MILITARY MEDICINE, 176, 10:1128, 2011

Disaster Aeromedical Evacuation Col Nicholas G. Lezama, USAF MC*; Col Lawrence M. Riddles, USAF MC†; Col William A. Pollan, USAF MC‡; Col Leonardo C. Profenna, USAF MC§ ABSTRACT Successful disaster aeromedical evacuation depends on applying the principles learned by moving patients since World War II, culminating in today’s global patient movement system. This article describes the role of the Department of Defense patient movement system in providing defense support to civil authorities during the 2008 hurricane season and the international disaster response to the 2010 Haiti earthquake. Adapting and applying the principles of active partnerships, establishing patient movement requirements, patient preparation, and in-transit visibility have resulted in the successful aeromedical evacuation of over 1,600 patients since the federal response to Hurricane Katrina.

INTRODUCTION The primary mission of the Department of Defense (DoD) Patient Movement System is to transport wounded, injured, or ill DoD beneficiaries from deployed or in-garrison medical treatment facilities to medical facilities around the globe where needed health care services can be rendered.1 In addition to its primary mission, and as a key element of the National Disaster Medical System (NDMS), the National Response Framework calls for the DoD to support state, local, and tribal civilian authorities when appropriate requests for federal assistance are made.2 Successful disaster aeromedical evacuation depends on applying the principles learned by moving patients since World War II, culminating in today’s global patient movement system. This article briefly describes the aeromedical evacuation responses to the 2008 Hurricanes Gustav and Ike and the 2010 Haiti earthquake and describes how the principles of active partnerships, establishing patient movement requirements, patient preparation, and in-transit visibility contributed to the successful evacuation of over 1,600 patients.3 FEDERAL DISASTER RESPONSE Disaster response is largely a state and local responsibility. The federal government can provide assistance when state and local governments are overwhelmed. The Federal Emergency Management Agency, within the Department of Homeland Security, is the lead coordinating agency for federal emergency assistance. The federal government can provide medical resources, such as emergency medical care and the evacuation of hospital patients during disasters through the NDMS, which is a partnership of Department of Homeland

*Department of Preventive Medicine and Biometrics, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814. †US Transportation Command, Command Surgeon Office, 203 West Losey St. Suite 1700, Scott AFB, IL 62225. ‡Air Mobility Command, Command Surgeon Office, 203 West Losey St. Suite 1600, Scott AFB, IL 62225. §USAF School of Aerospace Medicine, Aeromedical Consult Service, 2507 Kennedy Circle, Brooks City-Base, San Antonio, TX 78235.

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Security, the DoD, the Department of Veterans Affairs, and the Department of Health and Human Services (DHHS).4 The NDMS supplements Federal, Tribal, State, and Local capabilities by funding, organizing, training, equipping, deploying, and sustaining a specialized and focused range of public health and medical capabilities. The DHHS Assistant Secretary of Preparedness and Response has the authority to activate the NDMS. The three components of the NDMS are: — Medical response to a disaster area in the form of personnel (teams and individuals), supplies, and equipment — Patient movement from a disaster site to unaffected areas of the nation — Definitive medical care at participating hospitals in unaffected areas U.S. Transportation Command (USTRANSCOM) is a DoD Combatant Command and is the DoD’s Single Manager for Patient Movement. It provides disaster patient movement in support of the NDMS at the direction of the President or upon approval of the Secretary of Defense. During domestic disaster response, USTRANSCOM supports U.S. Northern Command (USNORTHCOM), the Geographic Combatant Command responsible for providing defense support to civilian authorities. Disaster patient movement is coordinated through the USTRANSCOM Global Patient Movement Requirements Center (GPMRC) located at Scott Air Force Base, Illinois. GPMRC personnel are trained to deploy as joint patient movement expeditionary team members to coordinate patient movement requests (PMRs) from civilian authorities and to track patient movement at aeromedical staging facilities (ASFs). The 18th Air Force (Air Forces Transportation), the Numbered Air Force of Air Mobility Command (AMC), is the air component to USTRANSCOM. It provides airframes, air crews, aeromedical evacuation medical personnel, and ASFs in support of NDMS patient movement. States may also use National Guard aeromedical assets during disaster response. Aeromedical evacuation oversight responsibilities are illustrated in Figure 1. Upon activation of the patient movement component of NDMS, GPMRC regulates aeromedical evacuation from Aerial

