Interactive: See how the roles in the current USAF en route continuous care system (Ercss) have improved on prior practice. Tap here in the digital edition or go to AviationWeek.com/ERCCS

Follow a simulated “patient” as Jim Mathews rides along on an airevac training mission. Watch it in the digital edition, or go to AviationWeek.com/video

U.S. armed forces quietly made medical history in March, when statisticians recorded zero combat-related fatalities among American service members deployed in Afghanistan. To be sure, the pace of operations has slowed from its peak a few years ago and that can partly account for the drop, but forces continue to engage and troops continue to be in harm’s way. In fact, during that record-setting March, seven American battle injuries were severe enough to require aeromedical evacuation. So far in 2014, 23 U.S. service members have died, and 93 suffered battle injuries that prompted an air evacuation.

Even so, the statistics for the duration of the wars show that the risk of dying in combat for U.S. military personnel wounded in Afghanistan and Iraq was almost half that faced by service members wounded in Vietnam in the 1960s and 1970s, and about 45% of that for World War II combatants. While there are many reasons for this—simple things such as soldiers’ improved self-care and buddy-care training along with widespread adoption of tourniquets play a role—perhaps the most decisive has been a shift in thinking about how to use helicopters, turboprop transports and long-range airlifters to project very sophisticated and complex medical care deeper into the battlespace than ever before, even to the point of injury.

“We have spent 13 years developing the most complex and the most effective by far deployed trauma system in the history of warfare,” says Air Force Col. (Dr.) Mark Ervin, a general surgeon who oversees the medical aspects of three Air Mobility Command programs that fuse airpower with doctors, nurses, medics and technicians. The Critical Care Air Transport Team (Ccatt) (see www.ccatt.info), the Tactical Critical Care Evacuation Team (Tccet) (see http://ow.ly/zt1zC) and En Route Critical Care programs send surgeons, trauma nurses, nurse-anesthetists, operating-room technicians and paramedics far forward to deliver care comparable to that received in an intensive-care unit or a Level I trauma center emergency room, either at the point of injury or in the air. It is difficult, complex and—until these conflicts—unheard of.

“Part of why we’re so good today is [nearly] 14 years of practice,” says Air Force Brig. Gen. (Dr.) Kory Cornum, Air Mobility Command surgeon. Cornum, a pilot and an orthopedic surgeon by training, shares the concern of many in the military medical community that with the coming drawdown, maintaining that combined clinical and aeromedical evacuation know-how could be a challenge. “We think about it all the time,” he says. It’s why we have people” in civilian trauma centers throughout the U.S., “it’s why we have really expensive simulators, and are looking at how [to] keep that capability hot, not just warm. Because when you need it, you need it.”

This Aviation Week & Space Technology editor, a former advanced life-support medic, recently participated in an exercise to demonstrate how medical and air assets from the active Air Force, Reserve and Mississippi Air National Guard and Army National Guard are trained and integrated to fly high-level medical expertise into and out of battlefields. The exercise included an engines-running offload of a simulated critical patient from a Chinook helicopter to a waiting WC-130J of the 53rd Weather Reconnaissance Sqdn. “Hurricane Hunters,” training at the Keesler AFB, Biloxi, 81st Medical Group’s hospital Tier I simulator lab, and a visit to Camp Shelby near Hattiesburg, to observe how special operators and medical teams can train cost-effectively in an environment that mimics deployment downrange.

This editor worked alongside the Tccet medics, one a veteran of several deployments and another a nurse officer preparing for first deployment on an actual mission. Our patient had suffered traumatic amputation of both legs, one above the knee and one below, and also had an assortment of other injuries, including compromised lungs due to a bullet entering his left chest and exiting on the right. This would be a complex case for any clinician, but for traditional battlefield medics—trained to a level roughly equivalent to either a basic emergency medical technician or even a full paramedic—managing the combination of blood loss and airway compromise would be overwhelming.

In the past, such patients would be “packaged” (IV lines inserted, oxygen administered, etc.) and moved to an aid station away from active combat, a process that could delay definitive medical intervention for up to 24 hr. But in the new continuous en route care model, our Tccet unit began advanced procedures close to the point of injury, essentially flying the emergency room to the patient and maintaining emergency room-level care in the helicopter.

Originally developed in June 2011 to receive complex patients at the point of injury from soldiers and basic medics trained in Tactical Combat Casualty Care techniques, Tccet today deploys itself to the point of injury in about a third of all cases. Another innovation just coming to fruition is the inclusion of a surgeon and an operating-room technician to immediately address higher-level care as the patient is airlifted to a hospital.

“The piece we are building now—we’ve already deployed the initial one, Tccet-Enhanced (Tccet-E) supporting [U.S. European Command]—supplies the capability to do life-saving surgery in flight if necessary,” Ervin says. The ability to operate inflight is not the ultimate goal, but it is a valuable asset, he notes.

This first Tccet-E, although it is a part of European Command, exists to support U.S. Africa Command and deploys from Eucom on African assignments.

On the ramp at Keesler AFB, the Tccet medics transferred our patient to a waiting WC-130J that had landed nearby just moments before. The patient was handed over to a Ccatt group who provided—in the back of the aircraft—the level of care received in an intensive care unit. Ccatts typically include doctors, nurses and respiratory therapists, bringing advanced-level skills and training to the Aeromedical Evacuation system.

