# Medevac



## soldier16 (24 Apr 2016)

Hello, I apologize if this question has already been answered. Do's Canada have air medical evacuation crews? and if so which occupation handles this ( medtech , SAR ext)

Thank you for your time.cheers


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## medicineman (24 Apr 2016)

Yes...the crews are usually med techs and NO's.

MM


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## Loachman (24 Apr 2016)

"Medevac" (MEDical EVACuation), vice "Medivac" as you originally had it in your title.

Not really, in the same way that the US Army and Air Force have.

Tac Hel does Vietnam War-style casevac, but there is a list of approved medical equipment held by the medical people for use when required. They would have to provide the Med Tech, as well.

I cannot speak for the SAR community's capabilities, but theirs is greater than ours as it is a greater part of their role.

Further, there are Forward Aeromedical Evacuation Specialists that accompany injured pers on seized-wing aircraft, but no dedicated aircraft.


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## mariomike (24 Apr 2016)

soldier16 said:
			
		

> Do's Canada have air medical evacuation crews? and if so which occupation handles this ( medtech , SAR ext)



Nursing Officers may be offered the opportunity to develop specialized skills through formal courses and on-the-job training, including:
•Aeromedical Evacuation Nursing
http://www.forces.ca/en/job/nursingofficer-53?olvPlayer=183s&module=cue_53_3#st

The "Nursing Officer" Merged Thread  
http://army.ca/forums/threads/4249.220;wap2
"Once you are OFP and generally completed one posting cycle as a NO you can apply for a position at the Air Evacuation Flight in Trenton. Once you are identified as someone with interest / suitable you will attempt to complete the air medical, aeromedical training program in Winnipeg and then the seven (?) week Aeromedical Evacuation  (AME) Course.  Once you have your AME wings you are then eligible for posting to the flight and if there is a position then you can be posted into it.  You can be posted to the Flight as a General Duty Nursing Officer (GDNO) in fact most of the positions are GDNO positions."

As they progress in their career, Medical Technicians who demonstrate the required ability and potential will be offered advanced training. Available courses include:
•Aero-Medical Evacuation
http://www.forces.ca/en/job/medicaltechnician-70#at

See also,

Aeromedical Evacuation ( AME )
https://www.google.ca/search?q=site%3Aarmy.ca+caf+recruiter&sourceid=ie7&rls=com.microsoft:en-CA:IE-Address&ie=&oe=&rlz=1I7GGHP_en-GBCA592&gfe_rd=cr&ei=fkMdV5CaCMmC8Qfrr4GYDg&gws_rd=ssl#q=site:army.ca+Aeromedical+Evacuation+


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## soldier16 (24 Apr 2016)

Thank you all for your quick and helpful replies


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## mariomike (24 Apr 2016)

That's quite a change from bomb disposal.  



			
				soldier16 said:
			
		

> hello I have a question about about EOD or bomb disposal guys are they combat engineers or ammunition techs?
> 
> 
> 
> ...


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## MedCorps (24 Apr 2016)

This is a subject of great discussion right now at the higher levels of the CAF, within the hallways of the CF H Svcs Gp HQ, RCAF, CA, CJOC and CFD.   

Lets cover some basics: 

CASEVAC - Casualty evacuation - the ﻿non-medicalised evacuation of patients without qualified medical escort. Must be distinguished from Medical Evacuation. (From NATO Allied Joint Publication 4.10B - Allied Joint Doctrine for Medical Support).  In the most basic form this could be dumping Pte Bloggins on the floor of a Griffon and flying fast to medical care. 

MEDEVAC - Medical evacuation - the medicalised evacuation of patients with qualified medical escort.  

There is a developing body of scientific literature (including some really recently US published stuff) which indicate that MEDEVAC vs. CASEVAC increases wounded soldier survival significantly. This data is coming out of Iraq and Afghanistan, mostly from the US (USAISR). As such it is a topic of great interest to the people who spend their time trying to figure out how to keep more wounded soldiers alive during the next war and debated with some zeal.   

So, where are we at... the CAF has the ability to put a medical technician with or without a nursing officer on a helicopter (Griffon or Chinook). There is a course called "Forward Medical Evacuation Specialist" which teaches how to care for a casualty while in flight on a helicopter. There is a small list of approved "air worthy" medical equipment which can be placed on a helicopter for casualty care. Finally we have had instances where helicopters have been assigned to the role of moving casualties from point of injury to a medical treatment facility. 

Based on the minutes, one of the questions that the Health Services Future Field Force Working Group is tackling is the question is the above package (a medic +/- nursing officer with some training and with some medical kit) CASEVAC or MEDEVAC?  Despite the NATO definitions provided above they are arguing that the CAF can do advanced CASEVAC but current capabilities do not cross the threshold of MEDEVAC.  