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Disaster Aeromedical Evacuation

medical teams provided initial medical response and evacuated patients out of Haiti to Florida until a mobile aeromedical staging facility (MASF) supplemented with a USTRANSCOM Joint Patient Movement team (JPMT) was in place.7 A small portable expeditionary aeromedical rapid response team assisted the MASF team to stabilize patients for flight and coordinated air evacuation to the United States. An expeditionary medical support hospital was set up and assisted in patient movement to and from the USNS (U.S. Naval Ship) Comfort hospital ship. USTRANSCOM patient movement situational awareness team members and AMC Command Surgeon medical planners augmented the U.S. Southern Command Surgeon’s Office in Miami and the Florida State Emergency Operations Centers (EOCs) in Tallahassee. GPMRC worked with Florida emergency management and health officials to regulate patients to Florida hospitals. Once the definitive care portion of the NDMS was activated, the FCCs were activated in Tampa, Florida, and Atlanta, Georgia, and over 360 patients were evacuated from Haiti utilizing DoD aeromedical assets. FIGURE 1. This diagram illustrates the aeromedical evacuation responsibilities of USTRANSCOM, Air Force Surgeon General, AMC Surgeon General, and AMC A3 (Directorate of Operations).

Ports of Embarkation to predesignated Federal Coordinating Centers (FCCs) and associated Aerial Ports of Debarkation. There are 72 FCC locations nationwide. The FCCs work with state and local health officials to transport patients to NDMS participating hospitals for definitive care. DISASTER PATIENT EVACUATION The aftermath of Hurricane Katrina in 2005 set the stage for health officials to review their plans for evacuating patients before hurricanes. As a result of Hurricane Katrina, hospitals in the New Orleans area were significantly affected by the flooding that followed the city’s levee breaks. Approximately 12,000 hospital patients and caregivers from 25 hospitals in the New Orleans area were evacuated from Katrina, including approximately 2,600 patients who were aeromedically evacuated from New Orleans via DoD airlift.5,6 DoD supported prehurricane patient evacuation in Texas and Louisiana for Hurricanes Gustav and Ike in 2008. Hurricane Gustav formed on August 26, 2008 southeast of Haiti and made landfall in Louisiana on September 1, 2008. Active duty and Air National Guard aeromedical evacuation personnel transported 833 patients from three ASFs in Texas and Louisiana before landfall. As Hurricane Gustav was making landfall in Louisiana, Hurricane Ike was forming in the Atlantic Ocean and made landfall in Galveston, Texas, on September 13, 2008. DoD support was again requested, and 428 patients were evacuated from three Texas ASFs before landfall. On January 12, 2010, a 7.0 magnitude earthquake occurred in Haiti and the DoD participated in the international disaster response efforts. Air Force Special Operations Command

ACTIVE PARTNERSHIPS GPMRC is one of four DoD Patient Movement Requirement Centers (PMRCs). PMRCs receive PMRs, validate the requirement for aeromedical evacuation, ensure patient preparation and movement precedence (routine, priority, urgent), and submit the requirement to the appropriate airlift center. PMRCs have ongoing communications with regional medical treatment facilities to ensure safe and responsive aeromedical evacuation. Similar partnerships have been established with federal and state health officials. Coastal states that are vulnerable to hurricanes have assessed their requirements for patient evacuation and have determined if they will need federal support for prehurricane patient evacuation. State emergency management officials work with a Defense Coordinating Officer (DCO) to establish requirements and plans for DoD disaster support. The DCO, a senior military officer, is supported by a staff which includes Joint Regional Medical Planners who plan, coordinate, and integrate Defense Support of Civil Authorities with Local, State, and Federal agencies. Each Federal Emergency Management Agency region has a full time DCO.8 In 2008, Texas and Louisiana had identified the requirement for federal assistance during prehurricane evacuations. USTRANSCOM deployed GPMRC patient movement enabler teams to Texas and Louisiana to work with Joint Regional Medical Planners, National Guard, federal, and state health officials to plan and regulate patient movement during the response to Hurricanes Gustav and Ike. These teams provided situational awareness, participated in planning at the Joint Field Office and State EOCs, and provided a vital link between ASFs, State EOCs, and GPMRC. Lessons learned and recommendations from the federal response to the 2008 hurricane season were presented at the 2009 Integrated Training Summit, sponsored by DHHS.9

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Disaster Aeromedical Evacuation

These annual summits provide a forum for thoughtful analysis and review of how the federal government responds to disasters and are a key element of ongoing federal and state disaster planning and preparation These relationships were again utilized during the Haitian earthquake response. Daily interagency conferences including TRANSCOM, DHHS, U.S. Southern Command, Joint Task Force Haiti, and other federal and state partners proved invaluable in providing situational awareness and establishing response priorities. Recommendations — Recognize that interface points are potential areas of communications challenges — Establish and maintain state, DoD, and interagency relationships before disasters occur

