Next Generation Stretcher Systems for Military Ambulances and Medical Evacuation Vehicles by The Magazine Production Company

Special Report

Next Generation Stretcher Systems for Military Ambulances and Medical Evacuation Vehicles

Converting Military Vehicles Into Ambulances 21st Century Stretcher Systems for Modern Military Medevac The Journey from Volunteer to Professional Military Ambulance Careâ&#x20AC;Ś The Evolution of 21st Century Military Pre-Hospital Treatment and Ambulance Care Future Stretcher Systems for Military Medevac

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Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom Switchboard: +44 (0)1737 850 939 Fax: +44 (0)1737 851 952 Email: info@globalbusinessmedia.org Website: www.globalbusinessmedia.org Publisher Kevin Bell Business Development Director Marie-Anne Brooks Editor Mary Dub Senior Project Manager Steve Banks Advertising Executives Michael McCarthy Abigail Coombes Production Manager Paul Davies For further information visit: www.globalbusinessmedia.org The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated. Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles. © 2013. The entire contents of this publication are protected by copyright. Full details are available from the Publishers. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical photocopying, recording or otherwise, without the prior permission of the copyright owner. Cover Image – Schiebel Camcopter S 100 – fully equipped with Volz Servos.

Optimizing Patient Care or Quantity? Treatment Inside the Vehicle Reliability and System Safety Survivability During Transportation Loading the Stretcher Patient Women in the Field Getting the Best Value from Your Ambulance

21st Century Stretcher Systems for Modern Military Medevac

Don McBarnet, Staff Writer

The History of Treatment for Soldiers Wounded in Battle A Small Improvement in Care During the Napoleonic Wars (1803–1815) The American Civil War Experience The Impact of Changes During World War 1 on Emergency Medical Care

The Journey from Volunteer to Professional Military Ambulance Care…

Mary Dub, Editor

Recognition of the Need to Reduce the Transit Time and Change Pre-Hospital Treatment Systems How the French Army and the American Expeditionary Force Developed Pre-hospital Treatment in an Age of Trench Warfare American Emphasis on Treatment During Evacuation While the French Approach was Rapid Transfer to High Quality Care

The Evolution of 21st Century Military Pre-Hospital Treatment and Ambulance Care

Mary Dub, Editor

TCCC (Tactical Combat Casualty Care) 21st Century Battlefield Care at the Point of Wounding The US Army’s Echelons of Care Transportation of Casualties Ground Transportation of Casualties by Ambulances

Future Stretcher Systems for Military Medevac

Don McBarnet, Staff Writer

The Importance of the Location of First Treatment Summarising the Debate about Forward Treatment First or Medical Evacuation The Argument For and Against Various Types of Medevac Transportation The Importance of the Design of the Stretcher for Manual Use, as a Litter or Airlift

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SPECIAL REPORT: NEXT GENERATION STRETCHER SYSTEMS FOR MILITARY AMBULANCES AND MEDICAL EVACUATION VEHICLES

Foreword T

he first treatment and transportation of

The First World War and the 20th century marked

casualties from the point of injury to high

the beginning of well-organized treatment and care

quality medical care is now an assumed right of the

for casualties, but their transportation was still the

soldier in action. However, this has not always been

task of trained volunteers. Differences in thinking

the case. This Special Report tracks the changes in

about the optimum system for the organization of

thinking and technological developments that have

first medical care are highlighted in the French and

dramatically reduced the probability of fatalities in

American approach to the provision of field hospitals.

the field of battle.

The fourth article reports on how medical treatment

The Report opens with an article that looks at the

has had to respond to the demands of different types

special requirements of ambulances in the battlefield.

of warfare and the way that there can be no absolute

These travel as part of an armoured vehicle fleet and

best practice, but perhaps a best adaptation to the

are required to have the same driving and protection

demands of a particular battle, or type of warfare.

capabilities as the rest of the fleet. However, they can

The final article, a glimpse at the future, looks at the

be built either as evacuation vehicles or treatment

Chilcot Iraq Inquiry and the testimony of Lt Gen Louis

ambulances and, when having to face all sorts of

Lillywhite. It makes the point that we should learn from

emergency needs on the battlefield, it is difficult to

the devastating impact of dramatic cuts in the â&#x20AC;&#x2DC;90s

know for which of these functions they should be

on skilled manpower capacity in military medical

designed. To overcome this problem, Frestems has

services. The lack of equipment and manpower

developed concepts that adapt ambulances for

handicapped the provision of high quality casualty

multiple roles. The main factors to be considered

care at the early stages of the Iraq war. In summary,

in designing military ambulances are safety and

it looks at recent developments in stretcher design

survivability during transportation, all in the most

and technology and looks towards rising demand

cost-efficient manner, while giving the best possible

for a vital component of emergency medical care for

performance to save lives on the battlefield.

21st century soldiers.

The second article notes the different time scales in Europe and America in realizing that a professional organized system of medical care was vital on the battlefield.

Mary Dub Editor

Mary Dub has covered the defence field in the United States and the UK as a television broadcaster, journalist and conference manager.