Here is the rub. The personnel are _ad hoc_ assigned to the flight crew (as specialists) and may or may not have had collective training with the crew they are flying with. Heck, they might have not even met them before the mission. The aircraft is not always optimally configured for MEDEVAC (often because it is executing other duties). The equipment is not dedicated to the aircraft or medical equipment scaled correctly for MEDEVAC. In some versions it is a medical team being picked up with all their kit and flown out to a casualty and in other versions the crew and medical team link up sometime before flying missions and come up with tactics, techniques and procedures. 

It has been suggested if the CAF is going to break the MEDEVAC threshold that we need to:

1) Assigned dedicated medical teams (Cpl and MCpl QL5A Med Tech) (likely OPCON) to tactical helicopter squadrons. 
2) Continue with the Forward Medical Evacuation course after re-validation.
3) Ensure that the medical team has a maintenance of clinical readiness package for thier duties as MEDEVAC medics.  
4) Ensure the current RCAF aircraft crew gets some training in the duties and nuances of casualty pick up  / flying / drop off
5) Ensure collective training standards exist with an operational readiness verification occurs with the medical team and the helicopter crew. This would require YFR being assigned to task. 
6) Have a proper scale of issue (complete with air worthiness checks) for MEDEVAC equipment assigned to a helicopter. In the more advanced MEDEVAC versions this would see some permanent fittings in the aircraft to enable casualty care. 
7) Have the RCAF / CF H Svcs Gp place this into doctrine. There is mention of it in Tactical Aviation 2017 (role for Chinook not Griffon) but this has not be bought into by D Air Readiness or Air Strat Plans as a capability to be developed. 

The RCAF has some concerns I am told about the concept of MEDEVAC including, YFR allocation, armament and red cross marking concerns.  I am not even sure these are real issues or have been discussed any depth. I also think the RCAF is concerned about loosing tasking flexibility in some of their aircraft if dedicated to the MEDEVAC role, which is a fair argument. 

There is also the fear of the other emerging helicopter medicine topics, like "critical on route care" transport helicopters (as part of the damage control resuscitation to damage control surgery continuum) and the vogue and sexy on route damage control resuscitation (Google UK MERT).  

So there you have it... the doctrine argument du jour. I know more then you asked for...  

MC


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## RocketRichard (24 Apr 2016)

MedCorps said:
			
		

> This is a subject of great discussion right now at the higher levels of the CAF, within the hallways of the CF H Svcs Gp HQ, RCAF, CA, CJOC and CFD.
> 
> Lets cover some basics:
> 
> ...


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## RocketRichard (24 Apr 2016)

Thank for this. I was wondering what the latest is in the world of CF Medevac. 


Sent from my iPhone using Tapatalk


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## SeaKingTacco (25 Apr 2016)

You forgot Sea Kings. We do medevacs all of the time from ships.

I doubt the RCAF is going to inject med pers full time into helo Sqns, on the off chance we do a medevac (btw, we get our med tech from the ship. He or she escorts the patient). 

We do not have enough YFR or pers to accomplish all of our primary mission sets, let alone add another mission.


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## Armymedic (25 Apr 2016)

We do strategic MEDEVAC, and tactical CASEVAC. Everything else is done the CAF way, ad hoc.

(The Sea King evac described above is actually CASEVAC, as well)

Edit to add: MC seems to be in basement-dwelling, doctrine-writing hell. That COS date can't come quick enough.


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## Loachman (25 Apr 2016)

MedCorps said:
			
		

> There is a developing body of scientific literature (including some really recently US published stuff) which indicate that MEDEVAC vs. CASEVAC increases wounded soldier survival significantly.



I should think that this is fairly obvious, and has been obvious for some time.

Enroute treatment by well-equipped and well-trained medical personnel is going to be far superior to mere transport. Casevac patients are supposed to be stable before transport as well, which adds a time penalty.



			
				MedCorps said:
			
		

> So, where are we at... the CAF has the ability to put a medical technician with or without a nursing officer on a helicopter (Griffon or Chinook). There is a course called "Forward Medical Evacuation Specialist" which teaches how to care for a casualty while in flight on a helicopter. There is a small list of approved "air worthy" medical equipment which can be placed on a helicopter for casualty care. Finally we have had instances where helicopters have been assigned to the role of moving casualties from point of injury to a medical treatment facility.



I am not sure what a nurse would add in this role. I don't know of anybody else that puts nurses on helicopters. Do nurses ever crew wheeled ambulances?

I have actually done the medevac role a small number of times. Our machine was reserved for that purpose, kitted (although not with much), a suitably-qualified Med Tech assigned (and training conducted with us), and all pre-flight checks conducted by the oncoming crew.

The first time that I ever saw this done was in Wainwright during RV85. One of the twenty-four Twin Hueys in the doctrinal Div UTTH Squadron was parked, fully-kitted, throughout at the Div Field Hospital, with the crew languishing somewhere nearby, and ready to go.



			
				MedCorps said:
			
		

> Here is the rub. The personnel are _ad hoc_ assigned to the flight crew (as specialists) and may or may not have had collective training with the crew they are flying with.



