The Flying Emergency Room

One reason more soldiers are making it home alive.

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Wounded service members are taken off a C-17

Wounded service members are taken off a C-17 and brought into Scott, which serves as a hub in moving the injured from the battlefield to U.S. treatment facilities. (USAF / Senior Airman Ryan Crane)

By Mike Klesius

Air & Space Magazine |
November 2012

During the Vietnam War, it took an average of 45 days to return severe casualties to the United States, and the survival rate was 75 percent. By the time of Operation Desert Storm, in 1991, getting wounded patients home averaged 10 days, but their survival remained stubbornly at 75 percent. Today, the Air Force has gotten the time down to three days or less from virtually anywhere on the planet, and as for the survival rate, “if you make it to a field hospital in theater with a heartbeat,” says Justin Brockhoff, an officer with the Tanker Airlift Control Center at Scott Air Force Base in Illinois, “you have a 98 percent chance of living.”

Two major factors account for the improvement in survival rates. First: Robust and sophisticated en route care, which is part of a continuum of advanced care that begins at the moment of injury—soldiers are trained and equipped to self-administer medical care, including tourniquets and even intravenous fluids. Second, improved evacuation logistics, thanks especially to aviation. Crews now move critical patients more safely and effectively with a wider array of equipment and airplanes. Much of this is orchestrated by planners at Scott, getting data on flights from a variety of sources.
The base is home to the 375th Aeromedical Evacuation Squadron, one of four active-duty aeromedevac units: Another is in North Carolina, one is in Japan, and one is in Germany. But Scott, about half an hour east of St. Louis, Missouri, is also the headquarters of the Transportation Command, the Air Force’s cargo-moving operation. “We’re like the quarterback: We make audible calls. We shift. We’re planning and tasking,” says Brockhoff of Scott’s NASA-style mission control, where banks of military and civilian staff watch flat screens and world maps sprinkled with icons representing airborne cargo, some of it U.S.-bound patients. “We’re here if they run into weather or maintenance problems.”
Scott also runs an Aeromedical Staging Facility, which can accommodate 40 patients overnighting on their way to other points for specialized care or discharge. “The facility is a little bit of home,” says Army Sergeant Leonard Hathaway, a coordinator in a Transportation Command program that welcomes home wounded soldiers. While visiting Scott, I talked to Private Tanner Williams, 20, who had just flown in on a sunny Monday morning. Williams was a member of the Iowa Army National Guard. If you could ignore his cast and crutches, he looked no different from a college kid watching TV in a dorm lounge. Williams had been stationed at Forward Operating Base Kalagush in eastern Afghanistan. The prior Wednesday evening, he had been part of a routine patrol when an improvised explosive device went off beneath his all-terrain vehicle.

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Evacuating the Injured

A Marine Corps pilot flies CASEVAC missions in Iraq.

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(Cpl Mark Sixbey/Courtesy Rocky Checca)

By Rocky Checca

Air & Space Magazine |
September 2012

After graduation from the Naval Academy and commissioning as a Marine Corps pilot, I went to flight school and selected the CH-46E Sea Knight out of Marine Corps Base Camp Pendleton, California. The CH-46 is the Marine Corps’ medium-lift assault support platform. I was detailed to join Marine Medium Helicopter Squadron 364 (HMM-364), the “Purple Foxes,” deploying to Iraq. Combat operations had supposedly concluded in May 2003 while I was still in flight school, well before I arrived on station. After I arrived, however, the insurgency began, and the situation in Iraq rapidly deteriorated. From early 2004 to February 2010, HMM-364, HMM-268, and HMM-161 operated on a continuous eighteen-month rotation at al-Taqaddum Air Base in Iraq.

