Flight nursing is a specialty all to itself in the civilian community. For a nurse assigned to the emergency department of the 10th CSH in Baghdad, it's considered an additional duty akin to courtesy patrol or pulling guard duty.
When we arrived in Iraq, the average ED experience of our team was only 4 months. This remarkably young team quickly learned to manage some of the most traumatic injures seen in the world from high-energy explosions. However, our greatest clinical challenge was still ahead of us. We were informed in early December 2005 that the neurosurgery team would be leaving us on the 15th of December. We had 2 weeks to train, equip, and identify nurses and medics from our current staff to configure a flight program to transport multiple trauma patients whose injuries included devastating trauma to the brain and the nervous system.
Make no mistake; our young medics who serve aboard MEDEVAC flights are some of the bravest soldiers in our Army. They provide one of the most essential missions and contribute to the historically high survival rate we have achieved in this conflict. However, they do not have the critical care training needed to fly intubated, brain-injured patients who may be fresh off the operating room (OR) table and commonly are receiving paralytic and sedative medications. With the high incidence of neurologic trauma we received at the 10th CSH, we immediately realized this would create a challenge. As the Head Nurse of the ED, I immediately began to brainstorm how we would be able to urgently evacuate these patients requiring lifesaving brain surgery to our sister facility in Balad, approximately a 20-25-min flight by helicopter.
Multiple challenges are inherent in flight nursing. Experience is critical to success. We were lucky enough to have one Certified Flight Registered Nurse (CFRN) to help sort through the many difficulties involved in starting a flight program from scratch. We developed a neurologic checklist (Figure 2) with the help of Captain B., a flight nurse, and Captain S., a critical care nurse, which we utilized to ensure that our patients were properly prepared for flight. Classes were held on the critical care drugs necessary to maintain a patient with a traumatic brain injury during flight through the combat zone. Additionally, with input from our departing neurosurgical intensivist, Dr L., and neurosurgeon, Dr E., we coordinated a few practice runs a week prior to their departure so they could help us troubleshoot any problems. With such a short notice, we decided to concentrate on preparing the four most experienced nurses in the unit to fly first, with the intent of expanding the program to the rest of the team (Figure 3). Utilizing the neurologic checklist, we developed and drilled the team on how to efficiently prepare the litter to transfer a patient. Standardizing patient packaging was one of the early lessons learned. This contributed to successful transport regardless of the type of Army MEDEVAC helicopter that picked us up. We have two distinctly different helicopter platform configurations and each presents unique challenges to the delivery of patient care on board. A commercially developed device called the "SMEED" (Special Medical Emergency Evacuation Device) was instrumental in standardizing the way we packaged our patients for flight (see Figure 4).
A second lesson learned in starting up a MEDEVAC program is that it was not a one-person job. Owing to the serious blast effect of IEDs on the pulmonary system and the tendency for midflight failures of our portable ventilators, we frequently had to manually ventilate the patient for a significant portion of the flight. These types of difficulties occurred in approximately 25% of all flights. We carried a supply of lifesaving medications and adjuncts to manually ventilate in the event of complete ventilator and monitor failure. When all else failed, our portable pulse oximeter provided some rudimentary monitoring capability.
We had all discussed at length, and planned on doing, "expectant" triage but no one mentioned deciding on who was to risk their lives flying over a hostile war zone to transfer a patient who may not survive a surgery. Some of the most challenging patients were taken directly off the OR table after damage control surgery to a waiting aircraft. This scenario confronted us with the challenges of both continuing resuscitation efforts as well as monitoring a fresh postoperative patient. At moments like this the surgical staff would hand the patient over to us with the simple statement "good luck." This was not a phrase that I was accustomed to hearing spoken to an ED nurse from the surgical staff.
At first we flew everyone. We rushed out the door to transfer unstable brain-injured patients to Balad with no consideration for the safety of the four-person aircrew or ourselves. Of special note, over 80% of these patients were Iraqi, not U.S. or Coalition Forces. We do not differentiate in the level of care rendered at the 10th CSH. Everyone gets whatever they need, to include $3,000-dollar medication or the benefits of a whole blood drive, with our staff as the donors. The criteria for transport are based upon the Glasgow Coma Scale (GCS). We also have the technology to electronically transmit computed tomography (CT) scans to our neurosurgical colleagues for advice. Any patient with a GCS of 7-12 is generally considered for transport. Patients with a GCS of 6 or lower and those with particularly devastating injuries are placed in our expectant category and receive supportive end-of-life care. Those patients with a GCS above 12 are monitored and do not receive neurosurgical intervention. The next step in the decision to transport is to consult the on-call surgeon, ED physician, and flight nurse. A group meeting takes place to discuss the pros and cons of each transfer. And, to the credit of our medical colleagues, most of them seriously consider the safety of launching a helicopter during daylight hours in a war zone. We have treated MEDEVAC crews for injuries here in Iraq and some have been lost to hostile action. I am relieved to say that we have had no MEDEVAC crew injuries during these 10 months of duty.
Operational security is a variable with which civilian flight programs do not normally have to contend. Threats from both direct and indirect fire are common. On one particular transport we had to set the aircraft down in an unsecured area to await gunship support. On another run, the receiving facility was actively taking incoming mortar rounds while we were trying to land, thus requiring us to take evasive actions that doubled our flight time to 40 min. The decision to launch had been initially delayed because the security status was "red," meaning unable to fly. Later I asked our doctor why we had ultimately been approved to fly and he told me that the base was being mortared but that the status had been downgraded to "amber," so it was safe. All these decisions were made right in the middle of our own 30-patient mass casualty event.
From both a clinical and wartime perspective, the startup of a new flight program in the middle of a tour in Iraq was nothing short of phenomenal. Remarkably we accomplished a 100% success rate in the transfer of 95 casualties over 10 months with a staff of 12 registered nurses and 18 medics who had little or no flight, emergency, or neurosurgical critical care experience. It is phenomenal that they became proficient emergency care providers in the unexpected but necessary role of flight nurse in less than 30 days. They made split-second, independent decisions and implemented interventions that saved many lives. They often performed while unbuckled and out of their seats, totally without radio contact, and in 125-degree heat. The fact that a high level of patient care was maintained on these transports and that young nurses could step up to the challenges of wartime nursing are testaments to the true spirit of nursing.