从角色2到角色3医疗设施期间战斗人员伤亡管理

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**从角色2到角色3医疗设施期间战斗人员伤亡管理**

*.* ![](/media/202412//1733389558.813658.png)![](/media/202412//1733389558.821395.png)*现役，约瑟夫·马德里上校，医学博士，美国空军，MC*，，；艾莉森。Arana博士；*

*；现役，史蒂文G。. Schauer，DO，MC，美国沙巴布，沙巴布，沙巴布；*

*劳伦·里夫斯，MsPH*；朱莉·e·Cutright，BSN，RN*；Joni A. Paciocco，ADN，RN*；*

*CristarAPerez，BSN，RN*；现役，威廉·特戴维斯少校，医学博士，美国空军，MC*，，；. .*

*现役军人，帕特里克少校，医学博士，美国空军，MC*，.*

**摘要**

**介绍**

通过军事疏散系统进行的紧急临床护理和病人的行动可以提高生存率。当从损伤点（POI）转移到第一个医疗机构（MTF）时，从角色2转移到角色3 MTF转移到MTF时不同，包括手术和高级复苏。本研究的目的是描述在战区设施间运输期间提供给患者的护理，并与院前运输（POI到第一个MTF）进行比较。

**材料和方法：**

我们对2007年至2016年在阿富汗和伊拉克的角色2到角色3的运输患者进行了回顾性图表回顾。收集的数据包括MTF和运输期间的程序和事件。我们将战区内运输数据（角色2到角色3）与之前一项评估创伤前运输（POI到第一个MTF）的研究数据进行了比较。

**结果**

我们回顾了869例角色2到角色3的运输患者的记录。与POI运输相比，角色2到角色3的运输持续时间更长（39分钟vs. 23分钟），并且更有可能由高级人员（护士、医生助理和医生）配备(57% vs。3%).样本主要包括患有爆炸或钝器伤害的军人男性（平均年龄27岁）。在护理的每个阶段进行的程序反映了团队和地点的能力。与角色2到角色3运输相比，疼痛和心脏事件在POI疏散中更常见，但呼吸事件、血流动力学事件、神经事件和设备衰竭的记录在角色2到角色3运输中更常见。从Role 2到Role 3队列的生存率略高（98% vs. 95%，差异3%[差异的95%置信区间1-5%]）。

**结论**

与POI运输相比，设施间运输（角色2到角色3）持续时间更长，运输的患者更复杂，并且配备了更高级级别的提供者类型。

**介绍**

国防部医务人员的任务是确定如何稳定战斗伤亡时

*美国空军途中护理研究/第59医疗联队/科学与技术，JBSA拉克兰空军基地，德克萨斯州78236，美国

布鲁克陆军医疗中心急诊医学系，JBSA Ft.山姆·休斯顿，德克萨斯州78234，美国

美国制服大学军事和急诊医学系，贝塞斯达，马里兰州20814

美国陆军外科研究所，JBSA Ft。山姆·休斯顿，美国德克萨斯州78234

2022年军事医疗保健研讨会，2022年特别行动医学协会，和2022年学术急诊医学学会。

本文所包含的意见或断言是作者的私人观点，不应被解释为官方的或反映了空军、陆军、国防部或美国政府的观点。

doi:<https://doi.org/10.1093/milmed/usad404>

由牛津大学出版社代表美国军事外科医生协会于2023年出版。这项工作是由(a)美国政府雇员(s)写的，并且是在美国的公共领域。

具有外科手术能力的军事治疗设施（MTF）在受伤后72小时内无法使用。1,2为了应对这一挑战，有必要了解其能力，如损害控制和稳定干预，以确保患者存活足够长的时间，以达到最终的护理水平。在战斗行动中，创伤性患者需要紧急的临床护理和快速疏散，以提高生存率。3部署在现场的地面医务人员通常是第一反应人员，但其能力和供应有限。航空医疗后送平台，如美国陆军医疗后送（MEDEVAC），允许紧急后送到角色2或角色3的设施，提供更高水平的护理。地中海直升机的运输时间可能因环境因素和在战斗地点着陆的能力而有所不同。4以前的数据表明，较长的运输时间与发病率和死亡率的增加有关。5–7

在伊拉克和阿富汗的冲突期间，国务卿盖茨的“黄金时刻”政策的实施导致了多个分散的角色2军事机构的建立

**军事医学，卷。**189, May/June 2024

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**表i。**事件的定义

净化结构7这一政策强制要求将战斗伤亡人员快速运送到损害控制手术和复苏术中。7有了这种前沿手术能力，就需要将术后战斗伤亡人员从角色2mtf转移到更先进的角色3mtf。医疗治疗系统主要设计用于疏散战场伤员和术前创伤管理。8那些在损伤控制手术和/或复苏后从角色2转移到角色3的患者与那些从损伤点（POI）转移的患者有显著不同。为了解决这一差异，美国陆军断断续续地用重症护理飞行护士补充了标准的辅助护理医疗直升机，尽管并不一致。9相反，美国。空军紧急护理航空运输小组（CCATT）由急诊医学或重症护理医生、急诊或重症护理护士和呼吸治疗师组成，作为“飞行重症监护病房”，并被用于角色2到角色3设施间运输。10然而，CCATT主要在固定翼飞机中运行，因此它们通常被限制从在机场或机场附近建立的角色2中进行运输。

Staudt等人评估了来自JTS数据库的数据，并描述了在角色2接受治疗并随后撤离到阿富汗的角色3的患者。11本研究提供了患者特征和途中护理人员的描述，但没有从个别飞行医疗记录中提取数据或评估患者的预后数据。作者主张在未来的研究中评估在角色2到角色3的MTF运输期间提供的护理，以及基于途中护理提供者技能水平的短期和长期结果。因此，我们进行了一项研究，描述了从角色2到角色3的航空医疗后送期间执行的干预措施，执行运输的航空医疗后送小组，以及与30天患者预后的关联。

**材料和方法**

加强流行病学中的观察性研究的报告指南被用来确认我们的观察性研究的适当报告（SDC 1）。我们回顾回顾了2007年1月至2016年12月在伊拉克或阿富汗的第2角色设施接受治疗的美国军方、美国政府雇员和美国承包商的医疗记录。我们排除了18岁以下的患者、被拘留者，以及那些在离开角色2设施之前死亡的患者。

我们询问了美国国防部创伤登记处，以确定符合我们的纳入标准的患者。然后，我们从关节创伤系统或CCATT试点单位获得这些患者的医疗治疗或CCATT患者护理记录。我们还查询了联合创伤系统角色2数据库，以确定在角色2设施和国防部创伤登记处执行的结果数据。经过训练有素的研究团队成员从

