ADVANCING IN-FLIGHT MEDICAL CARE 1
Advancing U.S. Coast Guard In-Flight Medical Care Within Alaska
Joseph M. Schlosser
California State University Maritime Academy, School of Graduate Studies ADVANCING IN-FLIGHT MEDICAL CARE 2
Disclaimer
The views expressed in this academic CAPSTONE Project are those of the paper’s author
(Joseph M. Schlosser) and the authors of quoted references, and do not reflect the official policy or positions of the U.S. government, Department of Defense, or Department of
Homeland Security. This paper is to be used to suffice course and graduate program completion requirements. ADVANCING IN-FLIGHT MEDICAL CARE 3
Abstract
Search and rescue within Alaska is locked into an everlasting battle against time and distance.
Military and civilian professionals alike, that brave the geographic and weather extremes that blanket this region in an attempt to aid those in need must continually evaluate and advance the ways in which they operate in order to best serve those in the Last Frontier. The U.S. Coast
Guard plays an extremely vital role in the missions to transport critically ill or injured persons from both marine and shore-based environments around the state. For a time, the level of in- flight care provided by the Coast Guard sufficed the needs imposed on the service; however, in recent years, Coast Guard operators have noted an increase in being unable to internally provide the appropriate level of in-flight care required for the patient being transported. Being unable to meet these needs has imposed new burdens onto medical evacuation missions that are costing the service in terms time and risk mitigation. This project outlines an effective way to increase the level of in-flight care provided by the Coast Guard in order to maintain its superiority as the leading maritime search and rescue entity with Alaska and the world.
Keywords: Air Force, aviation challenges, civilian air ambulance, Coast Guard, EMS history, EMT, FAA, level of care, materials, MEDEVAC, methods, NON-MARITIME, paramedic, pararescuemen, participants, references, statistics, summary, timeline. ADVANCING IN-FLIGHT MEDICAL CARE 4
Advancing U.S. Coast Guard In-Flight Medical Care Within Alaska
After serving as a Command Duty Officer and Search and Rescue Controller at the Coast
Guard’s Seventeenth District Command Center and Head Quarters (D17) over the past three years in Juneau, Alaska, I have become greatly vested in how the Coast Guard trains for, executes, and oversees its search and rescue (SAR) missions occurring in the Alaskan area of responsibility (AOR). Alaska’s unofficial state motto is, “The Last Frontier”. Even within the modern era, 2017 finds Alaska in many respects facing challenges encountered by the people of
Alaska almost 100 years ago. Alaska’s massive size and almost unearthly topography and weather conditions collide to create an operating theater that is unlike any other place on the planet. The waters surrounding Alaska account for 3.8million square miles of ocean, more coastline than both the Atlantic and Pacific coastlines combined, which total 44,000 square miles, and in size is three-fourths the size of the continental United States. Alaska, simply put, is huge.
The men and women of the U.S. Coast Guard that are stationed here are inevitably locked in a constant battle to combat the components of time and distance. Due to the immense size of the state many of Alaska’s population centers are located at great distances from one another.
Anchorage, the largest city in the state, is 573 miles from Juneau, the state’s capital. Outside of larger population areas, most of Alaska’s citizens reside in remotely located towns or villages.
Combining the remoteness of most population centers with the extreme weather conditions that occur here, as well as the long periods of darkness that happen during the winter months, creates a nightmare for civilian air ambulance services needing to reach people during critical times of need. It is for these reasons that the Coast Guard is utilized within Alaska more than any other state to provide emergency medical evacuations (MEDEVACs). ADVANCING IN-FLIGHT MEDICAL CARE 5
Normally, the Coast Guard is accustomed to executing MEDEVACs in the maritime domain; i.e. removing a patient from a vessel and transporting them to medical facilities ashore.
If a patient is requiring transport from a shore facility to another shore facility the mission is referred to as a non-maritime MEDEVAC. Currently D17 averages one non-maritime
MEDEVAC every two days, and most commonly these missions are conducted by Coast Guard air assets to include: HH-60 Jayhawk helicopters, HH-65 Dolphin helicopters, and HC-130H
Hercules airplanes.
One of the most critical components to any non-maritime MEDEVAC is providing sufficient in-flight medical care. Currently Coast Guard Aviation Survival Technicians (rescue swimmers) and flight corpsmen in Alaska are trained at the Emergency Medical Technician
(EMT) II level. Normally this level is adequate for most MEDEVACS. However, many patients in the care of shore facilities often have chronic or advanced conditions that require care beyond the scope of an EMT-II. To facilitate their care needs the Coast Guard often seeks a civilian medical care provider; e.g. paramedic, nurse, or physician assistant. This use of civilian medical care providers can mitigate risk for the patient but adversely create complications for the mission planners and aircrews. Any time a civilian is moved in a military aircraft there exists increased safety concerns and more time must be allotted for the mission.