Lt. Gen. (Dr.) Thomas W. Travis, the Air Force surgeon general, says that since the 9/11 attacks, the service has logged 194,300 patient movements, and that Ccatts transported more than 9,200 critically injured or ill patients. In addition, the Tccet, whose capabilities grew out of Ccatt to provide damage-control resuscitation on rotary-wing, forward-deployed fixed-wing and tiltrotor aircraft, has “accomplished more than 1,600 critical care patient movements since we began the program,” he says.

Are all those flights making a difference? Using case fatality rates, or CFRs, from the U.S.’s Operation Enduring Freedom in Afghanistan as the metric, the overall likelihood that any U.S. combatant wounded in action will survive combat trauma is 91.4%, compared with 83.9% in Vietnam—a substantial and clinically significant improvement. CFR measures the percentage of all combatants wounded in action who ultimately die as a result of their injuries, and takes into account all wounded combatants at every stop in the en route care system, from point of injury through deployed medical centers and U.S. hospitals. Cornum notes that using a slightly different metric, which measures death rate after admission, presents even stronger evidence: a U.S. combatant who survives through admission via the emergency rooms at Kandahar, Bagram or Bastion ABs in Afghanistan has a better than 99% chance of leaving the hospital alive.

Like others in military medicine, Travis agrees that this hard-won capability could diminish unless steps are taken to keep it active and working.

“We don’t have a [complete] answer, but we have a way forward,” Travis says. The solution includes continuous training, expanding cooperation with civilian medical facilities and more rotations for military doctors and nurses through designated U.S. trauma centers. “We don’t want to lose the lessons learned.”

The Air Force is moving to what Travis describes as a layered, centrally managed training structure called Sustained Medical Airmen, Readiness Trained, or Smart. In a three-tiered approach, doctors, nurses and technicians at USAF facilities of all sizes will train with a standardized curriculum using “organic training opportunities, local training affiliation agreements with partnering hospitals and, when necessary, regional currency sites to ensure required skills are preserved and staff is sustained in a trained and ready status.”

The first class is scheduled to begin at a regional Smart site on Sept. 15 at Nellis AFB in a partnership linking the Mike O’Callaghan Federal Medical Center, the University of Nevada School of Medicine in Las Vegas and the University Medical Center. The Nevada effort will provide all three tiers of the Smart program in a single place.

Col. Frank Amodeo, commander of the Air Force Reserve’s 403rd Wing who has logged more than 6,000 flight hours, notes that because the aeromedical evacuation skills are perishable, taking advantage of the 3,000 annual flying hours allotted to his Hurricane Hunters’ 10 WC-130Js makes sense as an additional way to get “the biggest bang for the taxpayer’s buck.

“We’re already flying a weather recon mission, so why not” use that “three-hour sortie” to train aeromedical evacuation crews and advanced medical teams, Amodeo reasons. It is “the best way make every dollar count,” he notes, and it is an imperative his units have embraced.

For the recent Keesler mission, the WC-130J that transported our patient was simultaneously conducting a weather reconnaissance training mission over the Gulf of Mexico and obtaining a qualification sign-off for a new mission pilot. The plan was for our aircraft, call sign Teal 33, to depart using visual flight rules out of Gulfport to practice weather-flight procedures and crew coordination between the flight crew and the aerial weather reconnaissance officer who directs the flight when in the storm area. We would also be dropping sensor packages called dropsondes into the ocean to gather critical weather data in real time as they fall through the air. Meanwhile, in the back of the airplane, the Tccet and Ccatt members were honing their skills in assessment, airway management and communication in the cramped, noisy environment aloft.

Although weather prevented the helicopters from completing their participation, overall the exercise succeeded in conducting three separate training missions in a single cost-effective flight: a combat medical extraction, a transfer to an aeromedical evacuation aircraft and a weather reconnaissance sortie.

“The biggest thing for us is we’re uniquely positioned at Keesler” to take the lead in this kind of training, Amodeo says. The southern part of Mississippi is unique in its ability to supply all of the pieces needed to train for en route medical care. The recent training day was scheduled to include the Ccatt and Tccet from the active Air Force’s 81st Medical Group at Keesler; the 53rd Weather Reconnaissance Sqdn. of the Air Force Reserve’s 403rd Wing, also from Keesler; the 172nd Airlift Wing’s C-17s and 186th Air Refueling Wing’s KC-135s, based in Jackson and Meridian, with the Mississippi Air National Guard; plus the Mississippi Army Guard’s UH-60, AH-64, CH-47 and LUH-72 battalions, along with the Army Guard’s 1108th Theater Aviation Sustainment Maintenance Group.

It is the combination of realistic training, the application of airpower and deployment of physicians, nurses and technicians that has led to breakthroughs in combat survival. And while all of the pieces need to work together to make the system function, Air Force officials agree that one aircraft has emerged as the game-changer: Boeing’s C-17 Globemaster III.

“That airplane has been a lifesaver in this war,” declares Travis. “The right people were listening to the right people at the right time” when the aircraft’s configurable cargo hold, power and other air evacuation-friendly systems were being designed.

Adds Cornum: “We get air evac done on other platforms but the platform of choice for air evac and Ccatt is the C-17, because for the first time we have a transport that has light, and room, and places to plug in equipment and oxygen and temperature control. If you’re going to have somebody” for a few minutes in the back of an ambulance temperature control “isn’t that critical, but if you’re going to have someone on the airplane for six hours, depending on what their injury is temperature control is huge.”

The C-17s used during the training exercise came from the Mississippi Air National Guard. According to Air Force data, 88% of aeromedical evacuation missions are conducted by Guard and Reserve aircraft.