*战斗伤亡人数的疏散，从角色2到角色3*

**事件类型定义**

疼痛

呼吸系统

血流动力学

心脏的

神经系统的

肾尿

温度

设备故障

异常实验室

增加现有镇痛的速率或剂量开始新的镇痛

关于疼痛的投诉的记录

由医疗人员确定，包括：头痛、胸部、腹部、背部、臀部、腿部/膝盖，

手臂/肩膀，肌肉疼痛

根据医疗提供者的记录，包括：

SpO2≤ 90%

FiO2增加>10%

O2L最小增加>4

PEEP≥5增加

根据医疗提供者记录的内容，包括： SBP≤90或≥180，比基线MAP≤65或≥120变化20%，或比基线CVP比基线5变化20%

HR <60次或>120次或20%的变化

基准

由医疗提供者确定的，包括：心脏骤停

心电图表现显著

由医疗提供者确定，包括：

躁动、癫痫发作、精神状态、运动、认知或感觉能力的改变

由医疗提供者确定，包括：

少尿（低尿量）、暗尿、肾结石

发烧(体温≥为100。5F或38 C)

低体温（由医疗机构确定的体温< 95 F或35 C）包括： Propaq故障，电池故障，呼吸机故障葡萄糖（<70或>105）

钾（<3.5或>5）

钠（<136或>145）

PTT (>35)

SBP，收缩压、MAP，平均动脉压、CVP、中心静脉压、HR、心率、PTT、部分凝血酶时间。麦德雷塔尔的定义.10

并将这些图表输入了一个电子数据库。这些记录包括人口统计学数据、损伤描述、提供者类型、飞行日期和时间、运输时间、临床数据（生命体征、如果可用的实验室值、程序、药物和事件）和30天生存率。使用我们之前的研究的标准，从患者护理记录中的事件描述中确定临床事件（表1）。10我们实施了质量保证措施，以确保经过培训的摘要之间的一致性，包括对100%的记录进行二次审查.12,13

除了专门为本研究收集的数据外，我们还使用了之前发表的一篇论文的数据，该论文描述了在阿富汗战斗中受伤并通过医疗直升机从POI撤离的患者.8该研究包括了2011年1月至2014年3月期间转运的1237名患者，包含了与当前数据集相似的变量。我们使用前一篇论文中的表格和图表来计算汇总数据（频率、百分比、平均值和标准差）来进行比较

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*战斗伤亡人数的疏散，从角色2到角色3*

**表二。**患者和服务提供者的特征

**变量**

**从角色2到角色3**

**(n = 869)**

**POI至第一MTFa**

**(n = 1,237)**

**差异（95% CI）**

年龄、年龄

27 (7)

24 (5)

−3（−4至−2)*

男性性别

97%

99%

−2%(−3%至−1%)*

最高提供者类型

护理人员

8%

21%

−13%(−16%至−10%)*

米迪克

14%

76%

−62%（−58%至−65%)*

先进的**

57%

3%

54% (51%至58%)*

未指定

20%

损伤严重程度评分

13 (13)

14 (14)

−1（−35至2）

ISS≤10

57%

50%

−7%(−11%至−3%)*

2019年10月11日

21%

25%

−4%（−8%至−1%)*

ISS 20-29

12%

14%

−2%（−5%至1%)

ISS 30-75

11%

12%

−1%（−4%至2%)

伤害类型

爆炸

42%

69%

−27%(−32%至−23%)*

钝的

29%

2%

27% (24%至30%)*

穿透的

27%

28%

−1%（−4%至4%)

燃烧

2%

1%

1%（0%至2%）

飞行时间，分钟

39 (20)

23 (56)

−16（−19至−13)*

数值为平均值（标准偏差）或样本的百分比。

*如果差异的95%置信区间不包括零，则差异具有统计学意义。

**高级提供者类别包括注册护士、医师助理和医生。

aPOI到第一MTF的数据来自Maddryetal。

从POI（之前的研究）和那些从角色2转移到角色3（当前的研究）的患者的特征、药物治疗、事件和结果。我们使用独立的t检验来分析连续变量和名义变量的凿子检验。结果报告为95%置信区间的差异；如果相应的置信区间不包括或跨越零，则结果被认为具有统计学意义。我们在SAS9.4版本（SAS研究所，Cary，NC，USA）中进行了所有的分析。

**结果**

我们分析了2007年1月至2016年12月期间从角色2转移到角色3转移的869名患者的数据。最常见的原始设施是Shank（33%）、贾拉拉巴德（16%）和Ghazni（11%）。患者被送往五个Role 3设施之一：巴格拉姆（76%）、坎大哈（14%）、堡垒（10%）、巴拉德（<1%）和巴格达（<1%）。从角色2到角色3的平均飞行时间为39 min，明显长于从POI到第一个MTF的平均飞行时间（表II）。从角色2到角色3的大部分运输人员都配备了高级提供人员（注册护士、私人助理、医生）和医务人员；相比之下，来自POI队列的航班主要由医务人员和护理人员组成。大多数从角色2转移到角色3的患者都是平均年龄为27岁的年轻男性。近一半的样本遭受了爆炸性损伤，超过一半的样本的损伤严重程度评分（ISS）为10或更低，平均损伤严重程度评分ISS为13。虽然从POI转移到第一个MTF的患者具有相似的平均ISS，但该队列的爆炸性患者比例更高

钝器损伤患者比例较低，ISS为10例或更低。

在每个护理阶段进行的最常见的程序反映了每个地点和团队的能力（表三）。在从POI到第一个MTF的运输过程中，大多数程序都与损伤控制复苏有关，如液体/血液给药、出血控制和低温预防。另一方面，Role 2 MTF的治疗程序更为先进，包括影像学（x线和超声）、插管和机械通气、液体/血液给药、剖腹手术、筋膜切开术和截肢。与从POI开始的首次飞行相比，患者在从角色2到角色3的设施间飞行期间更有可能需要呼吸机管理和接受药物治疗（表三）。

与角色2到角色3的运输相比，POI疏散中疼痛和心脏事件更为常见（图1）。相反，有记录的呼吸事件、血流动力学事件、神经系统事件和设备故障在从角色2到角色3的运输过程中更为常见。与POI队列相比，角色2到角色3队列的生存率略高(98% vs。95%，差异3%[差异1%至5%置信区间的95%至5%])。

**讨论**

在我们的研究中，我们评估了患者从角色2到角色3设施的运输，我们发现从POI到MTF的早期运输阶段存在显著差异。首先，根据部长盖茨部长的“黄金时间”政策，由于角色2接近战斗行动的分散，角色2到角色3的运输持续时间明显更长。第二，多数

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*战斗伤亡人数的疏散，从角色2到角色3*

**表III。**每个护理阶段的程序和机上药物治疗

**从POI到第一**

**MTF（n = 1,237）a**

**在角色2（n = 869）**

**从角色2到角色3的传输（n = 869）**

补充氧气（49%）

任何药物（30%）

镇痛（28%）

液体（28%）

静脉入路（22%）

压力填料（13%）

低温预防

(11%)

