Report: MCM Bricknell, LM Kelly
Tactical Aeromedical Evacuation
This paper discusses the principles of tactical aeromedical evacuation (TACEVAC) planning and execution with specific consideration of the command and control arrangements for TACEVAC. UK personnel may be familiar with TACEVAC procedures using UK national aircraft and aeromedical evacuation crews between national medical facilities. Recent operations, most particularly in Afghanistan, have illustrated the requirement to understand TACEVAC within a multi-national context as both our military hospitals have moved patients using other nations aircraft and medical escort crews, and UK aeromedical aircraft and crews have moved other nations’ patients.
Forward Medical Evacuation from point of injury to the initial medical treatment facility is MEDEVAC, whereas medical evacuation between medical treatment facilities within a Joint Operational Area (JOA) is tactical aeromedical evacuation (TACEVAC).It is a separate entity to strategic evacuation (STRATEVAC) from the JOA to a home or allied nation.STRATEVAC is primarily a national responsibility.Not all NATO nations utilise these definitions.This paper discusses the planning and execution with specific consideration of the command and control arrangements for TACEVAC.UK personnel may be familiar with TACEVAC procedures using UK national aircraft and aeromedical evacuation crews between national medical facilities.Recent operations, most particularly in Afghanistan, have illustrated the requirement to understand TACEVAC within a multi-national context as UK military hospitals have evacuated patients using other nations aircraft and medical escort crews, and UK aeromedical aircraft and crews have moved other nations’ patients.
Medical Evacuation Definitions and Resources
The movement of patients by air has been an important component of military medical health systems for nearly 100 years.With the advent of passenger and cargo planes, patients have been regularly moved by fixed wing aeroplanes (FW) within theatres of operations and from theatres of operations back to the home base.TACEVAC was an essential method for moving patients long distances during World War 2. During the Falklands War in 1982 the UK used hospital ships to TACEVAC from the South Atlantic and established a STRATEVAC route from Montevideo.For Op GRANBY in 1991, the UK established a TACEVAC loop between deployed hospitals in the Gulf, and STRATEVAC back to UK via Cyprus .TACEVAC loops were established to move patients during Ex SAIF SERREA in Oman in 2001 , for the early stages of OP TELIC in 2003 and are essential for the International Security Assistance Force (ISAF) mission in Afghanistan .
Whilst TACEVAC may be conducted by road, rail or sea, in recent operations it is almost invariably done by either Rotary Wing (RW) or FW aircraft depending upon distance and speed of response required.TACEVAC is arguably the most complex phase of aeromedical evacuation (AE) requiring coordination at many levels.The mantra ‘right patient, right time, right platform, right escort, right destination’ describes the multiple components of the patient movement.Whilst MEDEVAC tends to have RW lead and STRATEVAC has FW lead, TACEVAC requires close integration between clinical advisors and proponents of both types of airframe.
Command, Control and Co-ordination (C3).
NATO doctrine directs that medical evacuation is controlled by a Patient Evacuation Co-ordination Centre (PECC) which may be subdivided into the MEDEVAC Operations cell and the Evacuation Co-ordination Cell, managed by the Evacuation Co-ordination Officer (ECO) providing C3 to TACEVAC.TRAC2ES (the US system) and other national systems for managing TACEVAC must be visible to the theatre chain of command, either by providing liaison officers or by providing national electronic information systems and login details to ECOs in HQ appointments.This ensures that bed management, patient regulation and transfer from airfield to Medical Treatment Facilities (MTFs) are properly co-ordinated.