I would be at least mildly surprised if that were the case for a major exercise, let alone an actual op. I am very clear with people who request medevac missions. I tell them what we can do (generally casevac only as few requestors have access to the medical pers or equipment) and what we cannot do. The only true medevac missions in which I have been involved have had machine/crew/Med Tech/equipment set up as I have previously said.



			
				MedCorps said:
			
		

> Heck, they might have not even met them before the mission.



That's the vast majority of the people that we fly.



			
				MedCorps said:
			
		

> The aircraft is not always optimally configured for MEDEVAC (often because it is executing other duties). The equipment is not dedicated to the aircraft or medical equipment scaled correctly for MEDEVAC. In some versions it is a medical team being picked up with all their kit and flown out to a casualty and in other versions the crew and medical team link up sometime before flying missions and come up with tactics, techniques and procedures.



That should never happen with a medevac mission, if that is what has been requested, accepted, and tasked. That should only happen with Casevac. Medevac reduces the number of hels and crews available to support an ex around the clock - mainly crews as a minimum of two are required. Casevac is generally only provided while scheduled flying operations are ongoing, and would be done by a crew and machine diverted from a lower-pri task. This is a command decision - does the guy in charge want his assigned hels delivering troops to/from battle, or two sidelined for the duration?

TTPs are not complex - flying to the PZ and hospital is not any different from flying between any other locations. The only variable is the medical guy and the machines that go "ping". He/she has to become familiar with the aircraft, its communication system, how to move about the cabin in a manner other than rolling and the wisdom of knowing where his/her barf bag supply is (because it WILL be manoeuvring appropriately according to the tactical situation for ex/op purposes but stable for noduff ex purposes), and how to get the patient on and off.



			
				MedCorps said:
			
		

> 1) Assigned dedicated medical teams (Cpl and MCpl QL5A Med Tech) (likely OPCON) to tactical helicopter squadrons.



Permanently, or only for the ex/op, as is (should be and can be, at least, and has been) done now?



			
				MedCorps said:
			
		

> 4) Ensure the current RCAF aircraft crew gets some training in the duties and nuances of casualty pick up  / flying / drop off



I have no idea what those are.



			
				MedCorps said:
			
		

> 5) Ensure collective training standards exist with an operational readiness verification occurs with the medical team and the helicopter crew. This would require YFR being assigned to task.



This is not complex, and does not require a lot of flying time. No YFR needs to be specifically assigned. We do not care about that as some fleets do. We are not limited by YFR. 1 CAD still does not understand that we do not differentiate between FG and FE hours. Our crews get  most of their FG time while conducting FE, and are happier doing so. Scheduling can be a challenge, as can crew and hel availability, as we are generally fairly busy. This is why we massage FAES Crse locations and dates with 426 Squadron, who run them. They now run crses in Edmonton, Petawawa, and Valcartier rather than purely in Trenton and that makes it much easier for us to support. We understand the value of these courses and do our best to provide.



			
				MedCorps said:
			
		

> 6) Have a proper scale of issue (complete with air worthiness checks) for MEDEVAC equipment assigned to a helicopter. In the more advanced MEDEVAC versions this would see some permanent fittings in the aircraft to enable casualty care.



I cannot comment on the suitability of the equipment that is in the inventory and available, as that is obviously not our role. The airworthiness aspect is not a significant problem (although sometimes annoying and rant-inducing), and should be fairly quick once a new piece of equipment is identified - as long as it is not done at the last minute. Nothing is "permanently fitted" in a helicopter, nor should it be. You want to be able to move it if the helicopter breaks, and we will never have enough helicopters.



			
				MedCorps said:
			
		

> 7) Have the RCAF / CF H Svcs Gp place this into doctrine. There is mention of it in Tactical Aviation 2017 (role for Chinook not Griffon) but this has not be bought into by D Air Readiness or Air Strat Plans as a capability to be developed.



I am not sure what is needed in that regard, at least from our side. It's just one of many traditional Tac Hel tasks.

I also do not see any need to paint bright red and white aiming points on any of our machines while trying to pretend that there is any protective value to them. Nobody that we are ever likely to fight is going to respect them. Their only value might be to draw fire to unimportant parts of the machine, like the cabin doors, rather than engines, fuel tanks, front-seaters etcetera. Unfortunately for the Med Techs and patients, though, they are on the other side of those markings. The USAF medevac guys do not suffer any such illusions about red crosses, but they are CSAR anyway. Both HH60s operating together are armed with one GAU-21 M3 Browning .50 caliber machinegun per side and self-escort. The PJs who treat casualties are armed with M4 carbines and know how to use them very well. I have an enormous amount of respect for those guys - Pilots, PJs, and the whole organization. They were very effective and very efficient and very dedicated. The US Army UH60s are marked and unarmed, so each one operates with an AH64 as escort. I view that as inefficient and inflexible, as only half of the pair can carry and treat patients. The two US Army units with which I dealt in KAF did not come close to the standard of the USAF guys, at least in non-medical terms. They seemed disorganized and disconnected. I'd much prefer to be armed and unmarked, although the Griffon lacks space and power for real weapons plus Med Tech, equipment, and patient, and Chinook is unsuitable because of its size.