ESTABLISHING PATIENT MOVEMENT REQUIREMENT The DoD patient movement system is driven by patient movement requirements. In nondisaster scenarios, medical providers submit PMRs to a designated PMRC. During a disaster, GPMRC can deploy JPMTs to facilitate disaster patient movement regulation. Lessons learned from Hurricanes Gustav, Ike, and ongoing planning and exercises involving GPMRC and the states have resulted in improved processes to generate disaster PMRs and to accomplish timely patient movement. Prehurricane patient movement presents several unique operational challenges. State health officials and hospital CEOs assess the risks of shelter in place vs. hospital evacuation. With modern technology, storm paths can be predicted; however, the exact location and timing of hurricane landfall is still largely uncertain and delays in making a decision to evacuate reduce the number of patients that can be moved as the evacuation window narrows. During the early stages of the Haiti response, situational awareness regarding casualty estimates, medical care requirements, and available local medical care was lacking. DoD pushed large amounts of nonmedical assets to Haiti, which resulted in the delay of DoD medical assets reaching Haiti. Initially, there was not adequate screening of passengers on nonaeromedical airlift missions from Haiti. This resulted in receiving locations having to quickly arrange medical care for ill passengers upon arrival to the United States. The establishment of the MASF and JPMT team and arrival of DoD medical forces resulted in improved situational awareness and a better estimate of patient movement requirements. Recommendations — Identify patients that can and cannot be evacuated — Establish evacuation options and requirements for special needs of patients (neonatal, critical care, psychiatric, dialysis, nursing home)

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— Anticipate medical personnel and equipment requirements to transport a wide range of civilian patient categories

APPROPRIATE PATIENT PREPARATION The DoD aeromedical evacuation system moves stabilized patients (airway protected, breathing, and circulation controlled) with specialized equipment and aeromedical evacuation crews, comprised of flight nurses and aeromedical evacuation technicians. For movement of critical care patients, a Critical Care Air Transport Teams (CCATTs) comprising of a physician, nurse, and respiratory technician is added to augment the aeromedical evacuation crew. Patients moved in disasters are often high acuity critical care patients. Although there are no absolute contraindications to aeromedical evacuation, patient selection and preparation are key elements in safe patient movement. The major medical risks associated with air transport are hypoxia and gas expansion. Other factors that may affect patients include noise, temperature variations, vibration, low lighting, and the stresses of multiple patient transfers. GPMRC patient movement guidelines are listed in Table 1. During a disaster, the sending physician has to believe the level of care will be improved by transferring the patient from one medical facility to another and be willing to accept the risk associated with the transfer. This being said, a disaster may mandate hospital evacuation because of loss of infrastructure. The transferring physician should consider that it may take up to 12 hours before the patient is back in a hospital comparable with the one the patient left. Patients are typically transported to some form of an ASF at a designated airport before being loaded onto the aircraft. ASF medical personnel ensure that patients are appropriately prepared and stabilized. Determining the ideal location of an ASF in a prehurricane scenario is challenging because of the uncertainty of the storm path, uncertainty regarding a hospital’s decision to evacuate vs. shelter in place, and air lift operational requirements. The time required to mobilize forces, transport them to the location, and set up the facility has to be factored into the overall plan. The ASF is usually located in a building of opportunity at a predesignated airport and has limited patient care and holding capability. The lack of an appropriately staffed ASF can negatively impact patient preparation and proper patient loading. DoD is working with DHHS to train NDMS civilian emergency medical teams to augment domestic disaster ASF military personnel. Patients’ air evacuated from Hurricanes Ike and Gustav had significant requirements for critical care and patient stabilization at the ASF that impeded the military personnel assigned from performing their primary duty of air transport. Civilian critical care personnel can work alongside military ASF personnel to stabilize and prepare critical care patients for transportation. This will allow the USAF CCATTs to focus their efforts on patient transportation and

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Disaster Aeromedical Evacuation TABLE I.

GPMRC NDMS Patient Movement Clinical Guidelines7

Airway protected? CCATTs are trained to manage ventilated patients and can monitor endotracheal tube cuff pressure. Patients who have been recently extubated should be monitored for at least 4 hours before evacuation. Breathing adequately supported? Normally, oxygenation at altitude is impaired. Do not move vented patients with high oxygen requirements (FiO2 greater than 60%). Circulation acceptable? Do not transport patients with hemoglobin levels