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The Medical Aspects of Casualty Transport – Now and in Future

A coordinated system of medically suitable field ambulances is an essential requirement if adequate care is to be provided to casualties through the successive levels of treatment, from
point of injury to repatriation. This subject was discussed with the industry during a series of informal talks held in May 2011, and is reviewed from various perspectives.

The consequences of the attack on the German ISAF contingent (OP North, Regional Command North (RC North) on 18 February 2011 clearly demonstrate how important it is to have a successively coordinated system of transport vehicles in the casualty rescue chain. It is already apparent that primary evacuation with the aid of helicopters (FwdAirMedEvac), an essential element of the rescue chain, can be safeguarded only if the US continues to make an adequate number of helicopters available over a wider area as the German forces do not currently have the means at their disposal to undertake this role in Afghanistan.

Because of the casualty figures and the fact that the relevant devices had to be assigned to the US helicopters for in-transit support of casualties during the flight to higher level medical facilities, no further emergency equipment was available at the rescue station at OP North once all casualties had been dealt with. However, those familiar with the tactics employed by the Taliban in northern Afghanistan will know that it is their practice following an initial attack to launch a second assault on the reconstituted forces. Had this actually occurred, the local ISAF medical facilities would not have been capable of dealing adequately with any further casualties because of the consequent lack of equipment on-site.

If casualty transport is to be effectively prepared for its task, its objective within the rescue chain needs to be carefully considered and evaluated. It is essential, for example, to ensure that the quality of medical support provided on the next level up of the system does not fall short of that of the previous level (the “continuum of care” stipulated in MC 326/2 and AJP-4.10(A)).
Hence, the basic objective at the Role 1 level with its various transport media is to ensure that casualties are transferred as rapidly as possible and without succumbing to their wounds to surgeons at Role 2 and 3 facilities. And it is with this purpose in mind that the equipment of the various vehicles needs to be appropriately coordinated in terms of quality and quantity, while the absolutely essential time element must also be taken into account. In addition to immediate support from their comrades on the ground and self-treatment, the speed of evacuation and the rapidity with which casualties can be brought to the operating table are the factors that ensure that casualty mortality rates can be kept as low as possible.

Further along the chain, the Light Manoeuvre Role 2 mobile surgical hospital is designed provide emergency surgery within 2 hours of the wound while a standard mobile surgical hospital is to provide urgent surgery within 4 hours. The target of getting casualties to a facility for initial surgical treatment within 2 hours has been achieved in 84% of all cases during the deployment of the ISAF, despite all the geographical problems.

To provide for the medically supported transport of casualties who have undergone emergency surgery to a Role 3 medical facility, the necessary advanced equipment that is appropriate to the nature of the wound must be available. From this point, it is usually no longer the time factor that is the decisive aspect with regard to the transport of casualties requiring medical support in-transit to a Role 3 facility, so that it is the already adequately stabilised casualty that should be at the core of transport planning strategies.

The purpose of the acute clinical treatment provided at a Role 3 facility is to prepare casualties for repatriation to the homeland and to ensure that they are capable of withstanding the rigours of transport, which may well take several hours, to a final clinical care and rehabilitation centre in the homeland. With all this in view, it is quite apparent that is essential to guarantee that medical support and appropriately equipped medical transport are available 24/7. It must further be ensured that casualty transport systems are operational at all times. The requirements with regard to casualty transport and medical equipment are determined by the following:

• Protection:
  Casualty transport vehicles operating in the field must be provided with the same level of protection against weapons, mines and other explosive devices as the vehicles used by the combat troops they are supporting. This is a vital prerequisite if these vehicles are to accompany soldiers on the battlefield. In the current context, a red cross no longer provides for any form of special consideration, and casualty transport vehicles are treated in the same way as combat vehicles by the enemy, who freely attacks both – a new experience for the German personnel. But with the current armour systems and technology available, it is possible to protect passengers and crew in such vehicles against lethal injury should these come under attack. At the same time, it is possible that equipment – standard commercial equipment is being used in most cases – will be made inoperable by the effects of an explosion so that it is no longer possible to provide medical support to any casualties. 
• Operational sustainability and mobility:
  As in the case of protection, it is absolute essential that medical vehicles accompanying military operations have the same profile with regard to operational sustainability and mobility as the combat vehicles of the units being supported. Of course, where possible, the medical capabilities of these vehicles also need to be adapted to these requirements. As in the case of other allied nations, the provision of equipment for oxygen generation to casualty transport vehicles is now under consideration.
   
• Ergonomics/safety:
  With regard to other aspects of military medical support, equipment supplied to vehicles also needs to be suitable in terms of ergonomics and safety (e.g. resilience of equipment to effects of explosive blasts). These must also conform to the standards and regulations that apply to land and air transport so that they do not represent a risk to the occupants of the vehicle in critical situations during exposure to massive acceleration. Here it is the wellbeing of the occupants that is of primary concern – the ability of the equipment to function following such events is currently of secondary importance.
   
• Medical skills:
  The skills of the medical personnel should be strictly and primarily appropriate to the assignment. The corresponding casualty transport vehicles need to be equipped so that personnel can undertake their operational role without delay and can provide support to the achievement of the military objective in full.

These various requirements are in conflict to differing extents and so appropriate weighting with regard to importance is necessary. Certain demands also apply to the ability to compromise and the need to set priorities. But it is essential that the medical assignment and the military objective remain at the centre of focus. Because of this, the spotlight has recently been increasingly on the aspects of protection against ballistic weapons and mobility. It has been possible to integrate the necessary medical equipment  in existing vehicle types. At the same time, it is also necessary to decide whether the medical functionality is adequate. Deployment as part of the ISAF has again made it apparent that attacks are likely to result in more than one casualty. Hence, whenever possible, casualty transport vehicles need to have the capacity to transport at least two casualties at any one time - at least one intensive care patient (ventilatordependent) and one low care patient (requiring monitoring).

