Updated: Nov 4, 2020

Placing a blood pressure cuff on a patient is typically a simple task.  This time was an exception. I felt for the cuff in my bag, pulled it out and went to secure it around the patient’s arm. As I did the floor shifted again and I tumbled forward. I grabbed the guy’s opposite arm to prevent face planting into his stomach. Unfortunately for my patient I grabbed the rubber bone sticking out of his arm that was covered in fake blood. In a second attempt, I was more successful in actually getting the cuff around his arm. As I went to turn the vital signs machine and complete the ritual I paused for a long moment, turned away, and proceeded to vomit in a painfully small plastic bag. Once my stomach finished it’s rude interruption I was finally able to get a blood pressure.

After dressing his wounds I sat up for a moment giving my back and neck a much-needed rest from the weight of the armor platted vest and helmet. I drew in a deep breath of hot hydraulic fuel tainted air, and took in my surroundings. It was dark in the back of the C-130, and this was important to simulate the tactical environment. Three patients were secured to litters that were strapped to the bare metal floor. A wide variety of medical bags and pelican cases were secured to the floor and walls in any means possible. One of my fellow classmates was off in the far corner tucked into the fetal position clinging to his vomit bag. All the while his pretend patient lay unattended. As my vision shifted to one of the portholes the outside world took on a dimension of impossibility. What I perceived in my vestibular system to be straight and level flight was harshly contradicted by the ground 500 feet below. The assortment of trees spun by at a dizzying pace with no horizon in sight, which meant we were in a steep bank. In disbelief I moved my head around quickly testing my inner ear and felt the spinning sensation that only comes when one’s ears and eyes are in complete disagreement about the actual location of the body. This act of defiance was followed by yet another wave of nausea, and the lesion was learned.

The point of this flight was actually to induce all the uncomfortable sensations I was experiencing, and still provide some kind of adequate patient care. This experience was part of a larger weeklong course taught at Hurlburt field, Florida. The CASEVAC course as its known stands for casualty evacuation. This course teaches the fundamentals of evacuating patients from combat zones, and typically follows the Special Forces doctrine of “care under fire”. CASEVAC differs from other terms you may be familiar with such as MEDEVAC or Aeromedical Evac (AE) in that CASEVAC typically uses “vehicles of opportunity” to evacuate patients. These vehicles could be anything from fixed wing planes, and helicopters to pickup trucks, and donkeys. MEDEVAC and AE uses designated aircraft and are a more formal way of patient movement.

Another foreign concept that this course introduces is the paradigm shift in medical care that happens in the tactical environment. A few years after 9/11 the military was reacquainted with an old question. How to best treat wounded soldiers in the heat of battle? The observation was made that the most correctable battlefield injuries that resulted in death were massive bleeding and chest injuries resulting in a tension pneumothorax. The solution was to develop a school of thought that could not only address these immediate life threatening medical conditions, but address the tactical situation and evacuation as well, and so Tactical Combat Casualty Care or TCCC was born.  TCCC takes a shift away from more traditional views of trauma resuscitation in a few ways, i.e. bleeding is more important than establishing an airway, and returning fire or “putting lead downrange” is typically more important than anything, there are more examples, but to me those were the most stark. In the end it’s really just a means to establish short-term stabilization until the patient can be evacuated to a safer area where more definitive care can be administered (like the back of an aircraft…or fast moving donkey).

The CASEVAC course succeeds in not only teaching TCCC, but also simulating a variety of tactical environments to practice in. In addition to the vomit comet flight I discussed above they also have what I think is one of the most technically advanced simulation labs for battlefield trauma in the country.  The lab is a small room next to a small conference room in a building that looks like any other official building at Hurlburt Field. I remember my first experience in the lab.  A group of us were standing in the hallway in full tactical gear, helmets and all waiting to enter the lab when some guy walked down the hall, coffee in hand gave us a slight nod of approval suggesting that being dressed for the impending invasion was normal attire in this building.

When we were given the go ahead the door opened, the room inside was dark and about 20 degrees warmer than the hallway. The soundtrack was an eclectic mix of gunfire and aircraft engines that played over loud speakers. There was a pool of blood flowing across the room that originated at the stump of a mangled leg that belonged to a life size manikin. This manikin, whose price tag I can only imagine was about as real as they come. Controlled by a remote computer it breathed, talked, blinked, and even had real pulsating arterial wounds that spat blood across the room.

Accompanied by a medic we quickly began working on the manikin’s wounds. We applied a tourniquet to the leg to control bleeding and chest seal to its gapping gunshot wound on the left chest. After the initial critical wounds were addressed we moved our plastic companion across the room where a small area was set up to simulate the back of a helicopter. After securing the manikin and litter to the floor we began getting more equipment out to check vitals, establish an airway, etc. At the height of our adrenaline filled resuscitation the lights came on, and the soundtrack shut off. We were given feedback by the instructors observing all this, told to leave the room and then repeated this about three or four times all with varying scenarios.

You might be wondering why I would have to attend such a course. It helps to understand the majority of flight docs in the Air Force typically don’t deploy very often and spend most of their time seeing relatively healthy clinic patients, writing medical waivers to allow aircrew members to keep flying, attending rather mundane meetings, and keeping up with flying hours. I’m not bashing the average flight doc, its all well and good, and can be a rather enjoyable and meaningful job. But, given the opportunity I would rather do more. The “more” presented itself in an opportunity to be part of something called a Special Operation Forces Medical Element, or SOFME as its known.  A SOFME basically provides medical support to an operational squadron or any special ops units at really any location. This can range from large bases to small bare bones forward operating bases. The real guts and glory part of the job is to provide emergency medical support to a deployed SOF unit. Generally speaking this means far forward CASEVAC, and short-term casualty holding and staging for Aero medical Evacuation.

A SOFME at its full capacity consists of a flight surgeon and two independent duty medical technicians (IDMT). The medical gear to fulfill this mission objective obviously has to be miniaturized and tightly compartmentalized, and then it has to be adapted to work in whatever type of vehicle is used. So to put it frankly, knowing how my shit works is a big part of the job.  The CASEVAC course is only the first step in getting acquainted with this craft. Back at my base we run exercises as frequently as we can to continue practicing. For something like this practice not only makes perfect, it makes sure people stay alive. Most flight docs that are thrust into this position are GMOs meaning they have only had one year of residency training and are basically tossed into the deep end. There is no senior resident or attending physician to ask for help in the back of an aircraft above a battlefield, so the pressure to learn quickly and perform is well cemented.

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