脊柱稳定（6%）

骨内通道（5%）

止血带（5%）

血液制品（4%）

鼻腔/口腔气道（3%）

心肺复苏（3%）

Splint/sling (2%)

胸针（2%）

插管（2%）

镇静（1%）

止血剂（1%）

胸部密封（1%）

除颤（1%）

乳突甲状腺切除术（1%）

胸管（<1%）

X射线（89%）

静脉入路（78%）

液体（70%）

低温预防

(64%)

伤口敷料

(61%)

超声（60%）

稳定和固定

(52%)

排水沟（43%）

补充氧

(39%)

机械通风

(30%)

插管（29%）

血液制品（26%）

管（23%）

动脉线（16%）

中心线（15%）

腹腔镜切除术（9%）

外部固定器（9%）

Fasciotomy (9%)

胸管（8%）

截肢（6%）

预防低温（53%）任何药物（51%）

镇痛（44%）

补充氧（40%）

液体（30%）

机械通风（29%）稳定/固定

(26%)

镇静（24%）

瘫痪（15%）

胸管（7%）

止吐剂（6%）

血液制品（4%）

血管升压药（3%）

止血带（1%）

伤口敷料/填料（1%）肠外通路（1%）

抗生素（<1%）

aPOI到第一MTF的数据来自Maddryetal.8

患者护理团队包括一个高级医疗提供者（医生、PA或注册护士）。第三，患者更有可能需要呼吸机管理，并在运输过程中接受药物治疗。第四，患者在运输过程中更有可能记录有呼吸、血流动力学和神经系统事件。最后，更多的团队记录了在运输过程中的设备故障。

我们的研究强调了确保提供角色2到角色3运输的医疗团队拥有必要的知识和技能，以解决与POI早期运输阶段的差异的重要性。Mabry等。发现医护人员比医护人员运送的伤亡人员的存活率有所提高。4,14足骨。研究发现，由医生领导的英国医疗应急小组的结果与美国陆军医生相似，尽管照顾的是更高的伤员.15,16相反，Maddry等人没有发现先进的途中护理人员与30天生存率之间的联系，但理论上认为这可能是由于盖茨部长制定的黄金时间政策之后的运输时间很短。8将这些早期研究的结果推断到我们的研究结果表明，由于多种原因，需要先进的医务人员来确保设施间转移患者的生存。首先，我们的研究发现，在医生和护士可能使用的情况下，设施间运输的持续时间明显更长

产生更大的好处。第二，设施间的途中护理人员必须管理机械呼吸机、药物输液、麻醉剂、胸管和其他先进的医疗设备和程序。最后，设施间转移患者有记录的呼吸事件、血流动力学事件和神经系统事件的发生率更高。这些事件与急诊科和重症监护病房工作人员遇到和管理的事件类似。17,18相反，地面医务人员和医护人员更关注初始稳定，而不是稳定后持续的重症护理。培训医务人员承担这些职责是具有挑战性的，而且可能是不现实的。训练和维持这些技能所需的时间以及必要的临床经验提出了重大挑战。

乌克兰目前发生的事件突出了对战斗伤亡人员的地面运输的重要性。由于在乌克兰境内缺乏持续的空中优势，旋翼飞机面临着敌人攻击的重大风险，而且不能像伊拉克自由行动/持久自由行动（OIF/OEF）那样提供一致的运输解决方案.19虽然特种作战司令部拥有能够疏散伤亡人员的专业医生领导小组，军队也以护士、医生和医生助理补充了疏散小组，但常规美国的大部分。

**e1006军事医学，卷。**189, May/June 2024

*战斗伤亡人数的疏散，从角色2到角色3*

由客人于2024年6月27日从htps：/academic.oup.com/mimedlaricle/189/5-6/e1003/7421932下载

![](/media/202412//1733389558.9152083.jpeg)

图1。从受伤点（POI）或aRole l设施的实黑色bars)vs.lights到aRole3设施)的比较。IPOI和第一个MTF数据来自Madry等人。⁸*比较atP<0.05具有统计学意义。

军事地面疏散运输团队缺乏医生、PA和护理支持。未来的研究应评估CCATT、医疗直升机和其他军事医疗团队提供地面运输的能力。这包括使用缺乏电力、氧气和其他能力的军用和民用车辆提供疏散的能力

***限制***

我们的研究有几个局限性。首先，这是一项回顾性图表回顾，我们的发现可能由于完整或缺失而受到限制。具体来说，对运输提供者的任务需求因运输阶段而异，可能导致角色2到角色3的传输与来自POI的传输有不同的文档实践。数据抽象器的使用具有主观性的潜力；然而，我们实施了彻底的图表抽象、实质性的抽象者培训和质量审查程序来限制主观性。12,13其次，医疗药物单位和CCATT单位之间的文档实践的差异可能会影响角色2到3队列中数据的一致性。第三，虽然本研究发现POI运输和设施之间运输之间存在显著差异，但我们不能断言结果的任何因果关系。在外部效度方面，本研究主要关注军事创伤

在OIF/OEF期间的患者和我们的研究结果可能不适用于平民社区或其他冲突。未来军事冲突中的平民病人和伤亡人员可能与我们研究中讨论的创伤和医疗疾病显著不同

**结论**

与来自POI的MEDEVac运输相比，战区内的设施间运输（角色2到角色3）的持续时间更长，并利用更高级的提供者类型来运输更复杂的患者。军事医疗规划、培训和资源分配应考虑到这些因素，包括在为未来的军事行动做准备时，包括增加接受航空医疗后送培训的高级医务人员的数量

**确认**

没有声明。

**临床审判登记**

不适用。

**IRB人体受试者**

该研究被第59医学联队JBSA拉克兰IRB审查和批准为一项最低风险的人类受试者研究。

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*战斗伤亡人数的疏散，从角色2到角色3*

**机构的动物护理和使用**

**委员会（IACUC）**

不适用。

**个人作者的贡献声明**

J.K.M.：首席研究员，获得资助，设计研究，起草、编辑稿件。A.A.A.：协助研究设计，进行统计分析，并对稿件进行关键修改。A.M.：协助研究设计并进行统计学分析。S.G.S.：起草并编辑稿件。L.K.R.：抽象的数据。J.C.：抽象数据。J.A.P.：抽象的数据。C.A.P.：数据采集，进行质量控制，编辑稿件。W.T.D.：编辑并提供了对稿件的批判性修改。P.C.N.：编辑并提供了对稿件的批判性修改。