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SPECIAL REPORT: NEXT GENERATION STRETCHER SYSTEMS FOR MILITARY AMBULANCES AND MEDICAL EVACUATION VEHICLES

Converting Military Vehicles Into Ambulances Anna-Kaisa Lahdensivu, Frestems Oy

Stretcher loading systems and ambulance designs for military requirements

FRESTEMS CONVERTS MILITARY VEHICLES INTO AMBULANCES PROVIDING SOLUTIONS FOR SOLDIER SURVIVABILITY IN DEMANDING PATIENT RESCUE ENVIRONMENTS.

he chances for wounded soldiers to survive on the battlefield are largely dependent on the time a patient gets first aid and is moved to the nearest field hospital. In many cases, patients can only be reached by armored ambulances at the front line of the battlefield. Ambulances travel as part of an armored vehicle fleet and are required to have the same driving and protection capabilities as the rest of the fleet. Common vehicle design rarely considers the special requirements of an ambulance. Frestems helps vehicle manufacturers modify armored vehicles into ambulances. The company has extensive expertise in ambulance layouts, and provides leading stretcher fastening systems and other ambulance equipment to build effective and reliable ambulance solutions. At the start of a project, a layout study is made for the ambulance. An equipment layout is designed on top of a 3D model of the vehicle. The study gives the vehicle manufacturer

and the end-customer an idea of what the ambulance variant will look like. The layout options illustrate capacities for sitting patients, stretcher patients and medics. Early engagement of a professional ambulance designer helps to create cost efficient and high quality ambulance projects, avoiding many pitfalls. Frestems provides total solutions, from the design phase through to implementation and verification. Selecting a tried and trusted solution provider for your project is one less thing to worry about. The requirements for ambulance capabilities vary between countries. The level of the ambulance equipment reflects the budgets and strategies on patient rescue. There are no globally enforced standards for ambulance requirements.

Optimizing Patient Care or Quantity? Traditionally, the first decision for ambulance building is whether to build an evacuation www.defenceindustryreports.com | 3

SPECIAL REPORT: NEXT GENERATION STRETCHER SYSTEMS FOR MILITARY AMBULANCES AND MEDICAL EVACUATION VEHICLES

Frestems provides total solutions, from the design phase through to implementation and verification.

AMBULANCE INTERIOR CAN BE CONVERTED TO MULTIPLE ROLES ENABLING TREATMENT AMBULANCE TO BE USED FOR EVACUATION.

vehicle or a treatment ambulance. In a treatment ambulance, patient care possibilities are optimized, but the ambulance is often only able to transport one or two patients. In an evacuation vehicle, the amount of patients comes first and the treatment of severely wounded patients is challenging. In practice, you never know the emergency needs on the battlefield, so it is difficult to predict for which capabilities an ambulance should be optimized. To solve this dilemma, Frestems has developed concepts that adapt the ambulance for multiple roles. The limited space inside the vehicle can be used effectively to allow alternative configurations. To give a few examples of how the adaptation is made â&#x20AC;&#x201C; The solutions can be based on stretcher fastening systems that are foldable to the stowage position under the seats when not in use. Or stretcher platforms can be moved inside the vehicle with a push of a button. With special seat solutions, a stretcher platform can also be provided with cushions and used as a seating platform. Adapting an ambulance for multiple roles is challenging due to the limited space, but it is a mandatory requirement for a modern vehicle.

Treatment Inside the Vehicle The g-forces experienced by patients and medics in a moving vehicle on rough terrain causes strain to the patients and limits options for the medics to perform treatment during transport. The patient is given first aid and their condition is stabilized before transport. Patient treatment during transport consists mainly of pain relief, oxidization, hydration and monitoring the patientâ&#x20AC;&#x2122;s condition. If further treatment is needed, the vehicle should be stopped. 4 | www.defenceindustryreports.com

Civilian ambulances are transforming from simple transportation vehicles to first aid stations, where lifesaving operations can also be performed. This trend is gradually reaching the military sector. After the patient has been moved out of the combat zone, medics are able to treat the patient in a stationary, fully equipped military ambulance. Stretcher places with the capability to move the stretchers back and forth, vertically, horizontally or tilt to the shock position inside the vehicle, give medics better accessibility to the patient and better monitoring and treatment possibilities. Also, the positioning of the monitoring screens, targeted lights and reachability of the medical equipment should be carefully planned, as the best ergonomic treatment positions can have an enormous impact on the level of treatment. Even if the ergonomics and interior are properly designed, circumstances inside the vehicle may be challenging for the patient and the medics. The patient and medical equipment need to be kept near room temperature, with either a separate heating or cooling system, depending on the target environment. The internal temperature of the ambulance should be kept near +20 degrees Celsius. The lighting inside an armored vehicle is often insufficient for treatment activities. Other ambulance specific requirements include cleaning and hygiene requirements. Materials and equipment used in ambulance interior should endure cleaning with a pressure water jet and using strong disinfectant chemicals. Hygiene issues should be considered in keeping in mind not only the safety of the patient but also the safety of the medics.

