1
DOCTOR ON BOARD what is the optimum skill-mix
in military helicopter casevac?

• Lt Col Tom WOOLLEY
• Surg Lt Cdr Stuart MERCER
• Surg Cdr Steve BREE
• Lt Col Douglas BOWLEY

2
Civilian pre-hospital helicopter

• High profile
• Charitably-funded
• Accepted as invaluable by the general population

3
Does it make a difference?

• Mature urban trauma setting gt1800 patients
• Comparing airlifted patients and those who were
  transported by ground emergency medical service
  (GEMS) with transportation time that exceeded 30
  minutes (GEMS gt 30 minutes)
• No significant difference in mortality between
  the two transport modalities
• Talving P et al.
• Helicopter Evacuation of Trauma Victims
• in Los Angeles Does it Improve Survival?
• World J Surg. 2009 August.

4
Military pre-hospital care

• Helicopters accepted as vital
• terrain
• time-lines
• hostile action

5
Critical report

• In Vietnam, wounded soldiers arrived in hospital
  within 25 minutes of injury. In Iraq in 2005,
  that figure is 110 minutes, on Operation Herrick
  IV, (Afghanistan 2006 ) the average pre-hospital
  time was seven hours.
• Parker PJ.
• Damage control surgery and casualty evacuation
  techniques for surgeons, lessons for military
  medical planners.
• J R Army Med Corps. 2006 Dec152(4)202-11.

6
Introduction of MERT

• Dedicated air asset
• Doctor
• Flight nurse
• Paramedics
• We are bringing the emergency department forward
  on to the helicopter

7
MERT HERRICK 9

• July Nov 2008
• 324 missions
• 429 patients
• 303/324 94 to Bastion Hospital
• Median patients carried was 1
• range 1 13

8
Nationality of patients

• 242/429 56 were local nationals
• 150 35 were UK forces
• 37 8.6 coalition allies

9
Medical category assigned

• 95/429 22 were assigned category T1
• 223 52 were T2
• 93 21.5 were T3
• 18 4 were dead

10
Mechanism

• 208 48 had received blast injury
• 109 25 had GSW
• 6 1.5 had both blast GSW
• 41 9.5 were medical
• 23 5 were from MVC
• 42 10 had other diagnoses

11
Flight timings

• Median time from take off to delivery of
  casualty 44 minutes
• Range 10-183 minutes
• Doctor flew on 283/320 88 of missions

12
Did the doctor contribute?

• Of 283 missions, it was thought that the doctor
  was not required in 219/283 77

13

• Of 62 missions where doctor was useful,
• RSI 28/62 45
• Provision of analgesia/sedation/
• blood products 21/62 34
• Chest drain/thoracosotomy 3/62 5
• Pronouncing life extinct 4/62 6

14
MERT a difficult balance

• 77 missions doctor was simply a passenger
• Ground-to-air threat
• Distance from point of wounding to MERT landing
  site

15
MERT a difficult balance

• 23 missions doctor made ve contribution
• Knowing when NOT to intervene
• Morale effect to troops on ground

16
Summary

• The MERT is a high value asset which
• makes an important contribution to patient
• care. A relatively small proportion of
• missions require interventions beyond the
• capability of well-trained military paramedics.

17
Conclusion

• Casualty care is thought to by presence of a
  physician
• Military pre-hospital care should be led by
  doctors / paramedics