**机构许可**

该手稿由第59医学部/科学技术临床调查和研究支助部审查并批准传播。

**资金**

国防卫生机构研究和工程定向器内部J9，拨款号J917EC02。

**利益冲突声明**

所有作者均无任何利益冲突需要披露。

**数据可用性**

本文基础上的数据将在合理的要求下共享给通讯作者。

**参考文献**

1.李建民：为非军事调查人员理解医疗保健在未来大规模作战行动中的联合作用的概念框架。27(1)：67-74。[10.1080/10903127.2021.2008070](https://doi.org/10.1080/10903127.2021.-2008070)

2.李，李，李，李：在战斗环境中接受延迟手术干预的伤亡评估。医学（SamHoust）2023；（每2月2日3）：28-33。

3.等：从伤害点出发的途中护理能力影响了严重战时伤害后的死亡率。Ann Surg 2013；257(2)：330-4。[10.1097/SLA.0b013e31827eefcf](https://doi.org/10.1097/SLA.0b013e31827eefcf)

4.地中海医生：随着更高水平的飞行医疗训练，生存和生理参数得到改善。Mil Med 2013; 178(5): 529–36.[10.7205/MILMED-D-12-00286](https://doi.org/10.7205/MILMED-D-12-00286)

5.等：紧急医疗直升机直接送往大学医院创伤对严重钝器创伤患者出院前死亡率的影响。碎石治疗2012年；16(5)： R170。[10.1186/cc11647](https://doi.org/10.1186/cc11647)

6.VS：院前医疗后送（MEDEVAC）运输时间对不可压缩躯干损伤患者战斗死亡率的影响

还有创伤性截肢手术：一项回顾性研究。Mil Med Res 2018; 5(1): 22.[10.1186/s40779-018-0169-2](https://doi.org/10.1186/s40779-018-0169-2)

7.《黄金时间政策对战斗伤亡人员的发病率和死亡率的影响》。《美国医学会杂志》Surg 2016；151(1)：15-24岁。[10.1001/jamasurg.2015.3104](https://doi.org/10.1001/jamasurg.2015.3104)

8.《战斗医疗治疗》：按提供者类型的手术室途中创伤护理和30天患者预后的比较。J创伤急性护理报告2016；81（5补充2015年军事卫生系统研究研讨会论文集）：S104-10。

[10.1097/TA.0000000000001119](https://doi.org/10.1097/TA.0000000000001119)

9.纳格拉姆：在伊拉克自由行动中优化战时途中的护理。美国陆军国防部长J2011：51-8。

10.《重症护理航空运输团队（CCATT）呼吸机管理对战斗死亡率的影响》。J创伤急性护理报告2018年；84(1)：157-64。

[10.1097/TA.0000000000001607](https://doi.org/10.1097/TA.0000000000001607)

11.，Biever KA等：在阿富汗从角色2转移到角色3医疗机构的途中。2018年，38(2)：e7-15。[10.4037/ccn2018532](https://doi.org/10.4037/ccn2018532)

12.《急诊医学研究中医疗记录回顾研究方法的重新评估》。Ann Emerg医学杂志，2005；45(4)：448-51。

[10.1016/j.annemergmed.2004.11.021](https://doi.org/10.1016/j.annemergmed.2004.11.021)

13.《急诊医学研究中的图表综述》：这些方法在哪里？Ann Emerg医学杂志，1996；27(3)：305-8。[10.1016/s0196-0644(96)70264-0](https://doi.org/10.1016/s0196-0644(96)70264-0)

14.在当前的阿富汗战争中，经过危重护理训练的飞行护理人员对直升机疏散期间伤亡人员生存的影响。J创伤急性护理研究报告2012年；73(2附录1）：S32-7。

[10.1097/TA.0b013e3182606001](https://doi.org/10.1097/TA.0b013e3182606001)

15.《持久自由行动中前方空中医疗后送平台的性能改进评估》。J创伤急性护理研究报告，2013年；75(2附录2）：S157-63。[10.1097/TA.0b013e318299da3e](https://doi.org/10.1097/TA.0b013e318299da3e)

16.等：在途中护理期间战斗伤亡人员的血流动力学稳定性的改善。冲击2013；40(1)：5-10。已发表的修正出现在《冲击》中。2014年6月；41(6)：558。[10.1097/SHK.0b013e31829793d7](https://doi.org/10.1097/SHK.0b013e31829793d7)

17.库尼，穆拉诺，埃德加L：急诊医学里程碑2.0：为2025年及以后奠定基础。AEMEduc列车2021；5(3)： e10640。[10.1002/aet2.10640](https://doi.org/10.1002/aet2.10640)

18.《肺和危重病医学奖学金培训的优秀专业活动和课程里程碑》：多社会工作组的报告》。胸部2014年；146(3)：813-34年。[10.1378/chest.14-0710](https://doi.org/10.1378/chest.14-0-710)

19.等人：乌克兰利用北约的四级“根据需要改变”医疗体系管理战斗伤亡的经验。世界J Surg 2022；46（12）：2858-62。

[10.1007/s00268-022-06718-3](https://doi.org/10.1007/s00268-022-06718-3)

20.DuBose JJ，平稳DJ，BaudekA，等：生命和肢体飞行手术干预：15年联合医疗增强单元外科复苏团队的经验。JSpecOperMed 2020; 20(4): 47–52.

[10.55460/SI6S-XHCZ](https://doi.org/10.55460/SI6S-XHCZ)

**e1008军事医学，卷。**189, May/June 2024

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**Management of Combat Casualties during Aeromedical Evacuation from a Role 2 to a Role 3 Medical Facility**

*Active Duty, Col Joseph K. Maddry, MD, USAF, MC*![](/media/202412//1733389569.519827.png)![](/media/202412//1733389569.5295386.png)**,†,‡,§;Allyson A. Araña, PhD*;*

*Alejandra G. Mora, MS*;Active Duty, LTC Steven G. Schauer, DO, MC, USA†,‡,§;*

*Lauren K. Reeves,MsPH*; Julie E. Cutright, BSN, RN*; Joni A. Paciocco,ADN, RN*;*

*Crystal A. Perez, BSN, RN*;Active Duty, Maj William T. Davis, MD, USAF, MC*,†,‡;*

*Active Duty, Maj Patrick C. Ng, MD, USAF, MC*,†*

**ABSTRACT**

**Introduction:**

Emergent clinical care and patient movements through the military evacuation system improves survival. Patient man- agement differs when transporting from the point-of-injury (POI) to the first medical treatment facility (MTF) versus transporting from the Role 2 to the Role 3 MTF secondary to care rendered within the MTF, including surgery and advanced resuscitation. The objective of this study was to describe care provided to patients during theater inter-facility transports and compare with pre-hospital transports (POI to first MTF).