SPECIAL REPORT: NEXT GENERATION STRETCHER SYSTEMS FOR MILITARY AMBULANCES AND MEDICAL EVACUATION VEHICLES

Reliability and System Safety Today, system safety and risk assessment plays an important role in ambulance projects. With safety and risk analysis, many risk-mitigation actions have taken place in ambulance design, such as positioning oxygen bottles outside the vehicle to reduce burn rate level, and providing ambulances with oxygen level warning systems. The main challenges are in achieving the best possible patient care in any circumstance, and having a high functional reliability. Reliability requirements for military systems are much higher than in civilian products, i.e. the crash tests are inadequate for military customers. On the other hand, treatment capabilities are emulated from civilian ambulances. Accelerated life tests, live mine tests, environmental tests for extreme conditions, user tests for ergonomic and safety and electrical compatibility tests are used to assure military customers have reliable and functional ProMIL products under all circumstances.

Survivability During Transportation Acceleration forces inside ground vehicles are significant. The strain caused by the acceleration to the patient in a moving vehicle can be hard to bear even in wheeled ambulances, not to mention in tracked vehicles driving fast off-road. This makes one wonder, if it is at all possible for the patient to survive the transportation. Reduction of this strain is the one of the most important aspect to consider when increasing patient survivability during off-road driving. The latest vehicles are equipped with active suspension which also reduces the forces directed to the patient. In an ambulance, further damping can be achieved by using stretcher platforms with suspension.

One of the risks for vehicles in combat zones is land mines and IEDs. To mitigate the effects of a blast under the vehicle, the stretcher platform can be fastened to the vehicle wall instead of the floor. For sitting patients, a foot rest can be provided to keep feet off the floor. The foot rest can be mounted for example to the stretcher platform. When the stretcher system is fastened to the vehicle wall, protection from the side blast can be increased by adding attenuation to the stretcher system structure. In addition to the technical solutions to stretcher fastening systems, fastening and use of all other equipment or items inside a vehicle has to be considered. The tasks to improve mine safety may appear small, but at the end of a day, a loose can of soda or unattached safety belt can cause severe damage in mine blast.

Loading the Stretcher Patient It is a generally accepted practice in most countries to classify the personnel attached to ambulances as non-combatants; however, ambulance markings do not always exempt medical personnel from catching enemy fire â&#x20AC;&#x201C; accidental or deliberate. It is crucial to minimize the time the back doors of an ambulance are open and the vehicle stationary, to ensure patient and medic safety. The loading of a patient onto a stretcher platform, and pushing the stretchers into the vehicle, is more difficult and slow if the vehicleâ&#x20AC;&#x2122;s back doors are narrow and the floor level high. The patient is carried to an ambulance in field stretchers, usually by two to four medics, whom increasingly tend to be women. Lifting the stretchers onto a high ambulance can be aided by a lowered stretcher platform that slides out of the vehicle to an ergonomic loading height.

SUSPENDED STRETCHER PLACE ProMIL 360 WITH A CAPABILITY TO MOVE THE STRETCHERS BACK AND FORTH, VERTICALLY AND HORIZONTALLY.

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SPECIAL REPORT: NEXT GENERATION STRETCHER SYSTEMS FOR MILITARY AMBULANCES AND MEDICAL EVACUATION VEHICLES

The tasks to improve mine safety may appear small, but at the end of a day, a loose can of soda or unattached safety belt can cause severe damage in mine blast.

Stretcher carriers can then easily place the stretchers on the platform without lifting. After that, it is easy to slide the stretchers in. With Frestems solutions, only one movement is required for the stretchers to slide in, turned to the wall and automatically locked, ready for transportation. This can be done in only 30 seconds, from the moment the back doors are opened, the doors are ready to be closed again, minimizing the time the patient and the medics are under fire or at risk of being captured by enemy soldiers.

Women in the Field The floor level of military ambulance vehicles is often high, land mines being one reason for this. Loading a stretcher patient onto a high vehicle is challenging and has raised the issue of medicsâ&#x20AC;&#x2122; loading ergonomics. Today, medics on the battle-field are increasingly women, and at the same time the average patient weight has increased making patient loading even more challenging. In addition, with the growing amount of professional standing armies, more focus has been set on the working ergonomics of paramedics. Ergonomic loading can be achieved by lowering the height to which the stretchers have to be lifted, minimizing loading height. After the stretchers are loaded onto the platform, pushing the patient in can be assisted with platform functions that lighten the movement. Working ergonomics inside the vehicle can be improved by minimizing the need to move stretchers manually. If there are multiple stretcher places, stretchers can be moved to

another place by using for example roof lifters to avoid manual lifting. There are several options for building ergonomic stretcher loading systems. The loading systems can be fastened either to the vehicle floor, wall or roof. All options can be used when lifting stretchers from outside of the vehicle. Loading systems may include stretcher platforms that slide outwards and tilt to the lowered loading position. Roof-fastened lifting systems are useful for example in evacuation containers or boats. Traditionally, military stretcher loading solutions have been based on manually operated systems. The advantages of manual systems are reliability, non-reliance on external power, and an avoidance of any electromagnetic disturbances compared to electrically assisted systems. However, even with a good mechanical structure, a fair amount of force needs to be applied to manually load a heavy patient onto a high vehicle. We believe that, in the future, electrically assisted loading will become more common in military ambulances. The assisted system may also be an accessory that can be mounted to the stretcher platform afterwards.