Al-Taqaddum Air Base was located in the heart of the insurgency, halfway between the cities of Fallujah and Ramadi, in the infamous Sunni Triangle in al-Anbar province, in western Iraq. The primary role and mission of our squadron was casualty evacuations, CASEVAC. We also flew hard-hit raids, insertions, extractions, snap vehicle checkpoints, and night external resupply missions. The commanding general considered CASEVAC the “no-fail” mission in Iraq, making it clear to us that there would be no dropped CASEVAC missions for any reason.
Although CASEVAC were flown on a daily basis, multiple times a day, there was absolutely nothing routine about any of them. Each one presented unique challenges and problems. The pilots, aircrew, maintainers, and corpsmen prepared for the known task, but with ample contingencies for the “fog of war.” We had to be prepared to fly through any and all weather conditions, at any time, and into all kinds of enemy situations to save the lives of the people we were called on to evacuate.
The CASEVAC process was important to everyone in theater. If an individual can be provided medical treatment within one hour of an incident, the chances of survival increase exponentially. This is known as the “golden hour,” and that is why the entire CASEVAC process, from start to finish, is standardized, efficient, and quick.

Being on standby for CASEVAC was physically and mentally exhausting. We couldn’t leave the squadron area; food was brought to us; and if we had to use the bathroom, we hoped that the bell wouldn’t ring while we were sitting on the can. When the bell rang, we sprinted to the helicopters and would have a primary, a secondary, and a backup aircraft up and spinning four minutes after the CASEVAC bell rang. Many times we would be in the aircraft ready to taxi for takeoff having no idea where we were flying to or exactly what situation we would find once we got there. On many days the bell seemed to ring constantly, and we would fly CASEVAC after CASEVAC. Even on slow days, including days when no CASEVACs were flown, we would still be exhausted by the end of the shift because of the constant state of anticipation.
We flew CASEVACs for all coalition personnel, Iraqi civilians, and even insurgents. The lives of our forces took priority over the insurgents’, but if an insurgent’s life could be saved, he potentially could provide valuable intelligence that might save American lives. There were times when we would pick up insurgents and Marines who had just been fighting each other and would load them together into the back of the helicopter.
I experienced several close calls while flying. During my first deployment, on one of my first flights at night in Iraq, we received multiple RPG (rocket-propelled grenade) shots and small-arms fire while flying on final approach and on departure for a mass casualty call at Combat Outpost in Ramadi. The first RPG was shot from directly in front of us on final approach and passed 10 or 15 feet above our rotors. Another was fired from behind us on departure and passed the left side of the aircraft. RPGs and small arms were shot at our aircraft numerous times, and on several occasions aircraft took battle damage or were shot down. HMM-268 even had an incident where an RPG entered the bottom of the aircraft while it was flying, hit the crew chief in his back on his SAPI [Small Arms Protective Insert] protective plate and helmet—knocking him out—and then exited through the top of the aircraft, miraculously missing all the vital flight components and never detonating.
I distinctly remember evacuating a Navy SEAL on my second deployment in 2006 from the very same zone. He was the first SEAL killed in action in Iraq. One of his fellow SEALs came with him on the flight when we picked him up. He had a severe gunshot wound to the head and face but was alive during the transit. He succumbed to his injuries after we dropped him off. It became clear early on that no one was invincible here, not even a SEAL.
Mass casualties were the worst because improvised explosive devices and car bombs were usually the culprits. The odor of burned flesh is something I hope to never again smell. Lots of times, people with missing limbs were bleeding to death in the back of the aircraft. If it weren’t for the Navy corpsmen, who worked tirelessly to keep the wounded alive while in transit, many more would have died. They did the dirty work to keep everyone breathing or from losing that extra pint of blood that might cost the individual his or her life. They stopped bleeding from massive wounds or held someone’s guts in during the flight to keep them alive.
One of the worst things to hear a corpsmen say to a pilot is “Fly faster,” because that means the patient is slipping away. During CASEVAC, the pilots already fly as fast as the aircraft can go, so to get such a request from a corpsman leaves one with a helpless feeling. There were times when patients would expire in the aircraft en route. Those are some of the longest and quietest flights a pilot experiences. No matter what the situation is regarding the enemy or what is occurring in the back of the aircraft, you must force yourself to compartmentalize what you are seeing and hearing, separating it from the task at hand, which is to get everyone out of there as quickly as possible.