The objective for this project is to examine the possibility of increasing Coast Guard in- flight medical treatment to the paramedic level. The hope is that an increased level of internal medical training for rescue swimmers and flight corpsmen will streamline mission planning requirements and significantly reduce in-flight safety concerns in regards to adding additional non-military personnel to the aircraft. Ultimately, if this project can provide an executable recommendation to reduce mission time, reduce risk, and improve service, it has succeeded. ADVANCING IN-FLIGHT MEDICAL CARE 6
Coast Guard MEDEVAC History
In order to properly understand the origins of why there exists a need to question the advancement of in-flight medical care provided by the United States Coast Guard in Alaska, a brief yet thorough review of the Coast Guard’s history within the state must first be discussed.
One hundred and six years after the Coast Guard’s founding in 1790, the service began SAR operations within Alaska, just after the purchase of the territory from Russia in 1867
(Introduction to the Alaskan EMS System, 2017). During this time, SAR operations were not conducted by aircraft but rather by Coast Guard Cutters that were deployed to the region. For many years the Coast Guard was the sole representative of the U.S. military and federal government within Alaska. It was not until March of 1944 that the first Coast Guard aircraft began patrolling the vast expanses of Alaska. The Coast Guard’s first air station was established in Southeast Alaska on Annette Island, located 20 miles south of the more commonly known city of Ketchikan (Air Station Sitka, 2017). This modest air station, then known as a detachment, consisted of only one aircraft (Grumman Flying Boat), two pilots, and five enlisted crewmembers. For 33 years this air detachment conducted SAR missions within Alaska and provided a level of service never before known in the “Last Frontier”.
From the Coast Guard’s humble beginnings within Alaska to the establishment of the air detachment on Annette Island the service’s presence within the state has done nothing but increase. Today Alaska is known within the military as a Coast Guard stronghold. From the moment of the very first SAR mission the need for Coast Guard support within Alaska has only grown. Today two air stations and four Forward Operating Locations (FOL’s) share the burden of providing not only maritime SAR response, but also non-maritime SAR and medical assistance. Air Stations Kodiak, Sitka, and FOL’s Cordova, Cold Bay, Kotzebue, and Utqiagvik ADVANCING IN-FLIGHT MEDICAL CARE 7
(Barrow) play host to five HC-130H aircraft, nine HH-60 helicopters, and five HH-65 helicopters; a much more robust squadron than the single Grumman Flying Boat that started it all on Annette Island.
Figure I. This image depicts a layout of all air stations and FOL’s the Coast Guard utilizes in
Alaska. Also shown is the location of the D17 Head Quarters in Juneau and Joint Base
Elmendorf/Richardson in Anchorage where Air Force Rescue squadrons are located. Each ring on the map represents 200NM (out to 800NM) from Base Kodiak (the largest Coast Guard base ADVANCING IN-FLIGHT MEDICAL CARE 8 in Alaska). Lastly the SAR boundaries with Canada and the Coast Guard’s District 13 Search and Rescue Region (SRR) in Seattle can also be seen. (Alaska Force Projection, 2017)
With the creation of the National Highway Safety Act of 1966, Coast Guard units within
Alaska became an inevitable part of statewide EMS response. A written memorandum of understanding (MOU) was signed by the Governor of Alaska and the Commander of the Coast
Guard’s Seventeenth District and it outlined the relationship as such:
“The U.S. Coast Guard provides rescue facilities for the promotion of safety on and over
the high seas and waters under the jurisdiction of the United States. It is understood that
the primary missions of these facilities is maritime search and rescue and that response to
requests from the state and local authorities shall be made on an operations-permitting
basis only. It is further understood that this agreement is “interim” in nature, intended
only to fill a void until adequate commercial or civil government helicopter ambulance
service becomes available.” (Governor State of Alaska, 2017)
This MOU marked the first significant step in streamlining and organizing more extensive interactions by the Coast Guard with the civilian population of Alaska. This MOU still stands today.