Getting the Best Value From Your Ambulance In planning your ambulance vehicle specification, we urge you to demand cost efficiency and the best possible performance from your ambulance to save lives on the battlefield. Frestems provides ambulance layout studies, stretcher fastening systems and complete ambulance furnishing successfully to military customers in Nordic countries and Europe, and has done so since 1998. Frestems also delivers stretcher fastening systems for civilian ambulances, being the number one stretcher platform provider in Finland and Sweden.

Contact Imformation: Frestems Oy www.frestems.fi Phone: +358 3 51 57 357 Fax: +358 3 51 57 333 Ahertajankatu 16 FI-38200 SASTAMALA FINLAND

Sales Contact: Sales Manager Kari Laaksonen Mobile: +358 40 844 1706 Mail: kari.laaksonen@frestems.fi LOW LOADING HEIGHT MAKES IT POSSIBLE TO LOAD HEAVY PATIENTS ERGONOMICALLY.

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SPECIAL REPORT: NEXT GENERATION STRETCHER SYSTEMS FOR MILITARY AMBULANCES AND MEDICAL EVACUATION VEHICLES

21st Century Stretcher Systems for Modern Military Medevac Don McBarnet, Staff Writer

Bandaging a wound before moving a patient with ProMIL stretcher carts to an ambulance.

t was until recently, an unstated part of the modern soldier’s belief in the military covenant that, when injured in combat, he will receive rapid medical treatment, evacuation to a field station and good pre-hospital medical care. But how that treatment is given, and how the evacuation takes place to secure the best outcome for the wounded soldier, has become a hotly debated issue in military emergency medical writing. This Report will highlight some of the important changes in thinking about the timing and location of first aid/treatment, surgery for trauma and style of evacuation from the frontline to hospital care. There is no new absolute in this debate, merely learned best practice that illuminates how the wounded soldier in any current conflict, should be transported to medical care.

the 20th century. Before the First World War, the history of treatment and evacuation of wounded soldiers from the field of battle was governed by chance and local facilities. Before the 18th century surgeons accompanying armies served only the nobility. The troops had to depend on comrades or family. Queen Isabella of Spain was the first monarch to organize help for wounded soldiers. In 1487, at the siege of Malaga, her armies carried wounded soldiers in bedded wagons to large tent hospitals in safe areas. These ambulances were cumbersome requiring up to 40 horses to pull them and were stationed miles from the battlefield. Surgeons waited hours to provide what little care was possible. Progressive military leaders began to realize that poor health care was wasted military manpower and was demoralizing to the soldier.1

The History of Treatment for Soldiers Wounded in Battle

A Small Improvement in Care During the Napoleonic Wars (1803–1815)

The 21st century soldier’s assumption that, when wounded in battle, his platoon buddies and the army with which he is fighting will do their utmost to treat him and take him to a place of safety is a product of a change of thinking that took place in

Systematic collections of the wounded from the battlefield began during the Napoleonic Wars. Napoleon recognised that battlefield casualty care was chaotic and approached www.defenceindustryreports.com | 7

SPECIAL REPORT: NEXT GENERATION STRETCHER SYSTEMS FOR MILITARY AMBULANCES AND MEDICAL EVACUATION VEHICLES

Napoleon recognised that battlefield casualty care was chaotic and approached Baron Dominique Jean Larrey to develop what he called “ambulances volantes” or flying field hospitals.

Baron Dominique Jean Larrey to develop what he called “ambulances volantes” or flying field hospitals. These lightweight carriages, which were like horse drawn carts, moved quickly to collect, transport and care for the injured even as the fighting continued.2 This European system of care for French wounded soldiers compares favorably to the anecdotal evidence of care for the wounded during the American civil war (1861 to 1865).

The American Civil War Experience The first major test of military emergency medical care came during the American Civil War (1861 to 1865). More than 300,000 soldiers died on the Union side (The North) alone. An early battle, Bull Run (1861), was a disaster by most military and medical standards. The Union Army entered the battlefield with few ambulances or medical personnel. Litter bearers were untrained bandsmen who put down their instruments and picked up litters. Civilian ambulance drivers drank the alcohol in their medicine chest and stayed near the battlefield only long enough to rob the wounded. Nonwounded panicking Union soldiers often used ambulances that had not broken down or been commandeered by officers for their personal use. In the Union Army’s retreat not a single wounded person was transported to safety. Three days after the battle 3,000 wounded men lay on the battlefield without food, water or protection from the summer sun