TACEVAC planning should consider both RW and FW capabilities.RW tends to be more responsive because control is usually delegated to tactical commanders.It is usually of smaller capacity and shorter range.FW TACEVAC usually has higher volume and established mechanisms for patient escort but is more complex to organise because of the requirement to co-ordinate across service component boundaries and also across layers in the chain of command.Most current systems are based on re-allocating RW or FW aircraft from other transport tasks.An important aspect of medical planning is to determine whether this ‘in system select’ system is sufficient or whether it is more efficient to run a scheduled, dedicated aeromedical evacuation service that allows hospitals to hold patients confident in a planned TACEVAC programme.The current system also involves validation (clinical approval of the Patient Movement Request (PMR)) from a HQ separate from the sending MTF.This is satisfactory for a demand-led, low volume system but may need to change for a high-volume, scheduled system as the confirmation of the scheduled TACEVAC manifest should be done as late as possible.This might require delegation of PMR validation to the emplaning medical team.The final element of the TACEVAC plan is to consider the whole patient population and determine how emplaning rules should be adjusted for multi-national forces, indigenous security forces and local civilians.
The ECO function requires an understanding of all aspects of the ‘right patient, right time, right platform, right escort, right destination’ concept.The ECO should have sufficient clinical knowledge to understand the implications of clinical details entered into the PMR in the assessment of time, escort and destination for the patient.They also require sufficient operational understanding to match the airframe to the clinical requirement.This will normally require a Senior Non Commissioned Officer or officer with previous aeromedical evacuation training.
The correct selection of TACEVAC capability by the originating MTF is the key to successful TACEVAC.This requires a clearly designated Hospital Evacuation Co-ordination Officer who acts as the interface between the referring clinician, the hospital clinical director, the hospital commanding officer and the in-theatre, controlling military headquarters.The person(s) filling this function must understand all of the TACEVAC capabilities (including ground) available to support the clinical requirement.They may be supported by Subject Matter Experts (SMEs) for each specific type of Aeromedical Evacuation (AE) capability but practical experience has shown that SMEs do not replace the generic function unless they have been given this specific task.
No different to civilian practice, the TACEVAC requesting process is initiated by a formal referral from the attending clinician in the donor facility to a nominated clinician in the receiving one.Once the transfer has been agreed the sending MTF completes a PMR, a comprehensive summary of the medical condition of the patient, which allows confirmation of clinical details between hospitals and validation by the medical emplaning authority.The ECO’s role is the detailed co-ordination of all aspects of the patient’s movement including confirming agreement to the TACEVAC mission by all authorities, ground ambulance transport to and from the aircraft and collating PMRs into aircraft manifests.
For planning purposes, the speed at which casualties flow through the AE system is informed by ‘medical planning timelines’.Building on the foundation of existing doctrine, evidence from accumulated experience and that published in peer reviewed literature, the medical planning timelines for MEDEVAC have been changed to the 10-1-2 Guidelines.This advocates ten minutes to airway and bleeding control, one hour to be reached by MEDEVAC with skilled first aid and two hours to surgery.However, previous NATO ‘clinical timelines’ discuss reaching Damage Control Surgery (DCS) by two hours and Primary Surgery by four hours.The requirement for the casualty to reach primary surgery within four hours needs to be revalidated in order to set the minimum time requirement for TACEVAC.This is especially important for transfers from R2 to R3 for specialist care such as neurosurgery and ophthalmic surgery.It is suggested that TACEVAC timelines should be 2 (Urgent), 4 (Priority) and 24 (Routine) hours.These clinical timelines need to be balanced with operational constraints, especially when considering TACEVAC for specialist care such as neurosurgery or ophthalmology if the size of the population at risk does not justify deployment of specialist teams.
Whilst TACEVAC should be driven by clinical requirements, there may also be an operational requirement to move patients in order to clear beds in the sending MTF.This needs to be included in the PMR process in order for the MTF commander or controlling HQ Medical Director to request TACEVAC for a ‘bed clearing’ mission.