Should/could we take this role on? Yes, sure, add it to the list, but not as a highly-specialized role as it will take resources away from something else and we are hard-pressed to meet demand as it is. The Griffon is fine for this role in a training-only environment, but not in an operational one where a threat is present. There is no additional training bill for the aircrew, a very limited one for the Med Techs, and probably a cost for the fancy medical kit - and a much bigger cost for a suitable helicopter.


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## Good2Golf (25 Apr 2016)

Rider Pride said:
			
		

> We do strategic MEDEVAC, and tactical CASEVAC. Everything else is done the CAF way, ad hoc.
> 
> (The Sea King evac described above is actually CASEVAC, as well)
> 
> Edit to add: MC seems to be in basement-dwelling, doctrine-writing hell. That COS date can't come quick enough.



 :nod:

CAF Forward Aeromedevac (AME) doctrine is still churning (at least for the last eight years I know of, as I was a staff officer supporting the RCAF Command Flight Surgeon re-write Fwd AME doctrine).

Rider Pride notes the Strat Medevac the CAF conducts.  This is usually accomplished with the CC-144 Challenger (all on-board MED and PMED devices used by the aeromedically-trained med staff have been technically and operationally cleared for use on board the aircraft type [TAC and OAC for those familiar with the airworthiness terminology]).  Unless there are appropriately trained (aeromedically trained) med personnel on board with suitable (approved) medical equipment required to provide the level of medical support, it won't be considered AME (Forward or otherwise).

Loachman, the certification that MedCorps refers to in his point 6 is not "not a significant problem" as you imply...the fact that the clearance issues continue to be worked for a period approaching a decade indicated that some of the challenges can be, and indeed are...significant.  Technical airworthiness often is not 'purely technical' and then when added to the operational/tactical doctrinal machinations make the whole effort rather energy-draining.  Would one consider that equipment specifically made for aeromedical purposes should be relatively easy to certify on any number of different aircraft?  Well, I would have thought so when I started working the FwdAME file daily, but 'pragmatic realism' kicked in pretty soon, and I quickly appreciated that Aero-Medical Evacuation was likely going to be more difficult than getting any combination of the three services interoperating even remotely capably.

Like Rider Pride says, poor MedCorps needs a posting COS soon!  

Cheers
G2G


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## Blackadder1916 (25 Apr 2016)

soldier16 said:
			
		

> . . .  Do's Canada have air medical evacuation crews? and if so which occupation handles this ( medtech , SAR ext)



This may be of some interest to you. 

http://www.forces.gc.ca/en/training-establishments/international-training-programs-courses/aeromedical-evacuation-course.page


> Aeromedical Evacuation Course
> 
> Aim
> 
> ...



At 56 training days, the course is considerably longer than when I did it a long, long time ago - IIRC it was 21 training days which included the flying training missions.

Along with a change in AE training, the organization of AE medical assets has also apparently changed from the days when I occasionally flew as medical crew.  Back then it was a secondary duty at locations (primarily the AIRCOM bases) scattered across the country.  This is from the October 17, 2008 issue of "The Contact", the base newspaper of CFB Trenton.

http://thecontactnewspaper.cfbtrenton.com/archives/2008/03_October_2008/oct_17_2008/thecontact_oct_17_2008.pdf


> Aeromedical Evacuation Crew
> 
> Personnel from 8 Wing/CFB Trenton’s newest unit, The Canadian Forces Aeromedical
> Evacuation Flight (CF AE Flt) gave flight line tours of the four aircraft they normally use
> ...



Perhaps someone more in the know may be able to provide an up to date perspective on the flight's current organization and activity.

And this from 2012 is about the flight receiving the CF Unit Commendation.
http://www.trentonian.ca/2012/09/26/rcaf-commander-recognizes-cfb-trenton-personnel


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## Good2Golf (25 Apr 2016)

Good2Golf said:
			
		

> ...CAF Forward Aeromedevac (AME) doctrine is still churning (at least for the last eight years I know of, as I was a staff officer supporting the RCAF Command Flight Surgeon re-write Fwd AME doctrine).



I stand corrected - there has been progress.  

AME is now known as AE.


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## Loachman (25 Apr 2016)

Good2Golf said:
			
		

> Loachman, the certification that MedCorps refers to in his point 6 is not "not a significant problem" as you imply...the fact that the clearance issues continue to be worked for a period approaching a decade indicated that some of the challenges can be, and indeed are...significant.  Technical airworthiness often is not 'purely technical' and then when added to the operational/tactical doctrinal machinations make the whole effort rather energy-draining.  Would one consider that equipment specifically made for aeromedical purposes should be relatively easy to certify on any number of different aircraft?  Well, I would have thought so when I started working the FwdAME file daily, but 'pragmatic realism' kicked in pretty soon, and I quickly appreciated that Aero-Medical Evacuation was likely going to be more difficult than getting any combination of the three services interoperating even remotely capably.