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and rain. Some were without care for 6-7 days. Many died from lack of food, water or lack of basic medical care. This extraordinarily brutal lack of care for soldiers was recognized, and the beginnings of effective care was introduced by William Hammond, Surgeon General of the Union Army and Jonathan Letterman, Medical Director of the Army of the Potomac, who were the primary agents for change. Letterman is credited with the creation of the first army wide ambulance service in 1862. In 1887 the Hospital Corps was established – the forerunner of the modern enlisted medical corps.3

The Impact of Changes During World War 1 on Emergency Medical Care When the United States entered World War 1, their medical services were still nascent. To meet the needs of the war in Europe, the U.S. Army’s Surgeon General, Maj. Gen. William M. Gorgas, presided over an enormous expansion of the Army Medical Department. When the United States entered the war, his department consisted of less than 1,000 personnel, but it numbered over 350,000 when peace returned in November 1918. The Surgeon General’s Office mushroomed from a staff of 153 at the beginning of the war to over 2,100 at its end. The Medical Department had 444 physicians on the pay roll at the beginning of World War 1, but it had 31,530 when the war ended. Nearly 24 percent of all American physicians served in the Army.4 By 1917 the U.S. Army Ambulance Service had 209 officers.

SPECIAL REPORT: NEXT GENERATION STRETCHER SYSTEMS FOR MILITARY AMBULANCES AND MEDICAL EVACUATION VEHICLES

The Journey from Volunteer to Professional Military Ambulance Care… Mary Dub, Editor

‘Put on your old gray bonnet With the strap ahangin’ on it, And we’ll go through shrapnel and through shellThen on roads of desolation We will cure your constipation With a wild night ride in hell!’ The Helmet song of Section 605

ProMIL Stretcher platform is lowered for ergonomic loading.

his rousing s o n g n o d o u b t concealed a terrifying reality for the driver and an excruciating experience for the wounded soldier being evacuated from the First World War in France or Italy in a volunteer ambulance unit. Later, the American Red Cross Ambulance Service actively recruited through its headquarters in New York and established units in France and Italy.6 By the spring of 1917 it had forty-six ambulance volunteer units supporting the Allies. One who joined was eighteen-year-old Ernest Hemingway, who, as a Red Cross second lieutenant, became the first American wounded in Italy. The ambulances of that time were Ford, Fiat, Peugeot, and General Motors Company cars. These cars were

severely tested under combat conditions that demonstrated their advantages in speed and patient comfort over horse or mule drawn transport. The Ford Model “T” could climb narrow mountain roads where patient movement previously was possible only on mules or in horse-drawn carts. Although neither the Red Cross nor the American Field Service paid the volunteers, the French government insisted on reimbursing them at five cents a day, equivalent to the pay of a French soldier. However, this did not amount to much as the volunteers paid for their own transportation, clothing, uniforms, and personal equipment. As one put it, “the Americans not only had to be willing to risk their lives, they also had to pay to do it.” www.defenceindustryreports.com | 9

SPECIAL REPORT: NEXT GENERATION STRETCHER SYSTEMS FOR MILITARY AMBULANCES AND MEDICAL EVACUATION VEHICLES

While trauma on the battlefield was an enormous problem so was the general ill health of soldiers living in the trenches, without cover, for long periods of time.

Recognition of the Need to Reduce the Transit Time and Change Pre-Hospital Treatment Systems During the First World War the length of time required to transport wounded soldiers from the front lines to the field hospitals was affected by a variety of factors including road conditions, visibility, and traffic. The 3rd Division, for example, averaged five hours transit time during the Second Battle of the Marne and two and a half hours during the MeuseArgonne offensive. Overall, in the AEF, the time from wounding until the arrival at the first triage point was five to six hours. The field hospitals were in the order of more sophisticated dressing stations. Patients were stabilized there, as they were at earlier points in the evacuation chain, so that they could either be returned to their units or evacuated farther to the rear for more definitive care. Each hospital had a normal capacity of 108 beds, expandable to 162, thus providing a 432-bed (648-bed expanded) capability for a division in combat.

How the French Army and the American Expeditionary Force Developed Pre-hospital Treatment in an Age of Trench Warfare The AEF (American Expeditionary Forces) evacuation system moved serious cases as quickly as possible to the rear after the patients had been appropriately stabilized for further movement. AEF evacuation hospitals essentially served as clearinghouses. Surgery was performed only as necessary to enable further evacuation of the casualties, and patients were held only until they could be moved safely. The French, on the other hand, placed a more sophisticated surgical capability closer to the frontline than the Americans, and some of their hospitals had as many as 5,000 beds. The larger facilities provided definitive care for the wounded earlier in the evacuation chain. However, their large, immobile hospitals would

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be at a disadvantage, if trench warfare turned into a war of movement.7