With these aspects in view, a system of ground vehicles has been developed that essentially encompasses lightly armoured, moderately heavily armoured and heavily armoured medical transport vehicles. A lightly armoured medical vehicle has been introduced in the form of the EAGLE IV BAT, while the role of heavily armoured medical transport vehicles is currently being undertaken by a vehicle derived from the GTK Boxer. A moderately heavily armoured vehicle (mgSanKfz) is being developed under contract, and it is expected that this will be available from 2014, and that the construction process will be completed without a hitch and the necessary funds will be provided. Until this vehicle actually hits the road, it will be necessary to use the TPz Fuchs San to plug the gap.

The air transport of casualties - Aero Medical Evacuation (AE) – is classified in three categories according to purpose:

FwdAirMedEvac: Initial casualty transport from the scene to a primary medical
                                treatment  facility
TacAirMedEvac: Transport of casualties between medical facilities in the area of
                               operations
StratAirMedEvac: Transport of casualties from the area of operations to medical
                                 facilities in the country (but outside the area of operations) or to a
                                 transit country/ other country.

Helicopters to be used for medically supported casualty transport should be on 20- minute standby so that they, if possible, can reach the patient at the scene within 60 minutes of the wounding event.

Medevac systems

are under development for use onboard the CH53 medium transport helicopter and the NH90 light transport helicopter. These will replace the patient transport unit (PTE) system that has been used to date only in ISAF missions. It is also planned to install the recently developed “FwdAirMedEvac IOC+” system as initial operating capability in the NH90 light transport helicopter range, so that the German contingent can also directly participate in FwdAirMedEvac. The familiar CH 53 medium transport helicopter will continue to be used to facilitate the transport of patients in the event of major disasters within Germany.

In the case of fixed-wing aircraft, the generational upgrade from the A160 to the A400M will also be accompanied by a technological advance in terms of the equipment and standard fittings used in this area. The objective is to develop a follow- up system to the patient transport unit (PTE) system 

that has been used successfully for the past 15 years and to adapt the corresponding medical equipment to the current generation of devices.
For this process, it will be necessary to employ experience to date and take into account the new operational parameters. With regard to medical equipment, required will be the modification of the current equipment of Role 3 facilities in the area of operations and current equipment of Bundeswehr hospitals to ensure these are compatible with Medevac medical devices.

What casualty transport vehicles do the above considerations apply to?

Currently being used by the German military medical service are:

• Non-armoured vehicles
  + 2 tonne HGV as ambulance and medical team transporter (BAT)
  + Emergency physician vehicle (NEF), ambulance (RTW) and intensive care patient
     transporter (ITW) are used by the rescue services at Bundeswehr hospitals for training/
     exercise purposes
• Armoured vehicles (with various levels of armour protection):
  + Duro /YAK (accommodates one stret cher case) + TPz Fuchs San (accommodates one  
     stretcher case)
  + BV 206S Hägglunds (accommodates one stretcher case)
  + Lightly armoured vehicle EAGLE IV BAT (accommodates one stretcher case)
  + Wiesel 2 San (accommodates one stretcher case)
• Air transport vehicles:
  + Bell UH1D light transport helicopter (not in use in Afghanistan)
  + Sikorsky CH53 medium transport helicopter (used mainly for secondary transport)
  + Transall C-160 (used for TacAirMed Evac)
  + Airbus A320 (used for StratAirMedEvac)

To be introduced in future are:

• Armoured vehicles:
  + The heavily armoured BOXER (to replace the M113 ambulance)
  + A moderately heavily armoured vehicle (to replace the Duro/YAK and TPz Fuchs San)
  + A lightly armoured vehicle (to replace the Wiesel 2 San).
  + An armoured casualty transport container mounted on the MULTI FSA HGV chassis
     (for land-based secondary transport between various medical facilities and to airport of
     embarkation APOE)

• Air vehicles:
  + NH90 IOC+ light transport Eurocopter (accommodating two stretcher cases)
  + NH90 FOC light transport Eurocopter (accommodating two stretcher cases)
  + Airbus A319
  + Airbus A400M (to replace the C160)

It is apparent from the above list that the on-going developments and introduction of new platforms will also make it necessary to improve the capacity of casualty transport media accordingly. Existing medical equipment must be brought up to current standards in medical technology and continuously adapted to the persistent changes in medical treatment protocols. Not only is a high degree of medical competence required here, but it will also be necessary to coordinate matters with the relevant equipment suppliers in the defence sector.

The situation in Af gha nistan alluded to at the beginning makes it clear that our first objective must be to invest considerable input in the development of our FwdAirMedEvac capacity so that it can be used in support of our combat personnel on the battlefield. In addition, the new protective technologies coming in need to be analysed and evaluated to ensure that they are capable of effectively protecting the casualties under our care and our medical equipment by shielding man and materials from the effects of acceleration and by minimizing the threat risk at as early a stage as possible (active remote protection systems). The acceleration stress for personnel and equipment needs to be drastically reduced. In addition, the medical equipment used in StratAirMed- Evac must be modified to conform to the new parameters arising with the change in the air vehicle profile and adapted to comply with the advances made in commercial device technology.

Colonel (pharm) MC Rudolf Ernst Ziegler, SanABw II2

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