Maybe I've been lulled into a false sense of optimism (that NEVER happens) lately after having had a couple of good experiences regarding airworthiness matters. One would think that operational lifesaving measures might just move through the process a little faster.



			
				Good2Golf said:
			
		

> AME is now known as AE.



They've been calling them "FAES" (Forward Aeromedical Evacuation Specialist) Courses on their requests to us for the last few years, and they seem to run more that two annually. It's been awhile since we've received any, though, so maybe it averages out that way.


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## Good2Golf (25 Apr 2016)

> Maybe I've been lulled into a false sense of optimism...



???

Who are you, and what have you done to the real Loachman?


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## Loachman (25 Apr 2016)

It's alright. It passed quickly, but it had me worried, too, for a little while.

What an odd feeling. Almost scary.


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## MedCorps (25 Apr 2016)

Loachman said:
			
		

> I should think that this is fairly obvious, and has been obvious for some time.
> 
> Enroute treatment by well-equipped and well-trained medical personnel is going to be far superior to mere transport. Casevac patients are supposed to be stable before transport as well, which adds a time penalty.



I think obvious is not always obvious, especially in pre-hospital medicine.  For instance when we look at advanced Paramedics (EMT-P or ACP) there are some issues that have been discovered.  Intubation (the process of securing an airway by placing a tube into the trachea via the mouth), starting an IV and giving a liter or two of solution and placing people on spine board have been the gold standard of pre-hospital trauma care years. Heck, secure airway, give fluids to restore blood pressure and immobilize in case they have a spinal injury... what could go wrong. It turns out lots! When examined in large studies it turns out that they all contribute to higher overall levels of mortality in pre-hospital urban civilian setting and, broad brush, many services are moving away or minimizing these procedures for routine trauma care. 

Second to this, obvious is not obvious to everyone. It is hard to convince anyone at ADM(RS) (the new and improved CRS) or CFD, CProg or the bean counters that it is obvious especially when trying to justify a new expensive, PY requiring capability. Anecdotes do not create quantitative data sets. 

I would also argue in most pre-hospital systems (and many military situations) that having a stable casualty for CASEVAC from point of injury would be the exception to the rule. My experience has been that most of these unfortunate souls are in crap shape and actively dying. 



			
				Loachman said:
			
		

> I am not sure what a nurse would add in this role. I don't know of anybody else that puts nurses on helicopters. Do nurses ever crew wheeled ambulances?



STARs in Alberta has a medic / nurse helicopter crew. As does Orange in Ontario does when doing pediatric transport. It is also pretty common in the US and some of Europe. 

I think that the current CAF thought is that Forward AE should be QL5A Med Tech driven, Critical Care Fwd AE (en route care) should be Critical Care Nursing Officer driven (if that becomes a capability) and if we go all the way, damage control resuscitation Fwd AE (MERT) should be GDMO-Emergency Medicine or MED-SPEC-Anesthesia driven.    



			
				Loachman said:
			
		

> TTPs are not complex - flying to the PZ and hospital is not any different from flying between any other locations. The only variable is the medical guy and the machines that go "ping". He/she has to become familiar with the aircraft, its communication system, how to move about the cabin in a manner other than rolling and the wisdom of knowing where his/her barf bag supply is (because it WILL be manoeuvring appropriately according to the tactical situation for ex/op purposes but stable for noduff ex purposes), and how to get the patient on and off.



Ah, you missed the most important part of the MEDEVAC mission variable... the casualty!  Again in reading the training that pilots from Orange get they might argue with you, especially if flying MEDEVAC versus CASEVAC. As dedidated "air ambulance" pilots they get instruction on planning flights for casualties with increased intraocular pressure, pneumothorax, decompression illness, violent tendencies, and intracranial bleeding for example. This involves a package on flight physiology, common patho-physiology which is exacerbated by flight, and ways to mitigate exacerbating these conditions by altering ones flying techniques and procedures. The medic / nurse and the pilot need to come up with an optimal flight profile for the casualty (who is the mission). How do you fly a 22 year old infantryman with a rib fracture and a small traumatic pneumothorax? The 65-year-old with a mild chronic obstructive pulmonary disease exacerbation and an oxygen saturation of 93% on room air? The 8-year-old with otitis media? Do you make a quick unplanned landing in flight to allow the Medics to decompress a chest with a chest tube, electrically shock a patient in V. Tach, or sort out a REBOA which as shifted or do you "push through to the MTF which is X minutes away?" These are not always simple answers.   

Something to think about... interesting comments. 

