Critical Care A CCAT team is seen here setting up litter racks and patient care kits along with specialized medical support equipment to ensure patients have safe and comfortable flights out of Iraq. U.S. Air Force photo by Master Sgt. Lance Cheung.

Due to changes during the last decade in philosophy and operating procedures of the U.S. warfighter, military medical support also has significantly changed its operating procedures. One major change is that minimally or critically injured patients are no longer held for days or weeks in the theater of operation. Currently injured personnel are transported out of the theater within one to two days of injury and are typically in the United States within 72-96 hours. Due to “limited patient holding” capabilities in theater, there is a need to rapidly transport patients out of the theater usually within hours of injury while undergoing continuous stabilization. These patients require expedient transport to a higher echelon of medical care for more long-term stable recovery than is currently available in expeditionary medicine.

he United States Air Force (USAF) anesthesiologist currently has taken his/her capabilities of being a perioperative physician to new heights. An Air Force anesthesiologist’s “environment” can go from a typical operating room in a fixed location to providing anesthesia in a deployed location only protected by a tent/canopy. In addition, anesthesiologists are performing numerous other humanitarian and wartime deployable positions, one being an in-flight intensive care physician for transport of critically injured patients. The role of an anesthesiologist in wartime has expanded significantly in the past decade. The U.S. Air Force (USAF) has been a leader in the expanded role of the military anesthesiologist. I would like to describe the unique work environment in which a highly selective few military anesthesiologists are currently participating.

A Typical Patient
A 26-year-old otherwise healthy male is s/p multiple injuries secondary to improvised explosive device, or IED. Injuries include a right leg above-the-knee traumatic amputation, numerous shrapnel puncture wounds, right pneumothorax, second- and third-degree burns to right leg, right arm and right face (16 percent TBSA) and a right open-globe injury resulting in extrusion of the eye contents. The patient arrived to the forward surgical hospital via U.S. Army helicopter six hours ago.

This patient is initially stabilized at a forward surgical facility to include intubation, ventilatory support, bleeding control of the right leg with initial closure of the amputated stump, chest tube thoracostomy, wound care/dressings for the burns and protective covering of the open globe injury. The patient remains intubated, sedated, on inotropic support due to blood loss, pulmonary contusion and ongoing shock. He requires immediate transport for further life-sustaining treatment, including eyesight-saving surgery. You receive the patient just from the O.R., and he requires immediate transport to a higher level of medical care 3,500-plus miles from your current location.

Can this patient be safely transported for eight-plus hours on an aircraft to a higher level of care, or does this patient need to be further stabilized in place?

Historical Perspective
Prior to and during Desert Storm (1991) and subsequent military operations (Somalia, etc.), medical treatment options were to treat in-place until the patient improved enough to survive the aeromedical evacuation to a higher level of care or to take the in-theater assets (physicians, nurses, advanced intensive care unit [ICU] equipment) to accompany and manage the care of the patient during transport. These “medical attendants” may or may not be familiar with transporting patients in the typical aircraft environment (unfamiliar surroundings, noisy, turbulent, hot/cold, dry, little or no other support). USAF aeromedical evacuation (AE) historically consisted of specialized AE teams (flight nurses and AE technicians) who provide a “hospital ward-level” of patient care in the aircraft. No physician oversight was immediately available without obtaining a “phone patch” between the aircraft and the ground. These teams transport patients who do not require advanced medical care or procedures. Changes in patient status would result in the patient being denied aeromedical evacuation until more stable or, if during flight, landing at the nearest airfield and transferring care to the nearest medical facility.

Calm Amid the Storm A member of an aeromedical evacuation squadron provides comfort to a Gulf Coast evacuee aboard a C-130 Hercules from the 357th Airlift Squadron, Maxwell Air Force Base, Alabama. Photo by Maj. Jerry Lobb.

Due to changing world requirements for U.S. military operations requiring a more flexible and mobile force, transformation occurred in the 1990s from a fixed warfront to a rapidly changing, mobile warfront philosophy.