**Materials and Methods:**

We performed a retrospective chart review of patients with the Role 2 to the Role 3 transports in Afghanistan and Iraq from 2007 to 2016. Data collected included procedures and events at the MTF and during transport. We compared the intra-theater transport data (Role 2 to Role 3) to data from a previous study evaluating pre-hospiital transports (POI to first MTF).

**Results:**

We reviewed the records of 869 Role 2 to Role 3 transport patients. Role 2 to Role 3 transports were longer in duration compared to POI transports (39 minutes vs. 23 minutes) and were more likely to be staffed by advanced personnel (nurses, physician assistants, and physicians) (57% vs. 3%). The sample primarily consisted of military-aged males (mean age 27 years) who suffered from explosive or blunt force injuries. Procedures performed during each phase of care reflected the capabilities of the teams and locations. Pain and cardiac events were more common in POI evacuations compared to the Role 2 to Role 3 transports, but documentation of respiratory events, hemodynamic events, neurologic events, and equipment failure was more common during the Role 2 to Role 3 transports. Survival rates were slightly higher among the Role 2 to Role 3 cohort (98% vs. 95%, difference 3% [95% confidence interval of the difference 1-5%]).

**Conclusions:**

Inter-facility transports (Role 2 to Role 3) are longer in duration, transport more complex patients, and are staffed by more advanced level provider types compared to transports from POI.

**INTRODUCTION**

The Department of Defense medical personnel are tasked with determining how to stabilize combat casualties when

*United States AirForce En route Care Research/59th Medical Wing/Sci- ence & Technology, JBSA Lackland Air Force Base, TX 78236, USA

† Department of Emergency Medicine, Brooke Army Medical Center, JBSA Ft. Sam Houston, TX 78234, USA

‡ Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD 20814, USA

§ US Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX 78234, USA

2022 Military HealthCare Symposium, 2022 Special Operations Medical Associations, and 2022 Society for Academic Emergency Medicine.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Air Force, Department of the Army, Department of Defense, or US Government.

doi:<https://doi.org/10.1093/milmed/usad404>

Published by Oxford University Press on behalf of the Association of Mil- itary Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.

a Military Treatment Facility (MTF) with surgical capabili- ties is not available for up to 72 h after the time of injury.1,2 To address this challenge, it is necessary to understand the capabilities, such as damage control and stabilization inter- ventions, required to ensure the survival of a patient long enough to reach a definitive level of care. In combat oper- ations, patients with traumatic injuries require urgent clin- ical care and expeditious evacuation to improve survival.3 Ground medics deployed in the field are often the first respon- ders but have limited capabilities and supplies. Aeromedical evacuation platforms such as U.S. Army Medical Evacuation (MEDEVAC) allow for urgent evacuation to Role 2 or Role 3 facilities that provide higher levels of care. MEDEVAC transport times may vary depending on environmental factors and the ability to land in combatant locations.4 Previous data have shown that longer transport times are associated with increased morbidity and mortality.5–7

During the conflicts in Iraq and Afghanistan, the imple- mentation of Secretary Gates’ “golden hour” policy resulted in the establishment of multiple dispersed Role 2 military

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**TABLE I.** Definitions of Events

treatment facilities.7 This policy enforced the rapid transport of combat casualties to damage control surgery andresusci- tation.7 With this forward surgical capability came the need to transport post-operative combat casualties from the Role 2 MTFs to the more advanced Role 3 MTFs. The MEDE- VAC system was designed predominately for the evacua- tion of casualties from the field of combat and pre-surgical trauma management.8Those patients transported from a Role 2 to a Role 3 following damage control surgery and/or resuscitation are significantly different from those transferred from the point-of-injury (POI). To address this difference, the U.S. Army has intermittently supplemented the standard paramedic-based MEDEVAC with critical care flight nurses, though not consistently.9Conversely, the U.S. AirForce Criti- cal CareAir Transport Team (CCATT) consisting of an emer- gency medicine or critical care physician, an emergency or critical care nurse, and a respiratory therapist functions as a “flying Intensive Care Unit” and has been employed in Role 2 to Role 3 inter-facility transports.10 However, CCATT pre- dominately functions within fixed-wing aircraft, so they are usually limited to transport from Role 2s established at or near an airfield.

Staudt et al. evaluated data from the JTS database and described patients treated at a Role 2 and subsequently evac- uated to a Role 3 in Afghanistan.11 This study provided a description of patient characteristics and the en route care personnel but did not abstract data from the individual flight medical records or evaluate patient outcome data. The authors advocated for future studies to evaluate the care provided dur- ing Role 2 to Role 3 MTF transports as well as short- and long-term outcomes based on en route care provider skill level. Accordingly, we conducted a study describing the inter- ventions performed during aeromedical evacuation from a Role 2 to a Role 3, the aeromedical evacuation team per- forming the transport, and the association with 30-day patient outcomes.

**MATERIALS AND METHODS**

The Strengthening the Reporting of Observational studies in Epidemiology guidelines were used to confirm proper report- ingof our observational study (SDC 1). We conducted a retro- spective review of medical records of U.S. military, U.S. gov- ernment employees, and U.S. contractors who were treated at a Role 2 facility and subsequently evacuated to a Role 3 MTF in Iraq or Afghanistan from January 2007 to December 2016. We excluded patients under the age of 18 years, detainees, and those who died before departing the Role 2 facility.

We queried the Department of Defense Trauma Registry to identify patients that met our inclusion criteria. We then obtained these patients’ MEDEVAC or CCATT patient care records from the Joint Trauma System or CCATT Pilot Unit. We also queried the Joint Trauma System Role 2 Database to determine the procedures performed at the Role 2 facilities and the Department of Defense Trauma Registry for outcome data. Trained research team members abstracted the data from

*Evacuation of Combat Casualties, Role 2 to Role 3*

**Event type Definition**

Pain

Respiratory

Hemodynamic

Cardiac

Neurological

Renal/urinary

Temperature

Equipment failure

Abnormal lab

Increase in rate or dose of existing analgesia Start of new analgesia

A documented complaint of pain

As determined by medical provider to include: Headache,chest, abdominal, back, hip, leg/knee,

arm/shoulder, muscle pain

As documented by medical provider to include:

SpO2≤ 90%

FiO2 increase >10%

O2L min increase >4

≥5 increase in PEEP

As documented by medical provider to include: SBP ≤90 or ≥180 or 20% change from baseline MAP ≤65 or ≥120 or 20% change from baseline CVP change from baseline of 5

HR <60 bpm or >120 bpm or 20% change from

baseline

As determined by medical provider to include: Cardiac arrest

Notable findings on electrocardiogram

As determined by medical provider to include:

Agitation, seizures, change in mental status, motor, cognitive, or sensory ability

As determined by medical provider to include:

Oliguria (low urine output), dark urine, renal calculus

Fever (body temperature ≥ 100.5 F or 38 C)