American Emphasis on Treatment During Evacuation While the French Approach was Rapid Transfer to High Quality Care American soldiers wounded in World War I enjoyed a much greater chance of surviving than had their predecessors in any previous war. Much of that was due to an improved evacuation system. By the time of the Armistice, the Medical Department had evacuated 214,467 casualties in Europe and transported 14,000 sick and wounded to the United States. It evacuated another 103,028 patients to the United States following the Armistice. This record was achieved through major Medical Department improvements, beginning with its doctrine for support of an army in the field. The medical support apparatus fielded by the American Expeditionary Forces was enormously improved in kind and amount from anything previously attempted in wartime. This represented an important shift in care for wounded soldiers from a haphazard volunteer force to a professional system of care that was effective in saving wounded soldiers’ lives. It marked the early realization in Emergency Medical Services about the importance of immediacy in medical treatment at the place of wounding, the socalled ‘golden hour’. And it marked the beginning of the debate about whether speed in evacuation to high quality care was better than forward medical care that could deliver urgent trauma care quickly before stabilizing and moving the wounded soldier back behind the lines. However, while trauma on the battlefield was an enormous problem so was the general ill health of soldiers living in the trenches, without cover, for long periods of time. Leaving aside the risk of trauma, the soldiers in the trenches in the First World War suffered from diseases like influenza, pneumonia and measles and had to face medical treatment without antibiotics or sulfa drugs.

SPECIAL REPORT: NEXT GENERATION STRETCHER SYSTEMS FOR MILITARY AMBULANCES AND MEDICAL EVACUATION VEHICLES

The Evolution of 21st Century Military Pre-Hospital Treatment and Ambulance Care Mary Dub, Editor

n a comparison to the modern case fatality rate, between 1945, (the end of the Second World War) and 2005, it is clear that the provision of better practice and equipment is having a real impact on the probability that the wounded in action will survive. The percentage of fatalities fell from 19.1% in 1945 to 9.4% in 2005. (The statistics were taken from the war in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom)). What were the key factors that had led to this improved outcome?

TCCC (Tactical Combat Casualty Care) It is thought they were – improved personal protective equipment, TCCC (Tactical Combat Casualty Care), faster evacuation time, and bettertrained medics. 21st century tactical combat care places great emphasis on the importance of the first responder at the point of wounding. The reason for this is that up to 90% of all combat deaths occur before a casualty reaches a medical treatment facility. On the battlefield, the fate of the injured often lies in the hands of the person who provides the first care to the casualty. The difference in practice between military and civilian emergency care is based on the very different circumstances for the delivery of military medical care. The battlefield is, of course, a dangerous place with the probability of hostile fire, darkness, extreme environments such as mountainous terrain or desert, limited medical equipment, possible prolonged evacuation time, and the overriding importance of the unit’s mission and its tactical flow. For soldiers on operation their priorities must be to treat the casualty, prevent additional casualties and complete the mission. Frequently the first responder on operations will be another soldier. Because the causes of trauma are different, the setting in which the trauma occurs is different and even with the possibility of helicopter airlift, evacuation time is typically much longer in the combat setting.

21st Century Battlefield Care at the Point of Wounding The immediate treatment available from first responding fellow soldiers or forward medics has transformed the help available to wounded soldiers. The 1996 guidelines, which have been up-dated subsequently, include, the effective use of tourniquets, aggressive needle thoracostomy, nasopharyngeal airways, surgical airways for maxillofacial trauma, tactically appropriate fluid resuscitation, battlefield antibiotics, and improved battlefield analgesia. These measures combine good tactics and good medicine based on scenario training with lessons learned from combat medics included in the guidelines. Further, the experience in the management of the wounded in both Iraq and Afghanistan have resulted in additional improvements which have driven down the rate of fatality in battlefield casualties. One of the most important of these is what is known as the Israeli dressing which stops bleeding rapidly by the use of direct pressure on the sight of the wound with a dressing. TCCC now includes products like Hemcon and QuikClot, intraossseous infusion devices, hypotensive resuscitation with Hextend (a plasma volume expander), Fentanyl lozenges (an opioid agonist), Moxifloxacin (antibiotics) and improved hypothermia prevention.

The US Army’s Echelons of Care The US Army has a well-developed system of echelons of care for those wounded on the battlefield. Self and buddy care is the first echelon. Level 1 care is austere and its elements are light and mobile. This includes advanced trauma life support facilities carried by individual soldiers, including endotracheal intubation, tube thoracostomy, intravenous medication. Combat lifesaving is the second, and includes a divisional level ‘clearing station’ that is staffed by a medical company of physicians, nurses, and medics. Casualties are examined to determine treatment needs and evacuation precedence. Level 3 care www.defenceindustryreports.com | 11

SPECIAL REPORT: NEXT GENERATION STRETCHER SYSTEMS FOR MILITARY AMBULANCES AND MEDICAL EVACUATION VEHICLES

The LSTAT is the state of the art patient stretcher that allows more sophisticated patient monitoring and treatment than has been possible in the past. Stretcher loading has to be easy, reliable and ergonomic to assure fast loading.

is the first true medical facility a casualty will meet on the battlefield. Presently this will be a US Army combat support hospital. Level 3 hospitals provide comprehensive resuscitative surgery and medical care. Level 4 is represented by comprehensive theater hospitals variously designated as General, Field, Theater Area or Station Hospitals. The key feature of these levels of care is gaining access for the casualty by transportation to the best care as quickly as possible.