Alaska Emergency Medical Service (EMS) History
For generations in Alaska the process of moving a patient to a hospital or place of care was conducted either by dog sled team or boat. It was not until 1922 when Roy Franklin and
Ben Eielson, the two original Alaskan Bush Pilots, first moved patients via an airplane to receive medical care (Introduction to the Alaska EMS System, 2017). Though in subsequent years air travel in Alaska began to grow aggressively, it was not until the National Highway Safety Act of
1966 when efforts became formally organized in a manner to better serve the citizenry. Alaska ADVANCING IN-FLIGHT MEDICAL CARE 9 took an aggressive look internally and established a system that could effectively provide emergency medical services for its citizens despite most of its population centers being hundreds if not thousands of miles away from one another. This act along with the Emergency Medical
Services Systems Act (EMSS) provided the means for the Alaskan government to procure ground ambulances and establish a statewide emergency medical technician (EMT) training program (Introduction to the Alaskan EMS System, 2017). With a new state Office of
Emergency Medical Services, EMS grew quickly in the state. Despite providing more trained personnel to cities, towns, and villages, there still remained the problem of Alaska only having a few major hospitals to serve the whole state. Even today primary hospitals only exist in a few locations within Alaska. The cities of Anchorage and Juneau are home to the most prominent and capable hospitals while cities such as Kodiak and Sitka serve as host to a more intermediate level of care. With major hospitals in only a few locations and much of the state not connected by road, an alternate means of transport was needed to move patients.
The military was the logical starting point when it came to the utilization of air transport.
From the end of World War II through the mid 1970’s, the military played a crucial role in
MEDEVAC operations in Alaska (Introduction to the Alaskan EMS System, 2017). Throughout history the military has readily identified that the quicker a person is moved from the scene of trauma to a place of care, the higher their chances of survival will be. The addition of the helicopter to the military arsenal dropped the mortality rate from 4.5 deaths per 100 causalities during World War II to 2.5 deaths per 100 causalities in the Korean War (Introduction to the
Alaskan EMS System, 2017). This ideology was implemented in Alaska. Today in Alaska the
Coast Guard serves as the primary military service utilized to move citizens for medical purposes followed closely by the Air Force for cases occurring in more inland regions. Selected Army ADVANCING IN-FLIGHT MEDICAL CARE 10 and Air National Guard units are utilized as well. On the civilian side there now exists five separate air ambulance services that serve as the primary default for patient transport to higher levels of care. It is important to note a very distinct difference between the military units that move patients and the civilian companies and this line is often blurred or misunderstood.
Military aircrews with a SAR designation, which all Coast Guard aircraft are, have one primary focus, which is rescue. Coast Guard aircrews exist to remove people from dangerous situations while treating the medical condition is a secondary concern (Introduction to the Alaskan EMS
System, 2017). Civilian air ambulance companies are the opposite. Their primary focus is to care for the patient once removed from the dangerous situation. They provide medical stabilization and transportation to a medical facility and often carry with them a crew of highly trained medical professionals to include doctors (Introduction to the Alaskan EMS System,
2017).
Aviation Challenges
Despite the cooperation between both military and civilian air assets there still exists a hurdle that is near impossible to control, weather. Weather is the leading reason for why civilian air ambulance companies request Coast Guard assistance in executing a MEDEVAC. Within
Alaska there are 201 communities with no road access to the nearest inpatient medical facility –
25 of these communities have no airport. Furthermore, residents in these communities travel an average of 147 miles one way for access to the next level of care (Federal Aviation
Administration, 2001). Complicating this fact even further arw the complexities surrounding local weather. Alaska lays claim to nine distinct physiographic and environmental regions creating the widest climate ranges of any state. Alaska has temperatures that range from +100F to -80F, glaciers that cover 5% of the state, the largest temperate rainforest in North America, ADVANCING IN-FLIGHT MEDICAL CARE 11 vast arctic tundra, 40 active volcanoes, and 50 mountain ranges (Federal Aviation
Administration, 2001). The Federal Aviation Administration (FAA) is the federal entity charged with ensuring the safety of aircraft transiting this vast frontier. Within the 201 previously mentioned communities the weather, terrain, daylight saturation, airport lighting conditions, communications capabilities, and local infrastructures all limit what types of aircraft can service those areas and, more importantly, under what circumstances. There are 176 airports that serve the 201 remote communities; only 53 are equipped for at least minimum Instrument Flight Rules
(IFR) operations. All remaining airports lack some if not all of the essential elements of current weather, runway lighting, navigational aids, communications, and instrument approach procedures (Federal Aviation Administration, 2001). Further analysis and current safety standards to be observed by civilian air ambulance companies, and how the lack of above listed components are factored into their mandatory risk analysis systems is detailed at length within
FAA Advisory Circular AC 135-14B.
With this wide variety of possible aviation complications the FAA has imposed significant flight restrictions on civilian aircraft transiting Alaska. Civilian air ambulances are subject to all FAA regulations, which during inclement weather can be extremely limiting.