Until the mid-1990s, ICU-level patients were not transported until they improved, or they required a medical attendant to accompany them during flight. Medical operations also had to transform to support this new environment. The USAF transformed deployable assets to a “lighter, leaner force,” resulting in maintaining or expanding our capabilities while decreasing the size of the medical support as well as the “footprint” of equipment required. Due to the changes in patient holding and operating procedures mentioned above, some patients require ICU-level continuous medical care during the rapid evacuation. One result of this transformation was the development of an ICU-level transport team capable of rapid transport of critically injured personnel from the area of responsibility to a higher level of care; thus the Critical Care Air Transport Team, or CCATT (pronounced “See Cat”), was born. CCATTs have the ability to rapidly transport critically injured casualties out of the theater to a higher-level-of-care facility on any “aircraft of opportunity.”

CCATT Normal Operating Procedures
CCATT is a three-member team consisting of an intensivist (anesthesiologist, critical care physician, emergency room physician, surgeon, pulmonologist or cardiologist), a critical care registered nurse and a certified respiratory technologist (cardiopulmonary technician). This team has the capability of transporting ICU-level patients on any aircraft for extended periods (up to 72 hours) of time. The CCATT carries equipment for support of the patient to include ventilators, intravenous (I.V.) infusion pumps, physiologic monitors, suctions pumps, oxygen, I.V. fluids, extensive drug inventory, wound and dressing care and a defibrillator. In addition there is equipment for advanced ICU procedures (central venous access, chest-tube thoracostomy, intubation, cricothyrotomy, ICP monitoring, etc.) as well as the ability for blood transfusions and laboratory analysis (complete blood count, electrolytes and blood gases). Presently there are 249 CCATTs allocated in the Air Force manning structure. One hundred and ten active-duty team allocations are assigned to 11 different bases across seven major commands, with an additional 67 Air Force Reserve and 72 Air National Guard CCATT allocations.

This three-member team can provide care for three high-acuity patients (intubated, stabilizing, inotropic support, etc.), six lower-acuity patients or a combination of the above. A CCATT has the ability to take a patient from the ICU-level care in the process of being stabilized, place that patient onto an aircraft of opportunity converted to a mobile ICU, transport that patient multiple hours to a higher level of care, and provide ongoing medical care and procedures as needed during flight.

Currently CCATTs have carried more than 6,000 patients worldwide since October 2001 with no interflight deaths. Averages of 40-50 patients each month are transported by CCATTs, which has been consistently at 2 percent of the total AE patients flown. The ability for a CCATT to take critically ill patients and transport them on an aircraft converted to mobile ICU for multiple hours, while maintaining ICU-level care, has significantly impacted the outcome of the most critically ill patients carried. Because of three specific factors, CCATTs being one, the current conflicts (Operation Enduring Freedom and Operation Iraqi Freedom) have seen the lowest death-to-wounding ratios ever reported. Those factors are improved body armor, ability for rapid forward surgical stabilization and the ability to rapidly transport patients to a higher level of care.

Considerations for Transport
The previously mentioned patient can provide significant difficulties during transport. Considerations that have to be taken into account are ventilatory management, sedation, fluid management, blood transfusion, warming, altitude effects on pneumothorax as well as orbit contents, possible compartment syndrome and ongoing resuscitation. In addition the CCATT must take everything that it may need with it on the aircraft, including blood, I.V. fluids, on-board electrical capabilities and oxygen.

Needless to say, profound planning must occur for the transport of these patients; there is no capability to “resupply” while in the air. One final note to consider is that all the gear and supplies that CCATTs carry are carried on litters in gear bags.

Other Non-Wartime CCATT Utilization
Since their inception, CCATTs have participated in numerous operations: Operation Uphold Democracy, Operation Joint Endeavor and pullout of U.S. troops from Somalia, the Khobar Towar bombing, noncombatant evacuation of the U.S. Embassy in Liberia, the USS Cole incident and numerous peacetime and humanitarian missions, including:

• Korean Air crash in Guam

• Bosnia and Herzegovina

• Guantanamo detainee transport support

• Soyuz recovery support

• Presidential international travel support

• Hurricanes Katrina/Rita Evacuation

• High-profile patient transport.

Todd E. Carter, M.D., Lt. Col., Medical Corps, Senior Flight Surgeon, U.S. Air Force, is Anesthesia/Critical Care, Anesthesia Flight Commander, Malcolm Grow Medical Center, Andrews Air Force Base, and Chief Consultant to the U.S. Air Force Surgeon General for Anesthesia.