Transportation of Casualties The transportation modes include manual carries, ground vehicles, aircraft, watercraft, or any combination of these. In many military operations, the manual carry is the primary means of moving casualties from the point of injury or illness to a point of safety where the medical evacuation can begin. Despite tremendous advances in many other areas of evacuation, manual carries remain almost unchanged over the centuries. Manual carries can be exhausting work, and necessarily have a range limited to a few hundred or thousand meters. Litter transportation offers modest improvements over manual carries. Some support and comfort is afforded the patient and spinal immobilization, fracture splinting, oxygen therapy and other static treatments can often be maintained during movement. Airway management, ventilation, and other dynamic care remain difficult to perform.

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Litter carries have the additional advantage that two or four persons can share the task of transporting a patient.

Ground Transportation of Casualties by Ambulances Medevac, the medical evacuation of casualties, shares two significant limitations: availability and limited medical care en route. Battlefields and disasters are fluid and dynamic situations, making it challenging to anticipate where ambulances will most be needed. Field medical providers must be capable of improvising transportation when no ambulances are available. The second limitation of medevac is the difficulty in providing en route or ongoing care. Ground and air platforms are cramped, noisy, poorly illuminated and prone to vibration, jarring and sway, although attempts are being made to mitigate this. Patient access assessment monitoring and interventions are difficult at best. Only in the most modern platforms are there provisions for onboard oxygen and suction. Airway, breathing and monitoring equipment are built in and this must be brought separately. An attempt to compensate for this deficiency may be seen with the development of the Life Saving Treatment and Transport module (LSTAT). The LSTAT is the state of the art patient stretcher that allows more sophisticated patient monitoring and treatment than has been possible in the past.

SPECIAL REPORT: NEXT GENERATION STRETCHER SYSTEMS FOR MILITARY AMBULANCES AND MEDICAL EVACUATION VEHICLES

Future Stretcher Systems for Military Medevac Don McBarnet, Staff Writer

redicting the future is always a highrisk business. Unfortunately, the present and the future are marred by the repetition of past mistakes from which both political and military lessons have not been learned. The 1990s were a time of dramatic cutbacks and economies in military medical staff and facilities. The beginning of the Iraq war saw the provision of good medical care for casualties hampered by the lack of facilities and available trained staff. Lt Gen Louis Lillywhite was appointed Director General of Medical Operational Capability to rebuild that capability during the Iraq War. Lillywhite’s testimony to the Chilcot Iraq Inquiry was diplomatic: ”weaknesses, shortcomings, a need for modernisation that I had identified as Director General of Army Medical Services. It was decided that there was a need to actually look specifically at operational – medical operational capability.” He explained why this was necessary. “The defence cost studies of the mid-1990s, which abolished service hospitals, except for Haslar9, led to a major outflow of medical personnel. Indeed, the House of Commons Defence Committee report at that time did actually opine that the medical services might have been beyond recovery. So we had dropped to exceptionally small numbers.

I think there were only 20 anaesthetists left, for example…It was difficult to actually meet the requirement. The requirement was met. It was met by a variety of means: making greater use of the reserves, even on mature operations rather than simply on contingency operations, which was the original intent of the reserves; and by using international forces, so we had Czech surgical teams, for example, deployed to Iraq to our hospital; and to a lesser extent using contractors, although they were primarily nurses, latterly neurosurgeons.” The current drawdown from Afghanistan and the dramatic cuts in manpower in all regiments is not a good omen for the future as the potential risk in cutting highly skilled manpower beyond the point of recovery in the event of a future military crisis cannot be ruled out.

The Importance of the Location of First Treatment In his testimony Lt Gen Lillywhite emphasized the importance of lessons learned in the battlefield of immediate medical treatment as close as possible to the point of injury. Interestingly, in response to a question by Prof Sir Lawrence Freedman, he gave this reply summarizing current good practice: “… treatment at the point of injury has remained obstinately constant for many centuries www.defenceindustryreports.com | 13

SPECIAL REPORT: NEXT GENERATION STRETCHER SYSTEMS FOR MILITARY AMBULANCES AND MEDICAL EVACUATION VEHICLES

The design of the stretcher for use in manually carrying casualties to a place of safety and then to ground or airlift Medevac is a complex task.

until the recent conflicts. What we found in the later stages of Iraq and now in Afghanistan was that the introduction of new techniques, such as giving tourniquets to every single soldier – and tourniquets that worked, because it transpired that not all worked – giving them the new what’s called ‘the Israeli dressing’ that is particularly good at applying pressure over a wound, and introducing new dressings that actually cause blood to clot at the injury site, plus the training that was associated with that and the introduction of individuals such as team medics, those – that combination has improved the survival at the point of injury.”

