Patient movement is the process which provides a continuum of care and coordinates the movement of patients from the site of injury or onset of disease, through successive roles of care, to and between medical treatment facilities (MTFs) that can meet the needs of the patient. Patients are moved only as far rearward as the tactical situation dictates and as clinical needs warrant. Prompt movement of patients to the required level of clinical care is essential to prevent morbidity and mortality. Each Service component has medical evacuation (MEDEVAC) or casualty evacuation (CASEVAC) capability to do so. Patient movement consists of three components:
En Route Care (ERC) is defined in Joint Publication (JP) 1-02, Department of Defense (DoD) Dictionary of Military and Associated Terms and JP 4-02 as the continuation of the provision of care during movement (evacuation) between the health service support capabilities in the roles of care, without clinically compromising the patient’s condition. ERC involves the provision of transitory medical care, patient holding, and staging capabilities during transport from the point of injury or onset of disease throughout the continuum of care.
To ensure the safe transport of casualties during evacuation to definitive care, patients must be adequately prepared for evacuation. The purpose of this Clinical Practice Guideline (CPG) is to provide a ready resource for those who are responsible for preparing a patient for en route care.
The goal of ERC casualty preparation is to provide the continued level of medical support as the casualty is transported throughout the battlespace and differing roles of care. Considerations for planning during transport can be categorized into groups of concerns: 1)safety, 2) access, and 3) organization. When planning for any casualty transfer, the transport team should prepare for 2-3 times longer transport time than initially projected (i.e. If the transport is anticipated to take 2 hours, plan for 4-6 hours).
Transport safety includes the safety of both the casualty and the ERC team’s interaction with the casualty. All casualties should be provided thermal regulation, visual protection, and auditory protection from the transport environment. Casualty preparation for transport can be divided into two phases: ground preparation and transport team preparation.
Consists of planning and execution phases.
This phase begins upon receipt of the 9-line medical evacuation request and M.I.S.T. report. Each aspect of the 9-Line request is important for the transport team, but emphasis is placed on the number and criticality of casualties, as well as the tactical situation. Accuracy is key - as the incoming ERC team must ensure that the casualty load will not overwhelm their resources or capabilities. The ERC team’s clear understanding will lead to their arrival with the correct resources and the patient disposition to the appropriate medical facility.
During this phase, time is of the essence. Upon arrival at the initiating facility, the ERC team should contact the provider requesting the evacuation. The goal is to decrease the amount of time spent preparing the patient and rapidly move to transport. The ERC team will assign tasks to ensure that each member is appropriately utilized. Tasks that should be completed by the team include receiving report, assessing the patient, validating the movement of the casualty, verifying correct packaging in preparation for departure, packaging the patient for transport, and development of the en route plan.
The ERC team will guide the report and assessment process. The use of the MARCH acronym (Appendix B) can assist both the sending and transport teams in communicating the appropriate information in the least amount of time. Often the priorities of the sending team differ from those of the ERC team. The ERC team should receive report, ask questions pertinent to the status and transfer of the patient, and then provide an opportunity for the sending team to provide additional information. If hand off must occur in high ambient noise environments such as engines running on/off-load or helicopter hot-load sending, provider should point to each wound(especially areas of controlled or suspected hemorrhage) with confirmation of receiving team of wounds/injuries. Use of a communication device (such as the Atlantic Signal Tactical Medic Intercom) that allows sending and receiving team aircraft-side verbal communication is hugely beneficial and units/teams should coordinate this beforehand.
Once the report has been completed, an assessment will be performed to confirm findings and interventions. This assessment will develop the “Do Now” status of the casualty. The “Do Now” criteria are the current MARCH findings from the report and the assessment that need immediate intervention to prepare for transport. As each of the “Do Now” criteria are identified, secondary logistic supply needs and assessment needs are developed.
The findings of the ERC casualty assessment assist in the validation of the decision to transport the casualty. The JTS CPG on the Interfacility Transport of Casualties Between Theater MTFs gives clear guidance on the resuscitation goals that should be followed to identify when a casualty is safe to transfer. If one or more of these goals is not met, a plan must be developed to optimize the casualty in accordance with resources and tactical situations.
Once the casualty is validated for movement, supply needs can be filed under the “Take With” portion of casualty transport planning. The goal of this portion of the planning process is to ask the “what if“ question for each of the casualty’s interventions. This item list will include back-up support devices and batteries, dressing reinforcement supplies, next step interventions, medications for continued treatment, and documentation.
Package the casualty to ensure safety of the casualty and team, access to all relevant interventions, and organization of resources. Monitors should be placed on the litter structure or attached to a litter device to ensure that NO EQUIPMENT IS RESTING ON THE CASUALTY, it is fully secure to the litter system, and that all team members have access to and can view the monitors. Securing devices, such as litter straps used for equipment, should not be used for the casualty. All casualties should be secured with a minimum of two strap style devices. It is also recommended that any tubing or wires be secured with litter straps to prevent snaring or disconnection during movement.
Develop the assessment protocol for your casualty while in transport. This is an opportunity for the team to clearly subdivide tasks and ensure that all aspects of casualty care will be met. It is key to remember that vital signs should be checked regularly. This will create a pattern repetition or “battle rhythm” for the transport period.
Documentation and report are developed from the “en route” portion of the casualty transport plan. Depending upon the status and required effort of casualty care during transport, documentation on the DD1380 or DA4700 may prove to be difficult to maintain. It is imperative that, the team monitor, and document vital signs regularly as required by patient acuity, administer, and document medications, and perform and document any interventions in order that they have been completed in the casualty care record.
En route care of patients requires adequate equipment to ensure safe and successful transport. Certain information such as length of flight, number of patients to be transferred, and severity of patient condition should be taken into consideration when deciding the type and number of equipment to be used. The goal of preparing equipment for patient transport is to ensure all necessary items are accounted for, both consumable and non-consumable.
In general, each patient will require:
Models of these pieces of equipment may vary between each service depending on availability. Additional items should be available so that for each possible equipment failure or for deterioration of the patient there is a backup plan and the proper materials available for these plans. For example, if the external suction machine fails, a manual suction should be available.
The length of the transport will determine the amount of medication and number of consumables that should be brought with the ERC team. At minimum, twice the length of the transport should be planned for when packing items. Oxygen needs and consumption rate should be calculated prior to transport to ensure enough supply is available for all legs of the transport. For example, the flight time may be 15 minutes, but the ground transport time from the landing zone to the next echelon of care may be an additional 20 minutes.
Consumable equipment is that which expires or cannot be reused on another patient. For all non-consumable items, fully charging batteries and performing any function checks should be ensured before transport. Although some platforms have the ability to charge the equipment, it is not guaranteed on every platform. These items must be properly inspected by biomedical per the maintenance requirement recommended by the company of each respective piece of equipment.
Non-consumable equipment should be secured on the patient litter or transportation device so that the ERC team members can view them during transport. Equipment may be secured down by litter straps, ratchet straps, tape, or other securement devices. Consumables may be carried by the ERC team members via bag or backpack or may be prestaged in the transport platform.
Guidance on equipment, consumables, medications, and fluids can be found in Appendix A. Quantities of each have been left out as it will vary by transport. Although not all items on the list will need to be included for every transport, supplies needed for potential emergencies during transport should be considered.
Moving a patient from one echelon of care to another requires mitigation of safety risks through the use of personal protective equipment (PPE). PPE is determined, in part, by the mode of transportation and terrain. PPE must be applied prior to transport. Land, sea, and air are possible transport environments via ruck, truck, boat, or ship, rotary or fixed wing platforms. Critical thought must be used when considering the appropriate protective equipment which may include but not limited to:
Patient safety considerations also must be exercised when moving the patient to, from, and within the transportation platform. The patient must be properly secured to the litter or sled prior to movement. The securing devices must be reassessed after each movement to ensure all interventions are still in place. Consideration must also be given to have adequate numbers of personnel to move the patient from one echelon to another. A four-person litter team, directed by a medic, is the safest option when moving patients on a NATO litter. After the patient is transferred to a platform for transport, the final consideration is to ensure the litter or sled is secured to the conveyance. Though optimal, this final consideration may be omitted for the operational environment. If transporting via aircraft, work with air crew to determine the best patient position and securement method.
The above constitutes the minimum criteria for PI monitoring of this CPG. System reporting will be performed annually; additional PI monitoring and system reporting may be performed as needed.
The system review and data analysis will be performed by the JTS Chief and the JTS PI team.
It is the ERC team leader’s responsibility to ensure familiarity, appropriate compliance, and PI monitoring at the local level with this CPG.
Source: U.S. Army Aeromedical Evacuation Standard Medical Operating Guidelines, CY24 Version, Published 1 Feb 2024
PRE-FLIGHT CHECKLIST
(for Critical Care and Post-Surgical Transfers)
Once the decision is made to transfer a patient and an accepting physician has been obtained, the following steps will be taken to prepare the patient for transport:
**Ensure collaborative assessment for chest expansion and bag valve compliance
**Place pelvic binder or junctional tourniquets for all thoracic and abdominal injuries, as well as any traumatic lower leg amputations.
Ensure wet clothing is removed and place patient in an Absorbent Patient Litter System or HPMK if available. If only sheets or blankets are available, place one underneath and on top of patient for full coverage.
Illustration by Raymond Samonte
GTP: https://GTP.health.mil
The purpose of this Appendix is to ensure an understanding of DoD policy and practice regarding inclusion in CPGs of “off-label” uses of U.S. Food and Drug Administration (FDA)–approved products. This applies to off-label uses with patients who are armed forces members.
Unapproved (i.e. “off-label”) uses of FDA-approved products are extremely common in American medicine and are usually not subject to any special regulations. However, under Federal law, in some circumstances, unapproved uses of approved drugs are subject to FDA regulations governing “investigational new drugs.” These circumstances include such uses as part of clinical trials, and in the military context, command required, unapproved uses. Some command requested unapproved uses may also be subject to special regulations.
The inclusion in CPGs of off-label uses is not a clinical trial, nor is it a command request or requirement. Further, it does not imply that the Military Health System requires that use by DoD health care practitioners or considers it to be the “standard of care.” Rather, the inclusion in CPGs of off-label uses is to inform the clinical judgment of the responsible health care practitioner by providing information regarding potential risks and benefits of treatment alternatives. The decision is for the clinical judgment of the responsible health care practitioner within the practitioner-patient relationship.
Balanced Discussion
Consistent with this purpose, CPG discussions of off-label uses specifically state that they are uses not approved by the FDA. Further, such discussions are balanced in the presentation of appropriate clinical study data, including any such data that suggest caution in the use of the product and specifically including any FDA-issued warnings.
Quality Assurance Monitoring
With respect to such off-label uses, DoD procedure is to maintain a regular system of quality assurance monitoring of outcomes and known potential adverse events. For this reason, the importance of accurate clinical records is underscored.
Information to Patients
Good clinical practice includes the provision of appropriate information to patients. Each CPG discussing an unusual off-label use will address the issue of information to patients. When practicable, consideration will be given to including in an appendix an appropriate information sheet for distribution to patients, whether before or after use of the product. Information to patients should address in plain language: a) that the use is not approved by the FDA; b) the reasons why a DoD health care practitioner would decide to use the product for this purpose; and c) the potential risks associated with such use.
You can discuss this material on the TCCC forum