The medical escort must always match the clinical need of the patient to prevent deterioration en route.The confirmation of the patient’s suitability to fly and the assignment of a medical escort is termed ‘validation’.The medical escort requirement should be discussed during the ‘doctor to doctor’ referral discussion and entered on the PMR.The tasking authority for TACEVAC is responsible for validation and this should be done by an aeromedically trained clinician.The level of care can be adjusted from the highest level of a doctor-led intensive care team down to a flight medic for routine patients.The use of intensive care teams is not always possible on all types of aircraft because of the requirement for medical equipment to be tested for airworthiness on each specific aircraft.A number of local solutions have been developed.The US Army is deploying specially trained Intensive Care nurses to Afghanistan to provide additional personnel for the TACEVAC escort task.The exact methodology for their employment is currently being developed.The intra-regional movement of ambulatory ‘Routine’ patients should be carried out by regular ‘round robin’ RW routes with allocated medical escorts on board to collect these patients rather than utilize MEDEVAC aircraft.This will not denude capability for routine moves and allow for better planning as it will provide a regular outlet of patients for facilities.
TACEVAC ‘pull’/patient retrieval
• Collect from ‘downward’
• Maintains MEDEVAC laydown
• Takes in-flight team from receiving facility
• In-flight capability tailored to mission
• Receiving facility capacity reduced
• Handover from current care team
• No re-set for staff
Table 1. Comparison between TACEVAC ‘push’ and TACEVAC ‘pull’ /patient retrieval
There may be multiple types of TACEVAC aircraft available in an operational mission: in 2010 four types of RW and four types of FW were available for aeromedical evacuation from the UK hospital at Camp BASTION in Afghanistan.RW TACEVAC is usually controlled at the HQ level using helicopters assigned to the MEDEVAC mission.Often for urgent intra-regional moves, RW is the platform of choice as it can be quickly tasked and may be the only option if the MTF does not have an adjacent airstrip.This can result in the MEDEVAC ‘range ring’ being uncovered unless there is more than one assigned MEDEVAC taskline.This can be done as either a TACEVAC push or TACEVAC pull/patient retrieval mission (Table1).
Expanding on the C3 for TACEVAC, there are at least three FW TACEVAC options in ISAF, illustrating the complexity of FW TACEVAC tasking and the need for all Hospital Evacuation co-ordination Officers and ECOs to understand the whole system.
- The UK has a Tactical Aeromedical Evacuation Command Centre (Tac AECC) within the UK national Joint Force Support (Afghanistan) HQ.The Aeromedical Ops Officer (AEOO) requests UK RW or C130 assets within theatre and tasks UK aeromedical escort teams.The UK Aeromedical Evacuation Coordination Officer (AECO) validates all patient moves.This system provides delegated in-theatre authority for UK TACEVAC.It is quick and efficient and has been the method of choice for TACEVAC from the UK R3 at Camp Bastion as it can use either FW or RW.
- The main US Air Force (USAF) TACEVAC system requires the use of the CIS system called TRAC2ES and only has access to FW assets.The authority for TACEVAC to come from the Coalition Air Operations Centre (CAOC) within which is the Joint Patient Medical Regulation Cell (JPMRC – validation authority) and the Aeromedical Evacuation Control Team (AECT – aircraft and escort tasking authority).This method was designed to support STRATEVAC and has not been as quick as the UK system to authorize and validate Afghan patients for TACEVAC.
- The USAF have also deployed two HC130 aircraft in the personnel recovery mission that are available for TACEVAC.These should be requested by an ISAF PMR to the RC and are tasked by a ‘9 liner’.The precise mechanism for validation of the patient and medical escort is not defined.Finally there is a German C160 assigned to the TACEVAC mission that is requested via a PMR to IJC but controlled by German national authority in HQ RC(N).
Box 1 TACEVAC Options in Regional Command (South)
- Afghan National Security Forces (ANSF).As part of the Counter Insurgency (COIN) strategy, ANSF are seen as part of the coalition and are entitled to ISAF medical support within Medical Rules of Eligibility (MRE).After initial treatment they should be transferred to an Afghan National Army (ANA) regional hospital or to the ANA national hospital in Kabul.The Afghan National Air Force (ANAF) should have primary responsibility for moving ANSF casualties around theatre.Currently the in-flight care capability is very limited and the tasking mechanism does not allow for the urgent move of patients.There is scope to develop the ANSF to have a basic Aeromedical Staging Unit capability in order to give them the time to coordinate an ANAF TACEVAC move between ANSF hospitals.The movement of these casualties via TACEVAC is as complex as any other ISAF move.There are two key issues:
- Bed Regulation by ANSF.This is currently a problem in that, whilst ANSF facilities are not controlled by ISAF, the movement of ANSF from one facility to another is vital in ensuring that ANSF facilities have bed capacity available to take ANSF casualties.The ANA Kandahar Regional Military Hospital (KRMH) is the ANSF receiving hospital in the South of Afghanistan.It is regularly over 75% occupied for ICU.It is essential that ANSF casualties can be easily cleared from the South in order to maintain hospital capacity.The ANSF should be partnered and mentored to regulate their own casualties.ISAF needs also to be able to offer ISAF TACEVAC assistance ‘in-extremis’ to enable bed clearance from ANSF MTFs.
- Acceptance from Regional to National Hospitals.There are a number of patients who require long-term care who should be moved from ISAF MTFs direct to the National Military Hospital (NMH) in Kabul to avoid a transitory stay in KRMH.The acceptance of these patients is often difficult, for a number of reasons such as delays with ANSF ambulance movement in Kabul or that the NATO R3 in Kabul airport is unable to be the fall back plan should NMH be unable to take the patient once they have arrived in Kabul.NATO should engage at every level to support the ANSF to move their long-term patients to the NMH.
- Local National Civilians (LN).LN that fall within the MRE are accepted into ISAF MTFs.Similar to ANSF there are limited options for these patients to be moved on after their initial treatment.Every MTF should have an outlet into the LN healthcare system for various types of patients based on transfer to the Afghan hospital closest to the patient’s home consistent with the patient’s clinical need.NATO needs to have a robust reference system to track Afghan civilian capabilities in order to facilitate TACEVAC and acceptance of Afghan patients who have clinical needs that cannot be met at a local level.
- Detainees.This population have the longest Length of Stay within an ISAF MTFs.NATO doctrine makes it clear that detainees are the responsibility of the capturing Nation, however they may require specialist care at another MTF which may not be the capturing Nations’ facility.There is a clear need for theatre level policy on the management of detainees with on-going clinical requirements after emergency medical care.
Box 2.Three Non-ISAF populations and the problems inherent in their treatment
The theatre hospital laydown must ensure that R3 MTFs with specialist care are matched to the clinical demand and medical planning timelines in order to ensure patients can be moved by TACEVAC in time to meet their clinical need.The movement of casualties to the right MTF depends not only on the injuries sustained but also the type of casualty.Whilst the Medical Rules of Eligibility (MRE) apply for the entry of all casualties in the ISAF area of operations, doctrinally only NATO troops are discussed in the AE chain.In the ISAF operation the goal is for an ‘Afghan to treat an Afghan’ but unfortunately the limitations of Afghan medical capabilities may require the entry of Afghans into the ISAF medical system.The three non-ISAF populations present a variety of challenges (Box 2).
Governance Issues and Lessons Learned
NATO and troop-contributing nations have established governance arrangements for MEDEVAC including monitoring of MEDEVAC mission times.This needs to be replicated for TACEVAC with greater emphasis on clinical outcomes rather than time.Adverse outcomes from TACEVAC missions should be highlighted by a medical incident report and reviewed under the authority of the Regional Command Medical Director.This should be included within the wider healthcare governance processes.
This summarises the key elements of a deployed military TACEVAC system structured around the mantra for ‘intelligent tasking’ of ‘right patient, right time, right platform, right escort, right destination’.
Published in J R Army Med Corps 157(4 Suppl 2): S449-452
Corresponding Author: Colonel Martin CM Bricknell L/RAMC, HQ Land Forces, Army Medical Directorate, Ramillies Building, Marlborough Lines, Andover, Hampshire SP11 8 HJ
Source: Medical Corps International Forum 2/2013