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Soup of the Day
Dispatches from the Frontline
February 23, 2012
Posted by Michael Yon
Dispatches from the Frontline
Michael Yon
“After more than 9 years of conflict and more than 40 AAR’s recommending the evolution of MEDEVAC to current civilian standards, no institutional change has been made. Continuing the legacy model has resulted and continues to result in documented sub-optimal outcomes and increased deaths among patients transported by helicopter in the current conflict.”

Robert L. Mabry, FS, EMT-P
Lieutenant Colonel, MC
JTTS Medical Director, Enroute Care

23 February 2012

The United States Army has failed with extraordinary dexterity while executing the helicopter MEDEVAC plan in Afghanistan.  On the surface, the Army advertisement campaign sells a story that their performance is exemplary and unprecedented in the history of war.  The press machine churns out sound bites, which are picked up in major media without the barest pretense of auditing.  For instance, senior Army officers saying and committing to writing that the Army has achieved a 92% success rate on MEDEVAC.  The Army peddles this message, and yet nobody says, “Show me the money.  Where do you get these figures?”  There is growing evidence that the 92% figure is hollow and fraudulent.

For instance, in an internal memorandum, the issue of poor or nonexistent tracking is repeatedly hammered:

“Further, no systems exist that capture adverse outcomes, protocol violations or sub-standard care outside of the individual MEDEVAC unit or GSAB. Lack of patient care documentation in the medical record and trauma databases is the greatest hindrance to developing data needed to drive improvements in MEDEVAC care.”

Just how the Army derives a “92% success rate” (whatever that is) with data that it fails to track is unknown.

Another Army talking point is that the Dustoff MEDEVAC community is “purpose built” for MEDEVAC, and are the crème de la crème providers in Afghanistan.  Yet this same memorandum states in clear terms that of the three principal MEDEVAC/CASEVAC providers in Afghanistan (Dustoff, Air Force Pedro, British MERT), the Army comes in last place with substandard, archaic procedures and woefully undertrained flight medics.

Excerpted highlights:

**US Army flight medics, credentialed at the National Registry of Emergency Medical Technician-Basic (EMT-B) level, are not trained to perform critical care transport or aggressive advanced resuscitation at the point of injury like their civilian flight paramedic counterparts operating in CONUS [Continental United States].

**Current MEDEVAC staffing model is outdated and based on Cold War / Vietnam [era] doctrine.

**The current capability gap has been documented in more than 40 AAR’s [After Action Reports] since 2002 in both Iraq and Afghanistan. Lack of advanced flight medic capability has directly resulted in poor outcomes in multiple cases and was the impetus for the deployment of critical care nurses to fill this capability gap as well as the deployment of a physician medical director. A recent study that compared critical care trained flight paramedics from a US Army National Guard air ambulance unit versus the conventional MEDEVAC systems operating in OEF [Afghan War] showed a 66% reduction in death at 48 hours post-injury in severely injured patients. Several recent cases illustrate the complexity and acuity of patients currently being managed by a single EMT-B flight medic.  [Dustoff flies with a single medic.  Air Force Pedro flies with a minimum of two medics per bird (often three) who are on average more highly trained.]

** Discussion: Significant variability in unit capability performing MEDVAC exits in the AO [Area of Operations]. The operational units have attempted to fill the capability gaps of our current MEDEVAC model with ad hoc methods that are not standardized and often have significant operational limitations. This creates a situation where different units/personnel have to be used for different missions. Further, no US Army standard treatment protocols exist, as these are significantly variable across different units. This variable capability degrades the MEDEVAC commander’s flexibility to respond appropriately across the full spectrum of missions.

**National Guard flight medics are often credentialed paramedics with extensive training/experience in critical care transport able to operate across the entire mission profile.

**Regular Army flight medics with EMT-Basic credentials and are not trained to transport post-op or intubated patients, nor are they able to perform advanced airway or resuscitative interventions from the point of injury.

**Medics in RC-S [Regional Command South; based in Kandahar] (101st ABN Div) attended an abridged paramedic program before this most recent deployment. Only 15% of the medics passed this accelerated program and while the remainder are “paramedic trained” they not credentialed as EMT-P’s. They have an expanded Advanced Life Support scope that #2 lacks, but still are not trained in advanced airway management / critical care transport skills.

**Air Force PJ’s (PEDRO) are credentialed paramedics that operate in pairs but lack critical care transport skills and cannot transport ventilator patients. They are allowed to perform Rapid Sequence Intubation and administer blood products but these skills are rarely used or sustained.

**Enroute Critical Care Nurses are able to transport intubated patients from Role II but are not allowed to go to a Battalion Aid-Station or a Shock Trauma Platoon to pick up an intubated patient as these are considered Point of Injury.

**British MERT (Medical Emergency Response Team) is able to bring a full resuscitation team to the Point of Injury and provide aggressive treatment to severely wounded casualties but their response time is sometimes longer than Army MEDEVAC or PEDRO.

**Unit flight surgeons lack the clinical skills, experience and credentials to supervise and train flight medics.

**Discussion: Every GSAB flight surgeon currently deployed to Afghanistan is a PGY1 general medical officer with no additional training in out-of-hospital care, trauma management, medic training, in-flight critical care, or medical oversight of a helicopter EMS system. In most cases, the experienced flight medics have more knowledge of enroute care than the physician supervising them.

**Further, no systems exist that capture adverse outcomes, protocol violations or sub-standard care outside of the individual MEDEVAC unit or GSAB. Lack of patient care documentation in the medical record and trauma databases is the greatest hindrance to developing data needed to drive improvements in MEDEVAC care.

**Conclusions: After more than 9 years of conflict and more than 40 AAR’s recommending the evolution of MEDEVAC to current civilian standards, no institutional change has been made. Continuing the legacy model has resulted and continues to result in documented sub-optimal outcomes and increased deaths among patients transported by helicopter in the current conflict.

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