Air Guard Assists Critical-care Evacuations

By Donna Miles

American Forces Press Service

RAMSTEIN AIR BASE, Germany, May 3, 2011 – Minutes after takeoff here, Air Force Col. (Dr.) Charles Chappuis jumped to his feet aboard a C-17 Globemaster III aircraft to check on Army Spc. Adam Castagna, one of three critical patients under his care being transported to the United States for advanced medical care.

Chappuis is the surgeon for a three-person Air National Guard air transport team deployed to Ramstein to treat critically wounded and ill patients flown from the combat theater.

Castagna was among 24 patients aboard the April 29 aeromedical evacuation flight to Joint Base Andrews, Md. Seven patients were in critical condition, requiring two critical-care teams –- in this case, an Air National Guard team and an active duty team –- to monitor them continually during the eight-hour flight.

Eleven days earlier, 14 days shy of his 2nd Stryker Cavalry Regiment’s redeployment to Vilseck, Germany, Castagna had been on a patrol in the Panjwai district of Afghanistan’s Kandahar province. An enemy attack on his platoon, and the explosion that ensued resulted in the wounding of his right eye and liver which ultimately cost 37-year-old Castagna his spleen, his younger brother, Mike, explained.

In past conflicts, patients with wounds as severe as Castagna’s never could have been transported so early in their recovery. But the critical care air transport teams have changed all that, said Air Force Lt. Col. (Dr.) Raymond Fang, trauma director at Landstuhl Regional Medical Center in Germany.

The teams not only speed up the process of moving patients to increasingly more advanced care closer to their loved ones, but also free up hospital space needed for newer battlefield casualties.

“We can’t hold everybody at Bagram [Airfield in Afghanistan], and we can’t hold everybody until they are well at Landstuhl,” Chappuis said. “We have to keep them moving, because there are more coming. And if we don’t move them, then we reach our chokepoint. So our goal is to progressively move them until they are back in the United States.”

With every patient move, he said, the goal is to provide “not only first-class care, but a step up in the advancement of care.”

The critical-care teams work closely with primary-care and trauma teams to ensure patients’ movement through that continuum of care is as safe and smooth as possible. “We get them to as good as we can get them before they get on the aircraft” to minimize, and ideally, eliminate complications, Chappuis said.

With about 750 pounds of high-tech medical equipment that essentially turns an aircraft into an airborne intensive-care unit, the teams ensure there’s no lapse in patient care during transport.

“Our environment has been described as a flying ICU, and I think we provide the equivalent high-tech medicine that you would get if you were in an ICU in Washington, D.C.,” Chappuis said. “We have all the drugs and all the equipment to monitor the patients. And I think the proof of that is our success rates are so good.”

In January, the Air Guard readopted the critical-care transport team mission, which it had phased out about six years ago, bringing welcomed support to active-duty and Air Force Reserve teams that had been conducting the mission, along with a wealth of civilian trauma-care experience.

Chappuis, for example, has 30 years of surgical experience under his belt. When not in uniform with the Louisiana Air National Guard, he works as a professor of clinical surgery at Louisiana State University School of Medicine and as chief of surgery at the University Medical Center in Lafayette, La.

In addition to being a Kentucky Air Guardsman, Air Force Lt. David Worley, the team’s critical care nurse, works in his civilian capacity as a cardiac catheterization lab nurse at a hospital in Louisville, Ky. Air Force Tech. Sgt. Chris Howard, from the North Carolina Air National Guard, works as a respiratory therapist for the team, and also as a civilian at Carolinas Medical Center Pineville near Charlotte, N.C.

“From a Guard standpoint, we bring a tremendous amount of experience from the civilian world,” Chappuis said. “We do this almost every day at home, and it brings a tremendous amount of medical experience to the fight.”

Air Force Lt. Col. Kathleen Flarity, commander of aeromedical evacuation at Bagram, called incorporating the Air Guard into critical care teams “a great idea.” The biggest plus, she said, is the wealth of clinical experience the Guardsmen bring to the mission.

“They are phenomenal –- really smart, talented people,” she said.

Air Force Staff Sgt. Napolean Gifford, an active-duty respiratory therapist with the 10th Expeditionary Aeromedical Evacuation Flight, said he’s happy to work side by side with experienced Guard critical-care teams.

“It really helps, because they bring a lot of trauma experience from working at large trauma centers,” said Gifford, a Douglas, Ga., native.

With a steady load of patients being transported from the combat theater to Landstuhl and on to Andrews, Fang welcomed the expanded the pool of military professionals qualified to conduct critical-care air transport missions, noting that the number of people with their experience is limited, and the training experience in the Guard broadens the pool of people qualified to serve on the teams.

Developing the clinic skills and abilities for critical-care transport teams takes years, Chappuis explained. Beyond the traditional critical-care skill sets, it requires about five weeks of highly specialized training.

The training culminates with a demanding two-week Center for Sustainment of Trauma and Readiness Skills, or C-STARS, training at the University of Cincinnati in Ohio, where simulation that replicates realistic scenarios subjects trainees to the most extreme rigors they’ll face in critical-care transport.

“It is kind of like the ‘Wizard of Oz,’” Chappuis said. “There is somebody in the back room controlling the computer and videotaping everything, and then there is another person in the room actually watching you. And you are graded every time you go through the simulation.”

Successful completion of C-STARS is required before deploying for CCAT duty. “By the time you complete the course, you have demonstrated if you can cut it or not,” Chappuis said. “If you don’t make the cut at C-STARS, then you don’t deploy.”

While the teams are trained and equipped to treat the most severe medical complications in the most challenging in-flight situations, Fang said, the goal is to ensure a calm, controlled airborne experience.

“They are almost like the firemen,” he said of the critical-care teams. “You want them on the plane if the patient has problems, but ideally, it is a standard ICU shift. And in most ICU shifts, you don’t see people running around like crazy. You have it calm, and there is a plan, and you take care of the patient.”

Mike Castagna praised the care the transport team and every other military medical professional has provided since his brother was wounded. “The care he has gotten every step of the way has been exceptional,” he said. “It has far exceeded anything I have ever seen in a civilian hospital.”

Castagna’s movement through his continuum of care hasn’t been without its roller-coaster moments. He received initial care at the Kandahar Airfield Hospital, then the Staff Sgt. Heathe N. Craig Joint Theater Hospital at Bagram before making the seven-hour aeromedical evacuation flight her to get treatment at Landstuhl. During that flight, one of Castagna’s arteries burst, and a critical-care transport team immediately put him on life support, his brother said.

Castagna’s entire family and his fiancée flew to Germany to be with him, fearing the worst. But accompanying his brother during the flight to Andrews, Castagna marveled at his progress since the live-saving intervention.

“Literally, in a day and a half, he went from being on life support to talking with us,” he said.

Guardsmen say the chance to make a difference for wounded warriors like Castagna makes then want to be part of the all-volunteer mission. “Nobody called us up and said, ‘Hey, it is your turn,’” Chappuis said.

Howard, at Ramstein for a six-month deployment, said he jumped at the critical-care air transport opportunity as soon as the Air Guard adopted the mission. “It’s satisfying,” he said. “For me, it was a way to give back.”

“The opportunity to come here and help kids get home is a great opportunity for me, and that is why I chose to do it,” agreed Worley. “It’s a very good mission. It’s what we would want for our own families.”

That’s exactly what Chappuis said he tells his wife when he explains why he volunteered.

“I have grown children. If it was one of my children, I would want the absolute best care for them to make these multiple flights from Afghanistan or Iraq back to the United States,” he said. “And if that is my desire for my children, I should be ready to pony up and do it myself.”