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It was about two months into my second deployment in 2006 when I was assigned to fly a mission to al-Qa’im, near the Syrian border. I had been so glad when I learned I was flying to this desolate outpost, because I had heard a rumor that I could hardly believe. I had endured numerous months of compartmentalizing what I saw and only focusing on the task at hand. When we arrived and shut down the aircraft, I headed straight to the chow hall. As I approached the door to the small, rickety wooden structure, I saw the words “Winchester Hall” above the entrance. It made me smile ear to ear. I was nervous though, wondering about the rumor. I walked in the front door and looked around. There, just inside and to the upper left of the main entrance, was a glass case. Inside it, there it was—a big, bright-blue football jersey with white block letters on the chest: NAVY 73.
It was the Navy football jersey of Ron Winchester (USNA 2001). He had been a teammate, killed in action in Iraq in September 2004, a few months prior to my first deployment. Navy football is a brotherhood, built through strong bonds among teammates. Ron was the first person I knew who had given his life during the conflict. His death was shocking; I had a hard time absorbing that he was actually gone. It was one of those things that people never think will happen to someone they know. Two months later, J. P. Blecksmith (USNA 2003), another teammate, was killed in action. Other teammates, Bryce McDonald (USNA 2003) and Scott Swantner (USNA 2001), suffered injuries. I received telephone calls about all of them. My reaction to seeing Ron’s jersey was immediate and uncontrollable. I turned away and walked outside so the other pilots and crew chiefs wouldn’t see me.
Here, in this God-forsaken shithole of a place that looks like the surface of the moon, was the most beautiful thing I had seen in a long time. I pulled myself together by focusing my eyes on the metallic band around my left wrist that bears Ron’s name. I wore the band during all three of my deployments to Iraq. Every time it was hot, things were shitty, or I didn’t think I could do another day of the grind, I’d look at my wrist and be reminded of the numerous people, like Ronnie and J.P., who had counted on us on a daily basis.
Once I had pulled myself together, I walked back in, had a little something to eat, and then walked over to the glass case. I left Ronnie a note on the glass thanking him for his sacrifice and letting him know it had not been in vain. I also left him one of the squadron patches that we wear on our flight suits. At some point, he had been in the back of a CH-46 being CASEVAC’d while mortally wounded or his remains were transported via an “angel” transport to al-Taqaddum, where Mortuary Affairs was located.

Angel transport was a routine part of my squadron’s mission, so I knew that there was absolutely no delay in getting the remains of coalition personnel killed in action to al-Taqaddum. On the day they perished, the deceased were transported there and prepped for the return home. These missions were flown nightly, and like CASEVACs, I had to learn to compartmentalize and focus on the task at hand. One mission in particular, though, momentarily broke through the compartment.
I had been assigned to transport five Marines out of Ramadi who died in an IED blast. As we flew in, the entire Marine battalion that operated out of Ramadi was off to the right of the landing zone, standing in formation, at attention. After they brought four of the remains to the aircraft on stretchers, someone handcarried the remains of the fifth Marine in two body bags to the helicopter. When we had landed, the battalion’s commanding officer had come on board the aircraft to tell us that one of his Marines was going to accompany the remains back to al-Taqaddum. Passengers and “angels” were never on the same aircraft together, but in this case an exception was made. The Marine accompanying one of the bodies back was the deceased Marine’s twin brother.
Several months after seeing Ronnie’s football jersey in the chow hall at al-Qa’im, disaster struck within my squadron: Morphine 1-2, one of the call signs of our aircraft, was shot down by a man-portable air defense shoulder-fired missile near Karma while returning from a CASEVAC mission on February 7, 2007. Capt. Jennifer Harris (USNA 2000), 1st Lt. Jared Landaker, Sgt. Travis Pfister, Sgt. James Tijerina, Cpl. Thomas Saba, HM1 Gilbert Minjares, and HM3 Manuel Ruiz all perished. These individuals had saved hundreds of other people’s lives flying CASEVAC missions before giving up their own.
As I considered my time as a member of the Purple Foxes, I realized that the hardest part was the mental aftermath. I would lie in bed after a mission, alone with my thoughts. I recalled everything in detail—the sights, smells, radio calls, and what the weather was like. I felt somewhat responsible for any deaths although there wasn’t anything else I could have done. I thought about the fact that that person had a mom and dad who did not yet know what horrible thing had happened to their son or daughter. I wondered about the person who had just made the ultimate sacrifice.
It’s a mixture of emotions. I felt great about what we were doing, because we were saving lives, yet there were times when I knew that those who survived an incident were at the beginning of a painful postwar life. I often wondered about those whom we flew out of harm’s way because we never saw them again. Were they upset about their situation? Did they wish that they had not lived because their life from that point on would be so different and difficult? Were they glad they had survived despite their injuries? Were any of them like Lieutenant Dan from the movie Forrest Gump, who hated Tom Hanks’s character for rescuing him, forcing him to live life in a wheelchair instead of letting him die on the battlefield?
These thoughts weighed on my conscious for a long time, and then on October 21, 2008, I received the answer to some of the questions that I had been afraid to share with anyone. On that day, I received an email from another pilot with whom I had done the first two deployments to Iraq. He said that he had received an email from one of the Navy nurses who had flown with us during the second deployment. An Army sergeant by the name of John Kriesel was trying to get in touch with the squadron. Our squadron had CASEVAC’d him on December 2, 2006, in Zaidon, south of Fallujah, after the vehicle he was in struck a pressure-plate IED wired with two hundred pounds of explosives. It left a crater seven feet wide and four-and-a-half feet deep. One person died at the scene, and another died in the helicopter, but Sgt. Kriesel survived. Now, two years later, Sgt. Kriesel was searching for the crew, flown by a USNA 2000 grad, that had picked up him and his men that day. He wanted to tell us the following:

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(Continued from page 2)

I know that you said I don’t have to thank you, but I will always have an appreciation for you guys at TQ and the military medical system as a whole. Both of my sons know the story and always ask about you guys and even at 6 and 7 say that they thank God that you guys were there for me and my men. They know and understand that I wouldn’t be alive without you guys. My seven year old built a CH-46E Sea Knight with Legos and it looks pretty good. Take care and thanks again.
I remember reading that and bursting into tears. I got on my knees and thanked God that he and his family were grateful that he was alive, despite his having lost both his legs. Not only was he grateful that he had survived, but his kids were so glad to have their dad back with them. His email was an unexpected gift that helped relieve the weight I had felt about the missions we had flown. Sgt. Kriesel was grateful, and so was I.
That is what Marine Air is about—supporting the guy on the ground, whether through assault support or close air support. It certainly is not about us. It always has been and always will be about supporting the guy on the ground. It is clearly understood that when a pilot screws up—whether because of a bad decision, lack of attention to detail, poor planning, headwork, or situational awareness—many times it is the Marines on the ground who pay the price for the pilot’s mistakes. The driving force is the fear of failure and the thought of possibly letting someone down. People are relying on you to protect or save their life. Failure is simply not an option. If that doesn’t motivate a pilot, then Marine Air is not the business that person should be in.
Now, years later, I can say with certainty that the challenges of serving in Iraq combined with the lessons learned at the Naval Academy—along with the accompanying hurt, pain, adversity, and emotions—have built me into a much better person. I would not trade these experiences, the good and the bad, for anything. It was a gut check and trial by fire, a life experience that I will never forget. The lessons I learned are applied to every facet of my life every day.

The American way of life is not possible without the sacrifice of the few. Edmund Burke wrote, “All that is necessary for the triumph of evil is for good men to do nothing.” Those that sacrificed did something and are some of America’s bravest sons and daughters. I can only hope that the families of Ron and J.P., the crew of Morphine 1-2, and others that made the sacrifice knew that when things sucked over there, they were the ones that I thought of, that kept me going. I know that there is nothing I can say or do to make their families’ pain go away, but I hope and want them to know that there were people over there who found strength and drive in themselves at the very thought of their son’s and daughter’s sacrifice. I will forever remember what my passengers in the back of the CH-46 did for our nation and how humbling it was to have served them.
“Evacuating the Injured” by Rocky Checca is adapted from In the Shadow of Greatness: Voices of Leadership, Sacrifice, and Service From America’s Longest War, edited by Joshua Welle, John Ennis, Katherine Kranz, and Graham Plaster. Reprinted by permission of the Naval Institute Press.

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GTVRG TSUNAMI DISASTER 2004 DATABASE

Donnerstag, 9. Februar 2017

USAF TRANSSPORTATION COMMAND AEROMEDICAL EVACUATION UNITS