Hypothermia (body temperature < 95 F or 35 C) As determined by medical provider to include: Propaq failure, battery failure, ventilator failure Glucose (<70 or >105)

Potassium (<3.5 or >5)

Sodium (<136 or >145)

PTT (>35)

SBP, systolic blood pressure; MAP, mean arterial pressure; CVP, cen- tral venous pressure; HR, heart rate; PTT, partial thromboplastin time. Definitions from Maddryetal.10

these charts and entered them into an electronic database. These records included demographic data, injury description, provider type, flight dates and times, transport time, clinical data (vital signs, laboratory values if available, procedures, medications, and events), and 30-day survival. Clinical events were identified from the provider narrative and descriptions of events in the patient care records using criteria from our pre- vious studies (Table I).10 We implemented quality assurance measures to ensure consistency among the trained abstractors, including a secondary review of 100% of records.12,13

In addition to the data collected specifically for this current study, we used data from a previously published paper describing patients traumatically injured in combat in Afghanistan and evacuated from the POI by MEDE- VAC.8That study, which included 1,237 patients transported between January 2011 and March 2014, contained similar variables to this current dataset. We used the tables and figures from the previous paper to calculate summary data (frequen- cies, percentages, means, and standard deviations) to compare

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*Evacuation of Combat Casualties, Role 2 to Role 3*

**TABLE II.** Patient and Provider Characteristics

**Variable**

**Role 2 to Role 3**

**(n** = **869)**

**POI to 1st MTFa**

**(n** = **1,237)**

**Difference (95% CI)**

Age, years

27 (7)

24 (5)

−3 (−4 to −2)*

Male gender

97%

99%

−2% (−3% to −1%)*

Highest provider type

Paramedic

8%

21%

−13% (−16% to −10%)*

Medic

14%

76%

−62% (−58% to −65%)*

Advanced**

57%

3%

54% (51% to 58%)*

Not specified

20%

Injury severity score

13 (13)

14 (14)

−1 (−35 to 2)

ISS ≤10

57%

50%

−7% (−11% to −3%)*

ISS 11-19

21%

25%

−4% (−8% to −1%)*

ISS 20-29

12%

14%

−2% (−5% to 1%)

ISS 30-75

11%

12%

−1% (−4% to 2%)

Injury type

Blast

42%

69%

−27% (−32% to −23%)*

Blunt

29%

2%

27% (24% to 30%)*

Penetrating

27%

28%

−1% (−4% to 4%)

Burn

2%

1%

1% (0% to 2%)

Flight time, minutes

39 (20)

23 (56)

−16 (−19 to −13)*

Values are mean (standard deviation) or percent of sample.

*Differences are statistically significant if the 95% confidence interval of the difference does not include zero.

**Advanced provider category included registered nurses, physician assistants, and physicians.

aPOI to 1st MTF data are from Maddryetal.

characteristics, medications, events, and outcomes of patients transported from the POI (the previous study) and those trans- ported from a Role 2 to a Role 3 (current study). We used independent *t*-tests to analyze continuous variables and chi- squared tests for nominal variables. Outcomes are reported as differences with 95% confidence intervals; results are consid- ered statistically significant if the corresponding confidence interval does not include or cross zero. We conducted all anal- yses in SAS version 9.4 (SAS Institute, Cary, NC, USA).

**RESULTS**

We analyzed data from 869 patients transported from a Role 2 to a Role 3 MTF between January 2007 and December 2016. The most common originating facilities were Shank (33%), Jalalabad (16%),and Ghazni (11%). Patients were transported to one of five Role 3 facilities: Bagram (76%), Kandahar (14%), Bastion (10%), Balad (<1%), and Baghdad (<1%). The mean flight time from a Role 2 to a Role 3 was 39 min, which was significantly longer than the mean flight time from the POI to the first MTF (Table II). Most from Role 2 to Role 3 transports were staffed by advanced providers (RNs, PAs, physicians) and medics; in contrast, flights from the POI cohort were primarily staffed by medics and paramedics. Most patients transported from a Role 2 to a Role 3 were young men with an average age of 27 years. Nearly half of the sample suffered from an explosive injury, over half had an injury severity score (ISS) of 10 or less, and the mean injury severity score ISS was 13. Although the patients trans- ported from the POI to the first MTF had a similar mean ISS, that cohort had a higher proportion of patients with explosive

injuries and lower proportion of patients with blunt injuries and an ISS of 10 or less.

The most common procedures conducted at each phase of care reflected the capabilities of each location and team (Table III). During transport from the POI to the first MTF, most procedures were related to damage control resus- citation, such as fluid/blood administration, hemorrhage con- trol, and hypothermia prevention. On the other hand, proce- dures at the Role 2 MTF were more advanced and included imaging (X-ray and ultrasound), intubation and mechani- cal ventilation, fluid/blood administration, laparotomy, fas- ciotomy, and amputation. Patients were more likely to require ventilator management and receive medications (Table III) during the inter-facility flight from the Role 2 to the Role 3 compared to the initial flight from the POI.

Pain and cardiac events were more commonly documented in POI evacuations compared to the Role 2 to Role 3 trans- ports (Fig. 1). Conversely, documented respiratory events, hemodynamic events, neurologic events, and equipment fail- ure were more common during the Role 2 to Role 3 transports. Survival rates were slightly higher among the Role 2 to Role 3 cohort compared to the POI cohort (98% vs. 95%, difference 3% [95% confidence interval of the difference 1% to 5%]).

**DISCUSSION**

In our study evaluating the transport of patients from a Role 2 to a Role 3 facility, we found significant differences from the early transport phase from the POI to a MTF. First, the Role 2 to Role 3 transports were significantly longer in duration due to the dispersal of Role 2s close to combat operations per Secretary Gates’ “golden hour” policy. Second, the majority

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*Evacuation of Combat Casualties, Role 2 to Role 3*

**TABLE III.** Procedures and In-flight Medications during Each Phase of Care

**Transport from POI to first**

**MTF (*n* = 1,237)a**

**At Role 2 (*n*** = **869)**

**Transport from Role 2 to Role 3 (*n*** = **869)**

Supplementary oxygen (49%)

Any medications (30%)

Analgesia (28%)

Fluids (28%)

Intravenous access (22%)

Pressure packing (13%)

Hypothermia prevention

(11%)

Spinal stabilization (6%)

Intraosseous access (5%)

Tourniquet (5%)

Blood products (4%)

Nasal/oral airway (3%)

CPR (3%)

Splint/sling (2%)

Chest needle (2%)

Intubation (2%)

Sedation (1%)

Hemostatic agent (1%)

Chest seal (1%)

Defibrillation (1%)

Cricothyrotomy (1%)

Chest tube (<1%)

X-ray (89%)

Intravenous access (78%)

Fluids (70%)

