical crew director that includes a desk communication panel and a control panel to monitor, therapeutic oxygen and vacuum system. An auxiliary power unit that provides electrical power for uninterrupted cabin air conditioning, quick servicing during stops, and self-starting for the twin jet engines. Note: The C-9A has no defensive capabilities and is not likely to be sent into an unsecured hostile environment.

39 C-130 Hercules Mission: The C-130 Hercules primarily performs the tactical airlift mission. The aircraft is capable of operating from rough, dirt strips and is the prime transport for airdropping troops and equipment into hostile areas. C-130s operate throughout the U.S. Air Force, serving with Air Mobility Command (stateside), theater commands, Air National Guard and the Air Force Reserve Command, fulfilling a wide range of operational missions in both peace and war situations. Basic and specialized versions of the aircraft airframe perform many roles, including airlift support, Arctic ice resupply, aeromedical missions, aerial spray missions, firefighting duties for the U.S. Forest Service and natural disaster relief missions. Features: In its personnel carrier role, the C-130 can accommodate 92 combat troops or 64 fully equipped paratroopers on side-facing seats. For medical evacuations, it carries a maximum of 74 litter patients and medical attendants, 92 ambulatory patients or a combination of the two. Paratroopers exit the aircraft through two doors on either side of the aircraft behind the landinggear fairings. Another exit off the rear ramp is for airdrops. The C-130 Hercules joins on mercy flights throughout the world, bringing in food, clothing, shelter, doctors, nurses and medical supplies and moving victims to safety. C-130 Hercules have served other nations, airlifting heavy equipment into remote areas to build airports and roads, search for oil and transport local goods. The C-130J is the latest addition to the C-130 fleet and will eventually begin to replace retiring C- 130E's and C-130H's. The C-130J incorporates state-of-the-art technology to reduce crew requirements, lower operating and support costs, and provides life cycle cost savings over earlier C-130 models. Compared to older C-130s, the C-130J climbs faster and higher, flies farther at a higher cruise speed, and takes off and lands in a shorter distance. Currently, there are six aircraft in the test program.

40 C-141B Starlifter Mission: The C-141B Starlifter is the workhorse of the Air Mobility Command. The Starlifter fulfills a spectrum of airlift requirements through its ability to airlift combat forces over long distances, deliver those forces and their equipment either by air, land or airdrop, resupply forces and transport the sick and wounded from the hostile area to advanced medical facilities. Features: The C-141B is a stretched C-141A with in-flight refueling capability. The stretching of the Starlifter consisted of lengthening the planes 23 feet 4 inches (7.11 meters), increasing the C-141 cargo capacity by about 1/3, or an extra 2,171 cubic feet (62.03 cubic meters). Lengthening the aircraft had the same overall effect as increasing the number of aircraft by 30%. The C-141A, built between , was AMC's first jet aircraft designed to meet military standards for a troop and cargo carrier. The development of the B model was the most cost-effective method of increasing AMC's airlift capability. The standard C-141 configuration can carry 103 litters, or 160 seats or a combination of the two. A universal air-refueling receptacle on the C-141B, with the ability to transfer 23,592 gallons (89,649 liters) in about 26 minutes, means longer nonstop flights and fewer fuel stops at overseas bases during worldwide airlift missions. The C-141 force, nearing nine million flying hours, has a proven reliability and long-range capability. In addition to training, worldwide airlift and combat support, the C-141 has amassed a laudable record in responding to humanitarian crises. The C-141, with its changeable cargo compartment, can transition from rollers on the floor for palletized cargo to a smooth floor for wheeled vehicles to aft facing seats or sidewall canvas seats for passengers, quickly and easily, to handle over 30 different mission configurations.