Summarising the Debate about Forward Treatment First or Medical Evacuation Lt Gen Lillywhite puts on one side the debate about the preferred positioning of first treatment very astutely. “There is a debate as to what extent you should actually have surgery forward, where people say that that is a misuse of resources and may be a wasteful one if you cannot provide the ongoing care during evacuation, amongst those who say, “Yes, but for 5 or 6 per cent of those injured it is essential”, against those who say it would be better to actually concentrate on evacuation back to formal hospital facilities. I think that the debate is a bit sterile because it depends actually on the circumstances. Where you can’t evacuate casualties easily, forward surgery has a place. Where you can evacuate casualties safely, they should be evacuated straight to hospital and not have surgery forward…but what we are finding is that actually it is probably resuscitation that is important forward rather than surgery. I know there are surgeons that wouldn’t like me saying that, but that is where the evidence is leading.”

The Argument For and Against Various Types of Medevac Transportation During the Iraq war and again in Afghanistan the popular press and other media have raised the issue of the need for more helicopters for the transportation of troops because of the dangers on the road from improvised explosive devices and ambush. Helicopter airlift also has a critical role in the transportation of casualties away from the point of wounding. Lillywhite points to the value of ground transportation in Iraq where the terrain in many

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areas is flat. But where some of the terrain is mountainous and the distances long, helicopters hold key advantages: “Moving on to Op Telic 2 and beyond, we were using helicopters from places like Al Amarah (Iraq), straight back from the regimental aid post or the point of wounding to the hospital; from Basra City we were initially using armoured ambulances and occasionally using helicopters when it was felt to be too dangerous for armoured ambulances. In Afghanistan now, like Al Amarah, where the distances are long, it is almost entirely helicopter.”10

The Importance of the Design of the Stretcher for Manual Use, as a Litter or Airlift The design of the stretcher for use in manually carrying casualties to a place of safety and then to ground or airlift Medevac is a complex task. The design of a stretcher for mountain rescue is discussed by Peter Bell, who won a Distinguished Service Award for his work in improvements in mountain rescue of casualties. He describes the limitations of the basic Furley Stretcher made from pole and canvas. The stretcher was then developed to allow casualties to be hauled underground – the Low Moor jacket. He describes some of the criteria important for a stretcher being used for a manual carry on mountainous terrain without the provision of any ongoing treatment. First, minimum weight and quite exceptional strength and rigidity under varied strains are important. There needs to be provision for the loaded weight to be shared by more than the usual two bearers. The bearers should be able to walk in file on the level and to advance in line on a steep slope and it should be possible to take the stretcher apart for portability. The patient needs to be held in position with minimum discomfort when being lowered down a vertical face and added protection needs to be available to protect the casualty from contact with the rock or ground. It then needs to be able to be loaded easily on to a ground vehicle or helicopter without further discomfort to the casualty. This is a difficult design proposition to meet. But military stretcher designers have been working on this brief and new designs are now available that meet all these and many more criteria for the smooth and safe handling of military casualties.

SPECIAL REPORT: NEXT GENERATION STRETCHER SYSTEMS FOR MILITARY AMBULANCES AND MEDICAL EVACUATION VEHICLES

References: 1

Michel A Sucher: Prehospital Systems and Medical Oversight: National Association of E Physicians

Kendall Hunt, 1 Sep 2002 - Medical - 1000 pages

The Origins of Private Ambulance Services http://books.google.co.uk/books?id=ujVUnUVs9nQC&pg=PA81&redir_esc=y#v=onepage&q&f=false

Michel A Sucher: Prehospital Systems and Medical Oversight: National Association of E Physicians

Kendall Hunt, 1 Sep 2002 - Medical - 1000 pages

The Origins of Private Ambulance Services http://books.google.co.uk/books?id=ujVUnUVs9nQC&pg=PA81&redir_esc=y#v=onepage&q&f=false Michel A Sucher: Prehospital Systems and Medical Oversight: National Association of E Physicians

Kendall Hunt, 1 Sep 2002 - Medical - 1000 pages

The Origins of Private Ambulance Services http://books.google.co.uk/books?id=ujVUnUVs9nQC&pg=PA81&redir_esc=y#v=onepage&q&f=false The History of the Ambulance Service: US Army Medical Department

http://history.amedd.army.mil/booksdocs/HistoryofUSArmyMSC/chapter2.html Edward E. Harding, “Norton-Harjes Section 60,” in Virginia Spencer Carr, Dos Passos: A Life (New York: Doubleday, 1947), p. 133.

The History of the Ambulance Service: US Army Medical Department

http://history.amedd.army.mil/booksdocs/HistoryofUSArmyMSC/chapter2.html 7

The History of the Ambulance Service: US Army Medical Department

http://history.amedd.army.mil/booksdocs/HistoryofUSArmyMSC/chapter2.html 8

Michel A Sucher http://books.google.co.uk/books?id=ujVUnUVs9nQC&pg=PA81&redir_esc=y#v=onepage&q&f=false

Pre-hospital Systems and Medical Oversight National Association of EMS Physicians

Kendall Hunt, 1 Sep 2002 - Medical - 1000 pages: The Origins of Private Ambulance Services

Royal Hospital Haslar in Gosport, Hampshire a military hospital, whose military status was withdrawn in 2007. Evidence given to the Chilcot Iraq inquiry by Lt General Louis Lillywhite

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