Hypothermia prevention

(64%)

Wound dressing/packing

(61%)

Ultrasound (60%)

Stabilization/immobilization

(52%)

Drains (43%)

Supplementary oxygen

(39%)

Mechanical ventilation

(30%)

Intubation (29%)

Blood products (26%)

Tubes (23%)

Arterial line (16%)

Central line (15%)

Laparotomy (9%)

External fixator (9%)

Fasciotomy (9%)

Chest tube (8%)

Amputation (6%)

Hypothermia prevention (53%) Any medications (51%)

Analgesia (44%)

Supplementary oxygen (40%)

Fluids (30%)

Mechanical ventilation (29%) Stabilization/immobilization

(26%)

Sedation (24%)

Paralytic (15%)

Chest tube (7%)

Antiemetic (6%)

Blood products (4%)

Vasopressors (3%)

Tourniquet (1%)

Wound dressing/packing (1%) Parenteral access (1%)

Antibiotics (<1%)

aPOI to 1st MTF data are from Maddryetal.8

of patient care teams included an advanced medical provider (physician, PA, or RN). Third, patients were more likely to require ventilator management and receive medications dur- ing transport. Fourth, patients were more likely to have doc- umented respiratory, hemodynamic, and neurologic events during transport. Finally, more teams documented equipment failure during the transport.

Our study highlights the importance of ensuring medi- cal teams providing Role 2 to Role 3 transports possess the necessary knowledge and skills to address the differences from earlier phase transports from POI. Mabry et al. found improved survival of casualties transported by a paramedic versus a medic.4,14Apodacaetal. found physician-led British Medical Emergency Response Teams had similar outcomes to U.S. Army medics despite caring for casualties with higher ISSs.15,16 Conversely, Maddry et al. found no association between advanced en route care personnel and 30-day sur- vival, but theorized this was likely due to the brief trans- port duration following Secretary Gates’ golden hour pol- icy.8 Extrapolating the findings of these earlier studies to the results of our study suggest that advanced medical per- sonnel are necessary to ensure the survival of inter-facility transfer patients for multiple reasons. First, our study found inter-facility transports were of significantly greater dura- tion where the use of physicians and nurses is likely to

yield greater benefit. Second, inter-facility en route care personnel had to manage mechanical ventilators, medication infusions, paralytics, chest tubes and other advanced medical equipment and procedures outside of the standard medic’s scope of practice. Finally, inter-facility transfer patients had a higher incidence of documented respiratory events, hemody- namic events and neurologic events. These events are similar to those encountered and managed by emergency department and intensive care unit personnel.17,18 Conversely, ground medics and corpsmen are more focused on the initialstabiliza- tion as opposed to the on-going critical care after stabilization. Training medics to assume these duties is challenging, and potentially unrealistic. The time required to train and main- tain these skills as well as the necessary clinical experience present significant challenges.

The current events in Ukraine highlight the importance of ground transport of combat casualties. Given the lack of con- tinuous air superiority within Ukraine, rotary-wing aircraft are at significant risk of enemy attack and do not provide a con- sistent transport solution as occurred in Operation Iraqi Free- dom/Operation Enduring Freedom (OIF/OEF).19While Spe- cial Operations Command possesses specialized physician led teams capable of evacuating casualties and the military has supplemented evacuation teams with nurses, physicians, and physician assistants, the majority of conventional U.S.

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![](/media/202412//1733389569.618626.jpeg)

**FIGURE 1**.Comparison of inlightevents betweenfights from the point of injury (POI)or aRole l facility (solid black bars)vs.lights from aRole 2 toa Role 3 facility (shaded gray bars).IPOI to lst MTF data are from Madry et al.⁸*Comparisons were statistically significant atP<0.05.

military ground evacuation transport teams lack physician, PA,and nursing support.20 Future studies should evaluate the ability of CCATT,MEDEVAC,and other military med- ical teams to provide ground transportation.This includes the ability to provide evacuation using both military and civilian vehicles of opportunity lacking electrical power,oxygen,and other capabilities provided by some military aircraft

***Limitations***

Our study has several limitations.First,this is a retrospec- tive chart review and our findings may be limited as a result ofincomplete ormissing data.Specifically,the task demands on transport providers vary by phase of transport and may result in different documentation practices for Role 2 to 3 transports compared to transports from POI.The use ofdata abstractors has the potential for subjectivity;however,thor- ough chart abstraction,substantive abstractor training,and quality review procedures were implemented to limit sub- jectivity.12,13 Second,variations in documentation practices between MEDEVAC and CCATT units may impact consis- tency of the data within the Role 2 to 3 cohort.Third,while this study found significant differencesbetween the transports from POI and the transports between facilities,we cannot assert any causality with regards to outcomes.With regards to external validity,this study focused on military trauma

patients during OIF/OEF and our results may not be gener- alizable to the civilian community or other conflicts.Civilian patients and casualties in future military conflicts may have significantly different traumatic injuries and medical ailments than those discussed in our study

**CONCLUSION**

When compared to MEDEVACtransports from the POI,inter- facility transports within theater (Role 2 toRole 3)are longer in duration and utilize more advanced level provider types to transport patients of higher complexity.Military medical planning,training and resource allocation should consider these factors,to include increasing the number of advance medical personnel trained in aeromedical evacuation,when preparing for future military operations

**ACKNOWLEDGMENTS**

None declared.

**CLINICALTRIAL REGISTRATION**

Not applicable.

**IRB HUMAN SUBJECT**

This study was reviewed and approved by the 59th Medical Wing JBSA Lackland IRB as a minimal risk human subject study.

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*Evacuation of Combat Casualties, Role 2 to Role 3*

**INSTITUTIONAL ANIMAL CARE AND USE**

**COMMITTEE (IACUC)**

Not applicable.

**INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT**

J.K.M.: Principal Investigator, obtained funding, designed the study, drafted, and edited the manuscript. A.A.A.: assisted with study design, performed statistical analysis, and provided critical revision of the manuscript. A.M.: assisted with study design and performed statistical analysis. S.G.S.: drafted and edited the manuscript. L.K.R.: abstracted data. J.C.: abstracted data. J.A.P.: abstracted data. C.A.P.: acquisition of data, conducted quality control, and edited the manuscript. W.T.D.: edited and provided critical revision of the manuscript. P.C.N.: edited and provided critical revision of the manuscript.

**INSTITUTIONAL CLEARANCE**

The manuscript was reviewed and cleared for dissemination by the Clini- cal Investigations and Research Support, 59th Medical Wing/Science and Technology.

**FUNDING**

Defense Health Agency Research and Engineering Directirate Intramural J9, Grant number J917EC02.

**CONFLICT OF INTEREST STATEMENT**

All authors have no conflicts of interest to disclose.

**DATA AVAILABILITY**

The data underlying this article will be shared on reasonable request to the corresponding author.

**REFERENCES**

1. Schauer SG, Long BJ, Rizzo JA, et al: A conceptual framework for non-military investigators to understand the joint roles of med- ical care in the setting of future large scale combat operations. Prehosp Emerg Care 2023; 27(1): 67–74. [10.1080/10903127.2021.](https://doi.org/10.1080/10903127.2021.-2008070) [2008070](https://doi.org/10.1080/10903127.2021.-2008070)

2. Arnold JL, MacDonald AG, Baker JB, Rizzo JA, April MD, Schauer SG: An assessment of casualties undergoing delayed surgical inter- vention in the combat setting. Med J (Ft Sam Houst Tex) 2023; (Per 23-1/2/3): 28–33.

3. Morrison JJ, Oh J, DuBose JJ, et al: En-route care capability from point of injury impacts mortality after severe wartime injury. Ann Surg 2013; 257(2): 330–4. [10.1097/SLA.0b013e31827eefcf](https://doi.org/10.1097/SLA.0b013e31827eefcf)

4. Holland SR, ApodacaA, Mabry RL: MEDEVAC: survival and physio- logical parameters improved with higher level of flight medic training. Mil Med 2013; 178(5): 529–36. [10.7205/MILMED-D-12-00286](https://doi.org/10.7205/MILMED-D-12-00286)

5. Desmettre T, Yeguiayan JM, Coadou H, et al: Impact of emergency medical helicopter transport directly to a university hospital trauma left on mortality of severe blunt trauma patients until discharge. Crit Care 2012; 16(5): R170. [10.1186/cc11647](https://doi.org/10.1186/cc11647)

6. Maddry JK, Perez CA, Mora AG, Lear JD, Savell SC, Bebarta VS: Impact of prehospital medical evacuation (MEDEVAC) transport time on combat mortality in patients with non-compressible torso injury

and traumatic amputations: a retrospective study. Mil Med Res 2018; 5(1): 22. [10.1186/s40779-018-0169-2](https://doi.org/10.1186/s40779-018-0169-2)

7. Kotwal RS, Howard JT, Orman JA, et al: The effect of a golden hour policy on the morbidity and mortality of combat casualties. JAMA Surg 2016; 151(1): 15–24. [10.1001/jamasurg.2015.3104](https://doi.org/10.1001/jamasurg.2015.3104)

8. Maddry JK, Mora AG, Savell S, Reeves LK, Perez CA, Bebarta VS: Combat MEDEVAC: a comparison of care by provider type for en route trauma care in theater and 30-day patient outcomes. J Trauma Acute Care Surg 2016; 81(5 Suppl 2 Proceedings of the 2015 Military Health System Research Symposium): S104–10.

[10.1097/TA.0000000000001119](https://doi.org/10.1097/TA.0000000000001119)

9. NagraM: Optimizing wartime en route nursing care in Operation Iraqi Freedom. US Army Med Dep J 2011: 51–8.

10. Maddry JK, Mora AG, Savell SC, et al: Impact of Critical Care Air Transport Team (CCATT) ventilator management on com- bat mortality. J Trauma Acute Care Surg 2018; 84(1): 157–64.

[10.1097/TA.0000000000001607](https://doi.org/10.1097/TA.0000000000001607)

11. StaudtAM, Savell SC, Biever KA, et al: En route critical care transfer from a role 2 to a role 3 medical treatment facility in Afghanistan. Crit Care Nurse 2018; 38(2): e7–15. [10.4037/ccn2018532](https://doi.org/10.4037/ccn2018532)

12. WorsterA, Bledsoe RD, Cleve P, Fernandes CM, Upadhye S, Eva K: Reassessing the methods of medical record review studies in emer- gency medicine research. Ann Emerg Med 2005; 45(4): 448–51.

[10.1016/j.annemergmed.2004.11.021](https://doi.org/10.1016/j.annemergmed.2004.11.021)

13. Gilbert EH, Lowenstein SR, Koziol-mclain J, Barta DC, Steiner J: Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med 1996; 27(3): 305–8. [10.1016/s0196-](https://doi.org/10.1016/s0196-0644(96)70264-0) [0644(96)70264-0](https://doi.org/10.1016/s0196-0644(96)70264-0)

14. Mabry RL, Apodaca A, Penrod J, Orman JA, Gerhardt RT, Dor- lac WC: Impact of critical care-trained flight paramedics on casu- alty survival during helicopter evacuation in the current war in Afghanistan. J Trauma Acute Care Surg 2012; 73(2 Suppl 1): S32–7.

[10.1097/TA.0b013e3182606001](https://doi.org/10.1097/TA.0b013e3182606001)

15. ApodacaA, Olson CM Jr, Bailey J, Butler F, Eastridge BJ, Kuncir E: Performance improvement evaluation of forward aeromedical evacua- tion platforms in Operation Enduring Freedom. J Trauma Acute Care Surg 2013; 75(2 Suppl 2): S157–63. [10.1097/TA.0b013e318299da3e](https://doi.org/10.1097/TA.0b013e318299da3e)

16. Apodaca AN, Morrison JJ, Spott MA, et al: Improvements in the hemodynamic stability of combat casualties during en route care. Shock 2013; 40(1): 5–10. published correction appears in Shock. 2014 Jun;41(6):558. [10.1097/SHK.0b013e31829793d7](https://doi.org/10.1097/SHK.0b013e31829793d7)

17. Cooney RR, Murano T, Ring H, Starr R, Beeson MS, Edgar L: The emergency medicine milestones 2.0: setting the stage for 2025 and beyond. AEMEduc Train 2021; 5(3): e10640.[10.1002/aet2.10640](https://doi.org/10.1002/aet2.10640)

18. Fessler HE, Addrizzo-Harris D, Beck JM, et al: Entrustable pro- fessional activities and curricular milestones for fellowship training in pulmonary and critical care medicine: report of a multisociety working group. Chest 2014; 146(3): 813–34. [10.1378/chest.14-0](https://doi.org/10.1378/chest.14-0-710) [710](https://doi.org/10.1378/chest.14-0-710)

19. Kazmirchuk A, Yarmoliuk Y, Lurin I, et al: Ukraine’s experience with management of combat casualties using NATO’s four-tier” changing as needed” healthcare system. World J Surg 2022; 46(12): 2858–62.

[10.1007/s00268-022-06718-3](https://doi.org/10.1007/s00268-022-06718-3)

20. DuBose JJ, Stinner DJ, BaudekA, et al: Life and limb in-flight surgical intervention: fifteen years of experience by joint medical augmentation unit surgical resuscitation teams. JSpecOperMed 2020; 20(4): 47–52.

[10.55460/SI6S-XHCZ](https://doi.org/10.55460/SI6S-XHCZ)

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