Luckily for the residents of these communities, military aircraft are exempt from FAA regulations, which has made the Coast Guard and other military entities the current solution to this problem. This situation has placed the Coast Guard in a unique operating position that is not seen in any other region in which the service operates. Not only is the Coast Guard in Alaska completing more non-maritime MEDEVACS than the service is accustomed to, but it is caring for patients with more advanced conditions than what is normally trained for, and the service is providing that care most frequently during adverse weather conditions. Combine these factors ADVANCING IN-FLIGHT MEDICAL CARE 12 together and there exist a significant deal of inherent risk with these missions that Coast Guard operators must find a way to mitigate if lives are potentially going to be saved. The Coast Guard is a global leader in SAR execution and procedures, not sustained advanced medical transportation. However, with a lack of alternate solutions, the Coast Guard is forced to adapt and train accordingly to facilitate these requests in the best interest of the populous.
Coast Guard Level of Care
As the Coast Guard continues to play a primary role in the Alaskan EMS system, the level of medical care provided by the service is something that generates significant conversation between Coast Guard members actively involved in these missions. The nationwide standard for medical care provided by the Coast Guard is that both rescue swimmers and flight corpsmen must be trained at minimum to the EMT-Basic level. Due to the increased frequency of non- maritime MEDEVAC missions within Alaska, units here have voluntarily opted to train both rescue swimmers and flight corpsmen to the EMT-II level. Coast Guard rescue swimmers and flight corpsmen within Alaska train and hold medical certifications as outlined by the state of
Alaska. Per the Alaska Department of Health and Social Services an EMT-I and EMT-II are defined as follows:
An EMT-I is equivalent to the National Standard EMT-Basic, as described in the United
States Department of Transportation (USDOT) curriculum, revised in 1994, excluding
the use of advanced airway devices. The EMT provides basic life support such as
splinting, hemorrhage control, oxygen therapy, suction, CPR and use of automated
external defibrillators (AEDs). An EMT-I may assist with the administration of the
patient’s own epinephrine auto-injector, nitroglycerin, or hand held bronchodilator
inhaler (Division of Public Health, 2017). An EMT-II exceeds the National Standard ADVANCING IN-FLIGHT MEDICAL CARE 13
Training Program EMT-Intermediate, developed by the USDOT in 1985. An EMT-II
can initiate intravenous lines and administer fluids and certain medications. EMT-IIs
must have at least 10 patient contacts as an EMT-I and certification also requires
sponsorship of a department-approved physician medical director (Division of Public
Health, 2017). The final and highest level of certification within Alaska is a Mobile
Intensive Care Paramedic (MICP). An MICP is the equivalent to what is commonly
referred to as a paramedic on the national level. An MICP is licensed by the Alaska
Department of Commerce and Economic Development. MICPs can manage cardiac
functions, advanced airway devices, use morphine, lidocaine, atropine, and epinephrine.
MICPs function under the direct or indirect supervision of a physician and because of this
they are capable of handling extremely critical and advanced patients. MICPs can
administer injections, establish artificial airways, manage severe trauma, and sustain
patient’s vitals much longer than an EMT-I or II if properly equipped. (Division of
Public Health, 2017)
In 1999, D17 tasked Alaska-based rescue swimmers and flight corpsmen to be certified at the EMT-II level, which marked the first systematic change to increasing in-flight medical care.
Though this was a positive move on the part of Coast Guard units executing MEDEVACs within
Alaska, the decision still did not fully resolve the overriding issue. D17 air stations and command center personnel observed that since 2007 MEDEVAC missions had exceeded the standard EMT-II level of care by 60% (Non-Maritime, 2017). Within the last year alone approximately a quarter of all MEDEVAC missions require the Coast Guard to seek civilian personnel with higher medical licensing, e.g. paramedics, in order to execute the mission. In a focus paper drafted by the command of Air Station Sitka the inadequacies of current medical ADVANCING IN-FLIGHT MEDICAL CARE 14 care were highlighted quite bluntly. The paper stated, “While the EMT-II requirement represents a higher level of care than the rest of the Coast Guard, it is still inadequate to support the mission demand in Alaska. A local unit review of all MEDEVAC cases and medical care required or indicated that the necessary standard of care is more consistent with a paramedic scope of practice” (Non-Maritime, 2017). This confirmation by Air Station Sitka further reinforces what operators have been witnessing for around 10 years now. This existence of a lack in appropriate training is not only becoming a constant frustration but it also poses some serious concerns.