MC


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## MedCorps (25 Apr 2016)

Good2Golf said:
			
		

> Loachman, the certification that MedCorps refers to in his point 6 is not "not a significant problem" as you imply...the fact that the clearance issues continue to be worked for a period approaching a decade indicated that some of the challenges can be, and indeed are...significant.  Technical airworthiness often is not 'purely technical' and then when added to the operational/tactical doctrinal machinations make the whole effort rather energy-draining.  Would one consider that equipment specifically made for aeromedical purposes should be relatively easy to certify on any number of different aircraft?  Well, I would have thought so when I started working the FwdAME file daily, but 'pragmatic realism' kicked in pretty soon, and I quickly appreciated that Aero-Medical Evacuation was likely going to be more difficult than getting any combination of the three services interoperating even remotely capably.



I am told by the medical regulation folks that it gets even more complex when the medical device was licensed by Health Canada for hospital use or ground EMS use and now you want to use it on a helicopter or fixed wing aircraft.  It becomes expensive to get these things through the Health Canada and RCAF air worthiness testing hoops.  

There are also some things that make the RCAF airworthiness folks understandably nervous, like defibrillation and transcutaneous pacing (the application of electricity), anything to do with oxygen, battery diathermy and ultrasound emissions (such as FAST) on an aircraft. 

MC


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## mariomike (26 Apr 2016)

MedCorps said:
			
		

> As does Orange in Ontario does when doing pediatric transport.
> 
> Again in reading the training that pilots from Orange get they might argue with you,



Spelled  o  r  n  g  e.   ( See attachment. )



			
				Loachman said:
			
		

> I don't know of anybody else that puts nurses on helicopters.



Q: I am a Registered Nurse and wish to pursue a career as an air ambulance flight nurse. What do I need to qualify?

A: As per the Ontario Ambulance Act and current regulations, air ambulance operators do not employ, nor are able to employ, flight nurses. All air ambulance medical flight personnel are flight paramedics that hold Advanced Emergency Medical Care Attendant (AEMCA) certification and are aero-medically certified at the pre-hospital level. While several nurses have their AEMCA and aeromedical theory qualifications, they are not utilized nor recognized as nurses but rather as flight paramedics.

In addition, Ontario legislation does not allow for nurses to be substituted for flight paramedics on air ambulance flights. If a sending facility provides a nurse escort for outgoing patient treatment, they might use a flight nurse procurement company on a per-need basis. However all air ambulance flights must have a flight paramedic in attendance with the patient at all times, even if there is a registered nurse escort accompanying the patient. The flight paramedic is trained in emergency procedures and been trained on the specific aircraft's emergency procedures.
http://www.health.gov.on.ca/english/public/program/ehs/edu/equiv_qa.html#7



			
				Loachman said:
			
		

> Do nurses ever crew wheeled ambulances?



Q: I am a Registered Nurse and wish to pursue a career as a paramedic. What do I need to qualify?

A: You would be required to attain certification as an Advanced Emergency Medical Care Assistant (AEMCA). Certification follows the successful completion of an Ontario paramedic program or by completing the Paramedic Equivalency process.

Registered Nurses in Ontario with at least 450 hours of land ambulance pre-hospital patient care experience are considered equivalent for the equivalency process. Registered Nurses with extensive experience in critical care areas (emergency, ICU) may receive up to 330 hours of credit towards the 450 hours of land ambulance pre-hospital experience. For more information please visit the Paramedic Equivalency section or contact the equivalency liaison.
http://www.health.gov.on.ca/english/public/program/ehs/edu/equiv_qa.html#6


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## RubberTree (26 Apr 2016)

Blackadder1916 said:
			
		

> Perhaps someone more in the know may be able to provide an up to date perspective on the flight's current organization and activity.



The CF AE Flt is a lodger unit in Trenton belonging really to 1CAD in Winnipeg. Its complement is just a handful of nurses and techs as well as a PA as Sergeant Major and an HCA. They fly missions on a semi-regular basis (vague, I know) around Canada and the world transporting patients who have been injured/become sick on exercise, leave, training etc. They are supplemented by a physician on all of their flights and also have critical care teams on standby on a rotating schedule to augment the basic crew if required. They have a full kit of medical equipment, both basic as well as critical care which has been through the airworthiness process and has been approved for flight on the aircraft they fly on.


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## Hunter (1 Jun 2016)

mariomike said:
			
		

> Spelled  o  r  n  g  e.   ( See attachment. )



Thank you! Reading that repeatedly was starting to make me itchy.



			
				MedCorps said:
			
		

> Ah, you missed the most important part of the MEDEVAC mission variable... the casualty!  Again in reading the training that pilots from Orange get they might argue with you, especially if flying MEDEVAC versus CASEVAC. As dedidated "air ambulance" pilots they get instruction on planning flights for casualties with increased intraocular pressure, pneumothorax, decompression illness, violent tendencies, and intracranial bleeding for example. This involves a package on flight physiology, common patho-physiology which is exacerbated by flight, and ways to mitigate exacerbating these conditions by altering ones flying techniques and procedures.



Any chance you could provide a reference for where you read about this training package? 