41 C-17 Globemaster III Mission: The C-17 Globemaster III is the newest, most flexible cargo aircraft to enter the airlift force. The C-17 is capable of rapid strategic delivery of troops and all types of cargo to main operating bases or directly to forward bases in the deployment area. The aircraft is also able to perform tactical airlift and airdrop missions when required. The inherent flexibility and performance characteristics of the C-17 force improve the ability of the total airlift system to fulfill the worldwide air mobility requirements of the United States. The ultimate measure of airlift effectiveness is the ability to rapidly project and sustain an effective combat force close to a potential battle area. The size and weight of U.S. mechanized firepower and equipment have grown in response to improved capabilities of potential adversaries, significantly increasing air mobility requirements, particularly in the area of large or heavy outsize cargo. As a result, newer and more flexible airlift aircraft are needed to meet potential armed contingencies, peacekeeping or humanitarian missions worldwide. The C-17 was designed and built with this new scenario in mind. Features: The operational requirements impose demanding reliability and maintenance burdens on the C-17 system. These requirements include an aircraft mission completion success probability of 92%, only 20 aircraft maintenance person-hours per flying hour, and full and partial mission capable rates of 74.7% and 82.5% respectively. The Boeing warranty assures these figures will be met. The C-17 measures approximately 174 feet (53 meters) long with a wingspan of 169 feet, 10 inches (51.76 meters). The aircraft is powered by four fully reversible Pratt & Whitney F117-PW- 100 engines (the commercial version is used on the Boeing 757). Each engine is rated at 40,440 pounds of thrust. The thrust reversers direct the flow of air upward and forward to avoid ingestion of dust and debris. Maximum use has been made of off-the-shelf and commercial equipment, including Air Force-standardized avionics. The aircraft is operated by a crew of three (pilot, copilot and loadmaster), reducing crew requirements, risk exposure and long-term operating costs. Cargo is loaded onto the C-17 through a large aft door that accommodates military vehicles and palletized cargo. The C-17 can carry virtually all of the Army's air-transportable equipment. Maximum payload capacity of the C-17 is 170,900 pounds (77,519 kilograms), and its maximum gross takeoff weight is 585,000 pounds (265,352 kilograms). With a payload of 160,000 pounds (72,575 kilograms) and an initial cruise altitude of 28,000 feet (8,534 meters), the C-17 has an unrefueled range of approximately 2,400 nautical miles. Its cruise speed is approximately 450 knots (0.74 Mach). The C-17 is designed to airdrop both equipment and 102 paratroopers. It can also carry 48 litters and 54 ambulatory patients and attendants. The design of the aircraft lets it operate from small, austere airfields. The C-17 can take off and land on runways as short as 3,000 feet (914 meters) and as narrow as 90 feet (27.4 meters) wide. Even on such narrow runways, the C-17 can turn around using a three-point star turn and its backing capability.

42 AEROMEDICAL EVACUATION CHECKLIST Personal Information: Your Name: Patient s Name: Rank: SSN: Organization: Command: Diagnosis: Category: Requested Movement Date: Must have: Movement Priority: Destination (Potential): Hospital/Clinic Name: Physician: Local Phone Number: Special equipment needs, in addition to the AE equipment carried: Special medical personnel needs, in addition to the AE crew: Note: If the political climate is such that the information above cannot be given, inform the aeromedical evacuation coordinator at the patient movement requirements center that this is a SOF movement.

43 DATE: SPECIAL MISSION INFORMATION ONE PATIENT PER PAGE, PATIENT # 1. INDIVIDUAL ANNOTATING INFORMATION: 2. VALIDATING PHYSICIAN: 3. NATURE OF INJURY: 4. VITAL SIGNS: 5. REQUESTED AIRFIELD FOR PICK-UP: 6. REQUESTED AIRFIELD DESTINATION: 7. SPECIAL EQUIPMENT REQUIRED FOR MISSION: 8. SPECIAL MEDICAL PERSONNEL REQUIRED FOR MISSION: 9. MAJCOM POINT OF CONTACT TO BE NOTIFIED (Request to be made by the on-ground originating requester, prompt for a telephone number as necessary): 10. OTHER CONTACTS NEEDING TO BE MADE, IF ANY: 11. PMCC NOTIFIED: NOTE 1: GPMRC WILL TASK COMPONENT COMMAND AS NECESSARY FOR PATIENT MOVEMENT. GPMRC AND TACC WILL COORDINATE MOVEMENT OF PATIENT/S FOLLOWING NON-STANDARD PROCEDURES. AE AIRLIFT WILL BE COORDINATED WITH TACC. TELEPHONE NUMBERS: GPMRC TACC SCOTT AFB, IL DSN DSN /5434 TOLL FREE COM. (618) COM. (618) FAX DSN: /8892

44 NOTE 2: TPMRC-E/TPMRC-P WILL VALIDATE THE PATIENT REQUIREMENT AND COORDINATE WITH THE AIR MOBILITY OPERATIONS COMMAND AND CONTROL (AMOCC) OR WITH TACC FOR LIFT. TPMRC-E TPMRC-P DSN: /8040 DSN /4857 COM: (49) COM: