Air Force Medicine Expands Capability

455th EAES creates mobile ICU for in-flight care.
by Lt. Gen. Mark Ediger, U.S. Air Force Surgeon General
September 26, 2017

Medical Airmen must be prepared to deploy on short notice to provide life-saving and performance-enhancing healthcare in diverse, austere and isolated locations. In addition, all Airmen must be medically ready to deploy. More than ever, this dual requirement calls for Air Force Medical Service (AFMS) to maintain readiness and agility. It also requires AFMS to engage in strategic partnerships to leverage every available resource to accomplish the mission.

The 12 hospitals and 64 clinics that comprise Air Force military treatment facilities (MTFs) serve as dual platforms. They ensure all Airmen meet medical standards to deploy and all medical Airmen have the training and skills necessary for deployment. Medical group commanders tailor care and training at each MTF, so no two air bases have the same mission portfolio. Each has unique medical support requirements.

An example is the 19th Medical Group (19 MDG) at Little Rock Air Force Base (AFB), Ark. The medics from Aerospace Medicine Squadron High Altitude Airdrop Mission Support Center are experts in the care of high-altitude operators, which includes unique oxygen monitoring and physiologic performance requirements. This type of expertise, like others organic to Air Force Medicine, is not required at every installation nor would it be efficient to deploy it at all 76 AFMS facilities.



The knowledge, skills and abilities gained at these fixed facilities translate into outstanding care in a deployed environment.  A valuable tool for AFMS to extend this care downrange is its Expeditionary Medical Support Health Response Teams (EMEDS-HRT). They allow medical Airmen to rapidly deploy a mobile tent hospital, which can provide emergency care within an hour of arrival on the scene of a disaster or other casualty situation. This provides capability to deliver surgery and critical care within six hours of arrival with full hospital capability within 12 hours.

Properly training medical Airmen to deploy and operate EMEDS-HRT requires a specialized MTF readiness platform. Four are presently staffed, including the 633rd Medical Group at Joint Base Langley-Eustis in Virginia, which devotes time and resources to a critical deployment platform that other MTFs are not resourced to deliver. At the 633rd, the Global Response Force coordinates with Air Combat Command to run annual training exercises on EMEDS-HRT. Medics from the 633rd practice rapid deployment and simulated casualty care with a wide assortment of patient scenarios. These well-trained Airmen deploy in support of a variety of mission types around the world – from combat operations support to humanitarian assistance and disaster relief (HA/DR).

Once fully operational, EMEDS-HRT can provide surgical and trauma care, prevention, acute intervention, primary care and dental service to a population of more than 3,000. AFMS expert teams continue to find innovative ways to decrease size and weight, and increase speed of deploying these mobile hospitals. They can also be tailored to a specific mission, adding specialty care like obstetrics/gynecology and pediatrics for HA/DR or other missions involving populations with special healthcare needs.

Medics at most MTFs can rotate through EMEDS but may not receive the in-depth training available to Airmen at Joint Base Langley-Eustis. This tailored mission support is critical to building and sustaining an agile and flexible force, capable of completing myriad health-related missions around the globe at once.



Most care provided by AFMS is in its 76 MTFs located around the world, which also serve as the aforementioned training platforms for medical Airmen. Training is supplemented through partnerships with other military, government and civilian health systems to meet specialty and surgical currency requirements. This model has served the Air Force well for many years, but as its mission requirements change, so must its readiness platforms.

To effect this change, AFMS continues to expand its partnerships with other health entities. Most Air Force MTFs lack the volume of severely injured trauma patients needed to prepare its medics for deployment in combat or disaster response scenarios. AFMS employs numerous partnerships that each offer a different mix of clinical capabilities and/or serve different geographical areas. Since each MTF has its own medical mission to support, these partnerships provide valuable experience and sustain readiness for areas outside an MTF’s ability to provide care.

One example of the value of these partnerships is the 99th Medical Group at Nellis AFB in Nevada. A Sustained Medical and Readiness Training partnership with the University Medical Center of Southern Nevada in Las Vegas allows surgeons from the 99th to maintain their clinical currency by increasing the caseload beyond what is available at the MTF. Air Force orthopedic surgeons work part-time at Nellis and part-time at University Medical Center. This more than doubles the number of surgeries they perform each year. This achieves a state of readiness that would not be possible within an MTF alone while also allowing them to treat patients at the MTF.

Another valuable partnership is between the 1st Special Operations Medical Group (SOMDG), stationed at Hurlburt Field in Florida, and several trauma centers throughout the country. SOMDG operates Special Operations Surgical Teams (SOST) that deploy into extremely volatile and isolated regions with little other support. These highly trained and highly innovative teams provide robust medical capability anywhere, anytime.

A recently deployed SOST team saved the lives of four allied coalition service members utilizing resuscitative endovascular balloon occlusion of the aorta (REBOA). This technology, invented by an Air Force surgeon, helps control blood loss in severely wounded patients more effectively than traditional clamping. This was the first reported use of REBOA outside of a hospital setting, which demonstrates exactly the type of added value that cross-trained special operators and medical Airmen offer.

Preparing Airmen to execute this type of mission requires immersion in high stakes trauma care that is not available at MTFs. So, 1st SOMDG has partnerships to embed SOSTs at some of the most prestigious U.S. trauma centers, including University of Alabama-Birmingham Hospital and University of Miami Ryder Trauma Center.

What makes these partnerships unique for AFMS is that SOSTs embedded in these trauma centers are stationed there full time when not deployed. They receive continuous exposure to treating high-level trauma patients, such as victims of car accidents, shootings, stabbings and other severe injuries, similar to types of injuries they may see while deployed. These teams are stationed at partner hospitals for three to four years at a time, achieving full clinical currency in treating trauma victims while growing and developing their teamwork and leadership skills.



A key and unique component of AFMS is its global patient movement mission. Air Force aircraft can become flying intensive care units using the Critical Care Air Transport Team (CCATT). CCATTs transport critically ill or injured patients who require continuous stabilization or other advanced care. Teaching Airmen to deploy and to operate CCATTs is a highly specialized training mission, which is why AFMS partners with University of Cincinnati Institute for Military Medicine through the Center for the Sustainment of Trauma and Readiness Skills (C-STARS). This important CCATT training platform offers advanced training and simulation throughout a 12-day course with more than 170 graduates each year.

University of Cincinnati is home to one of three C-STARS partnerships in the United States. These partnerships, managed by the U.S. Air Force School of Aerospace Medicine, provide initial and advanced en route care education and training for Total Force (Active Duty, Guard and Reserve) physicians, nurses, medical technicians and respiratory therapists. C-STARS provides real-life readiness training at some of the country’s busiest trauma centers. In addition to University of Cincinnati, University of Maryland Medical Center R. Adams Cowley Shock Trauma Center in Baltimore and Saint Louis University Hospital in St. Louis serve as C-STARS hosts.

Medical Airmen participating in C-STARS receive training in a wide variety of trauma and critical care procedures, including patient resuscitation, damage control surgery, critical care evacuation and high-acuity inpatient care. More than 800 Airmen graduate annually with clinical training and currency not available at the vast majority of Air Force hospitals and clinics. AFMS medical Airmen bring important value to the institutions and their patients as well when they share battlefield experiences and innovations with civilian counterparts.

Another vital AFMS partnership is with the United Kingdom’s National Health Service (NHS) at three hospitals in England:  Norfolk Norwich University Hospital, Cambridge University Hospital and West Suffolk NHS Foundation Trust Hospital. Medical Airmen based at Royal Air Force (RAF) Lakenheath near Brandon, England, participate in a variety of advanced surgical procedures and care not performed at RAF Lakenheath. Specialties include general surgery, ear, nose and throat surgery, urology and orthopedic surgery. This partnership is now expanding into other NHS hospitals with potential to enable Airmen stationed elsewhere in Europe to participate. Partnerships like these are vital to sustaining a force of ready medical Airmen and vital to the future of AFMS.

An ongoing requirement for AFMS is the need to develop and train more agile and mobile units to deliver downrange care anywhere at any time. When the U.S. military deploys Airmen, Soldiers, Sailors or Marines to some of the most inhospitable and remote places imaginable, AFMS is prepared and continues to improve its ability to deliver the best-trained and equipped medical support to those in harm’s way.

One recent deployment saw a Mobile Forward Surgical Team (MSFT) from the 79th Medical Wing (now 11th Medical Group) at Joint Base Andrews, Md., deploy to an austere environment in the Middle East. Finding no suitable medical facilities, running water or electricity upon arrival, MFST converted four buildings into triage, treatment and surgical rooms that allowed them to treat more than 1,000 patients in seven weeks.

The seven Airmen of MFST were awarded the Bronze Star for their meritorious service. They demonstrated flexibility to meet unforeseen challenges on an evolving battlefield. The training they undergo, and care they provide at the 11th MDG, prepares them to execute these missions. Situated in the National Capitol Region brings unique resources for 11th MDG to utilize to help train MFST members. Partnerships with Walter Reed National Military Medical Center and Fort Belvoir Community Hospital allow for additional opportunities to maintain acute surgical currency that are not available at all Air Force MTFs.



Even with the ongoing expansion of health care into more agile and downrange environments and training partnerships, MTFs still achieve most of its dual readiness requirements. Most patients interact with their health teams in primary care clinics, so they are a key area for readiness and innovation. Air Force MTFs utilize the Air Force Medical Home (AFMH) model, a team-based approach to care that embeds specialty providers into primary care clinics. This removes barriers to care and drives efficiency. Mental health providers, physical therapists, clinical pharmacists, social workers and others augment or deliver primary care appointments in close coordination with the primary provider and other members of the team.

The AFMS Behavioral Health Optimization Program (BHOP), which embeds mental health providers in primary care clinics, has been particularly beneficial. Building a mentally resilient force is a key to readiness, but stigma can sometimes create a serious hurdle to seeking mental health care. BHOP is an effective way to initiate this care, starting informal conversations with mental health professionals. Brief meetings in the context of a primary care appointment can lead to earlier treatment of a mental health condition, thus preventing a more serious problem.

The AFMH model also incorporates the Base Operational Medicine Clinic (BOMC), an occupational medicine, flight medicine and deployment health-focused clinic. BOMC is separate from primary and family care clinics at MTFs because they devote resources solely to readiness. Previously, flight and occupational medicine clinics made patients visit different departments to receive pre-placement exams and exposure assessments. Under BOMC, all exam components are centralized in one clinic and use standardized procedures. This model is especially valuable at MTFs that host fighter wings or other units that call for a high volume of aerospace medicine services.



Battlefield medicine and en route care are not the only areas where AFMS is expanding its readiness capabilities and deploying care where needed. It is finding new ways to improve access to primary and specialty care in MTFs and beyond. Patients help identify where and when it is best for them to receive care, which improves access, quality and outcomes by putting medical resources in the right place at the right time. Expanding these avenues is critical to building and preserving a force of medically ready Airmen prepared to execute a broad spectrum of missions.

AFMS is improving readiness by integrating providers into units. For example, the 31st Rescue Squadron, based in Kadena, Japan, trains, equips and employs combat-ready pararescue specialists, including Pararescuemen (called PJs) and Combat Rescue Officers. These specialists function at the highest levels of battlefield athleticism and must maintain a high state of readiness and human performance for years. To help meet these requirements, the squadron now has an embedded athletic trainer. This trainer takes an active role in the unit’s training, thus providing preventive care and treatment for injuries sustained during training.

Soon after being assigned to the 31st, trainers found that nearly 30 percent of operators in the squadron would benefit from weekly physical therapy and rehabilitation services. The embedded athletic trainer offers rapid access to care, reduced time to care and consistency provided by dedicated specialists. In Air Force maintenance jargon, embedded trainers take “partial mission capable” operators back up to “full mission capable” status in much less time than previously possible.

Another area where AFMS has moved care into an operational setting is in maintenance squadrons. High rates of musculoskeletal injuries were in these squadrons but many Airmen were not seeking treatment. Minor injuries accumulated or deteriorated, thus leading to surgery, rehabilitation and missed time from duties. Now, embedded physical and athletic trainers can identify, diagnose and rehabilitate injuries in days or weeks, instead of months.



As AFMS continues to serve warfighters by shifting care downrange and expanding capability, mobility and agility of forward deployed forces, it relies on the remarkable medical Airmen who are its providers, nurses, technicians and patients. The people I serve with – men and women of amazing compassion, skill, training and creativity – continually inspire me. As U.S. Air Force Surgeon General, my job is to build a system that allows them to succeed to the maximum extent of their abilities and to create space for them to successfully innovate. The strength of AFMS is undoubtedly its mighty medical Airmen.

In any organization, once change has begun, the biggest challenge is to sustain it and build on initial momentum. The AFMS readiness focus is not only for today’s requirements but also for new missions it may be called upon to execute tomorrow. As AFMS supports the increasingly in-demand, 24/7 mission of its globally engaged Air Force, some challenges will be small while others will be immense. By creating a flexible and resilient organization, AFMS will be able to meet any readiness mission it is called upon to deliver in the future.