Pilot involvement in patient care is limited to a few areas. Their job is to determine if we can safely make the trip (weather considerations primarily but also duty day limits), and are there any limitations to how long they can stay on the ground before we have to leave the sending facility. Reasons for this are varied, but related primarily to weather and time limitations. 



			
				MedCorps said:
			
		

> The medic / nurse and the pilot need to come up with an optimal flight profile for the casualty (who is the mission).



They need to know the weight of the patient and family escort as well as any special equipment we might need to bring for the call which would not routinely be on the aircraft. Examples which come to mind first are the incubator or the intraaortic balloon pump.  They are also responsible for assisting with loading, offloading patients.

There are occasions where we may request certain altitude restrictions or other flying considerations such as a flight path to minimize turbulence. We do not discuss patient care details or the what and why of the request. We make the request, and if they can do it safely they always accommodate our request. 

One example could be a college boy goes home to northern Ontario and his hipster attitude combined with talking when he should have been listening results in an attitude adjustment which leaves the left side of his face head and chest caved in. Positive halo sign from left ear and nare suggest cranial vault insult. Very large flail segment suggest potential to develop pneumothorax. Two hour flight time to receiving facility. We request field level cabin. This is achievable with an actual altitude anywhere up to 15,000 (ballpark, I'm not a zoomie). Pilatus PC12 is a great aircraft and can glide a long way with a dead engine, but flying field cabin altitudes over Lake Superior is a big risk. Pilots will get us a field cabin, but fly around the lake instead. In turn, we must plan accordingly (meds, fluids, oxygen, a snickers bar for when your partner turns into Betty White) for a longer flight

Another example could be buddy doing home renovations accidentally discharges his nail gun into his sternum, and he ends up with the a 2-inch nail buried to the head into his chest, and the tip lodged into the septum of his heart. Warm, humid local conditions with lots of forest fires in the area causing a very rough approach to the sending airport. Naturally we need to keep this guy very still, and the turbulence was rough on the approach. Not a lot we can do about the bumpy takeoff other than keep the patient as still as possible, but we would ask the pilots to find the calmest air between there and the destination. This could involve flying higher or lower, or flying around developing weather cells and other known areas of turbulence. This is not always possible but they do whatever they can to accommodate our request.

Another aspect of how it works is that the pilots get the call first, and they check weather and other pilot-ish stuff to determine if they can safely fly us to the sending location and then to the receiving location. No medical information other than patient and escort weight is provided at this point, and this is only provided for fuel planning and range considerations. Once the pilots accept the call, only then is the actual call info sent to the medics. This prevents any possibility of pilots feeling pressured to accept a call in questionable weather conditions, putting them in a situation that could put patient and crew at risk.

To answer a couple other questions...

How do you fly a 22 year old infantryman with a rib fracture and a small traumatic pneumothorax?
	⁃	ask the pilots to fly with a field level cabin and for rotor airframes they fly close enough to ground level that the effect of pressure change is negligible.  

The 65-year-old with a mild chronic obstructive pulmonary disease exacerbation and an oxygen saturation of 93% on room air? 
	⁃	since the therapeutic target for oxygen admin is 94% and up (some docs want >=95%), we would give a sniff of oxygen via cannula starting at 2Lpm and titrate to achieve target and desired effect. A mild COPD exacerbation can become a severe exacerbation pretty quickly for many reasons, so we would be monitoring ETCO2 and if we saw signs of ETCO2 rising outside the range that is normal for this patient we might consider serial blood gases with iStat and treat accordingly.  Depending on how sick the patient is, existing comorbidities, anticipated clinical course and bed-to-bed out of hospital time, there may be a discussion with our docs about whether to tube and vent this patient. 

The 8-year-old with otitis media? 
	⁃	Early antibiotics, appropriate analgesia, field level cabin, a Flyin' Lion (the Ornge mascot) stuffed animal, and lots of TLC.

Do you make a quick unplanned landing in flight to allow the Medics to decompress a chest with a chest tube, electrically shock a patient in V. Tach, or sort out a REBOA which as shifted or do you "push through to the MTF which is X minutes away?" 
	⁃	We would not make an unplanned landing for any of these reasons. If these interventions needed to be performed, they would be done so in flight. The only reasons I have heard of any crew making a landing en route to the receiving facility would be for fuel (planned), or in very rare instances arrangements were made for blood products to be delivered to a crew that had picked up a patient on a scene call, and that patient was in dire straits and would likely not survive the rest of the trip without blood products.

These are not always simple answers.   
	⁃	True, but we want those answer before we leave the sending facility. A big aspect of this type of transport medicine is considering anticipated clinical course, all the ways it can go sideways, and what we would need to do correct the situation during flight. Then take steps before we leave the sending facility to ensure that none of these things happens. This approach is effective 99% of the time. The other 1% is where flight medics get their war stories.


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## mariomike (1 Jun 2016)

Hunter said:
			
		

> Thank you! Reading that repeatedly was starting to make me itchy.



Me too. Having worked on the ground with Ornge Flight Paramedics enough times, I learned how to spell their name.


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## MedCorps (1 Jun 2016)

Hunter said:
			
		

> Any chance you could provide a reference for where you read about this training package?



It was in a BN presented by the MEDEVAC Sub-Working Group to the CFHS 3rd Future Field Force Working Group. It looks like some of the members spent some time talking to Col (ret'd) Tien who is now the Chief Medical Officer of Ornge (apologies for my error in my above post, spell check got me I suspect). They may have also spoke with the former CFHS Gp COS who was a RCAF pilot and went on to become VP Operations (or some such title) at Ornge before going off to TC to become Chief of Flight Standards (where I think he is now). The BN also had sources from STARS in Alberta so some of the information might have come from there also. 

I hope that helps.  Nothing says that the officers conducting the meeting understood correctly (or I read it wrong). It could also be something this is "on the books" but not done or something that might be in the pipeline to come in the future... who knows. I guess it was striking enough that I remembered reading it and thinking, wow that is operator / medic integration... good to see, might be a model worth emulating.  

Enjoyed your clinical examples (and Betty White reference)... a good read, thanks. 

MC


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## MedCorps (1 Jun 2016)

Hunter said:
			
		

> Do you make a quick unplanned landing in flight to allow the Medics to decompress a chest with a chest tube, electrically shock a patient in V. Tach, or sort out a REBOA which as shifted or do you "push through to the MTF which is X minutes away?"
> ⁃	We would not make an unplanned landing for any of these reasons. If these interventions needed to be performed, they would be done so in flight.



I am not remotely considered knowledgeable of flight medicine, so do not take anything I say on this topic as authoritative. My reading of the various proceedings has been that the "CAF experts" seem to be concerned about some of these things. I am not sure I would want to put in a chest tube or mess with a REBOA in a Griffon while in flight, especially tactical flight. The configuration is just not designed for it, especially if the casualty is in the litter kit (limited casualty access) or the flying is under NVG. I am also not sure what 1 CAD / 1 Wing says about delivering electricity to a casualty in-flight, but that might be a concern". I guess that is the advantage of having a dedicated, purpose built air ambulance that you work in versus a military utility helicopter we dump casualties in. 



			
				Hunter said:
			
		

> ⁃	True, but we want those answer before we leave the sending facility. A big aspect of this type of transport medicine is considering anticipated clinical course, all the ways it can go sideways, and what we would need to do correct the situation during flight.



I think that is another difference in military forward air evac (rotary wing) medicine. The "sending facility" might be a few sections of mod on the side of a road located in a very tenuous tactical situation that does not allow much helicopter ground time, or might be hand over from a casualty collection point where the medics are working on other casualties and the combat arms guys "dump" the casualty (or casualties) on your helicopter under the direction of the CSM. 

Good conversation.  

MC


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## Loachman (1 Jun 2016)

MedCorps said:
			
		

> I think that is another difference in military forward air evac (rotary wing) medicine. The "sending facility" might be a few sections of mod on the side of a road



The "sending facility", from what I've seen, is much less than that - casualties are generally picked up from the site of injury.


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## MedCorps (2 Jun 2016)

I think there are two models the rotary wing MEDEVAC people are looking at (based on my read of the draft doctrine which is about to be promulgated)  

1) Forward Aeromedical Evacuation (Med Tech staffed)
 - Move casualty from Point of Injury to medical treatment facility 
 - Move casualty from medical treatment facility to medical treatment facility. 

Note: A medical treatment facility, in it's most primal form is a medical detachment, which is a few sections of mod tent.  

2) Critical care Forward Aeromedical Evacuation (Critical Care On route care - Critical Care Nursing Officer / Med Tech staffed). 
- Move casualty from a medical treatment facility post-damage control resuscitation (DCR) to a medical treatment facility with damage control surgery (DCS) in order to meet NATO ratified timelines (ideally one, maximum two hours from DCR to DCS). There has been some good analysis by the Role 1 sub-working group and the Operational Medicine folk at DHSO looking at the requirement to have this capability. There is no use in doing forward DCR (blood, ventilation, advanced airway, advanced venous access, advanced medication, etc, etc) if you are going to turn the casualty over to a QL3 Med Tech in the back of an LSVW Amb and tell them to drive quickly to the field hospital so the guy gets surgery. Remembering that "these guys" are our brothers in arms and deserve the highest chance of survival should they find themselves shot up.    

Note: a medical treatment facility with DCR might be attached to a UMS under a few sections of mod tent.  The doctrine has been written and soon to be officially released (CFJP 4.10, if anyone cares). Now the wizards need to figure out how to operationalize these new doctrinal concepts (critical on-route care, DCR, DCS). That is part of the mandate of the Future Field Force Working Group.  

As mentioned earlier, there is also some highly debated talk about DCR at point of injury delivered by Chinook.  This is the UK MERT model.  We will see how these discussions go, but there are good arguments both for an against.  For video of the MERT see: 

https://www.youtube.com/watch?v=KczXs6Lh4TY

Cheers, 

MC


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