The Coast Guard has taken steps to mitigate these concerns but the current mitigation measures alone only minimize risk in one of the two most critical issue areas. Currently Coast
Guard command center personnel will direct the use of civilian medical care providers (i.e. paramedic, registered nurse, physician assistant, or physician) when the patient’s medical condition is beyond the scope of care of either the rescue swimmer or flight corpsman on board.
Extensive conversations are had with command center personnel, Coast Guard flight surgeons
(physician), and the responding aircraft crew to determine the most appropriate course of action to most adequately care for the patient while in flight. In addition to triaging the patient’s condition, command center personnel and the pilots take into consideration weather, distance, and availability of equipment and receiving facilities before the final “Go/No Go” is given. If it deemed necessary to bring civilian medical care providers on board risk is mitigated for the patient. It is important to remember that anytime a patient is moved via a Coast Guard aircraft the level of care for that patient is almost always lowered since military aircraft are not always specifically configured for air medical transports. Military aircraft are situated in a manner to execute a number of different missions and though the Coast Guard routinely moves patients via ADVANCING IN-FLIGHT MEDICAL CARE 15 its helicopters and airplanes they are not equipped to the extent an air ambulance is. The largest difference is with the lack of advanced life support equipment on military aircraft.
Though the presence of a civilian medical care provider lowers the risk for the patient while on the aircraft it adversely increases the risk for the crew. The aircraft utilized by civilian air ambulance companies within Alaska are significantly different from the aircraft the Coast
Guard operates. Anytime an untrained person is brought onto a Coast Guard aircraft there now exists a concern for that person’s safety in the event of an aviation emergency. This additional person does not wear the same safety and life saving equipment as the aircrew and is normally unfamiliar with the emergency procedures and evacuation protocols that exist on the specific airframe. Additionally, any medical equipment they bring on board to care for the patient must be cleared and checked as intrinsically safe prior to the mission. Their physical presence utilizes space within the cabin which on Coast Guard helicopters is limited, especially if the patient is non-ambulatory and secured in a litter. This confliction between minimizing risk for the patient or minimizing risk for the aircrew has become a consistent issue that is beginning to consume precious time during the initial planning phase of the mission which in turn delays the movement of the patient.
Synopsis of D17 MEDVAC Statistics
Below is a collection of MEDEVAC statistics outlining the most frequent types of medical missions Coast Guard aircrews respond to, and other pertinent information to Coast
Guard MEDEVAC capabilities in Alaska.
ADVANCING IN-FLIGHT MEDICAL CARE 16
Figure II. This is the number and percentage of all emergency cases Coast Guard aircrews have responded to within 2013. A MEDICO is when a Coast Guard Flight Surgeon provides medical advice to a concerned party but the person’s symptom or condition do not warrant a response by the Coast Guard. (Medical Transport Statistics, 2013)
ADVANCING IN-FLIGHT MEDICAL CARE 17
Figure III. This is a further breakdown of the same information but focuses on the general type of medical emergency responded to. (Types of Medical Cases, 2013)
ADVANCING IN-FLIGHT MEDICAL CARE 18
Figure IV. This depicts a breakdown of Coast Guard aircraft capabilities within Alaska. Radius of Action is also in nautical miles (NM). (D17 Aircraft Capabilities, 2017)
U.S. Air Force EMS Role in Alaska
The Coast Guard is not alone in the fight to manage the MEDEVAC needs of the Alaskan populous. Though the Coast Guard is responsible for a considerable amount of Alaska, the U.S.
Air Force as outlined in an MOU from the Commander of the Eleventh Air Force and the
Commander of D17 is specifically charged with the responsibility of ensuring aeronautical SAR
(search and rescue coordination for emergencies involving aircraft) and support for the interior portions of Alaska. The MOU also provides for the effective coordination and utilization of available SAR facilities of the Air Force, Coast Guard and other Armed Forces of the United
States in all types of search and rescue missions in the Alaskan Theater (Memorandum of
Agreement, 2007). This collaborative effort by both the Coast Guard and the Air Force allows for there to be federal coverage/support state wide when civilian entities cannot perform the ADVANCING IN-FLIGHT MEDICAL CARE 19 emergency tasks at hand. Routinely Coast Guard and Air Force assets utilize facilities and installations controlled by the other to expand one another’s sphere of influence.
One major advantage the Air Force has over the Coast Guard is the level of medical training required for Air Force Pararescuemen (PJs). Pararescuemen are among the most highly trained emergency trauma specialists in the U.S. military. They must maintain an EMT-
Paramedic qualification throughout their careers. With their medical and rescue expertise, along with their deployment capabilities, PJs are able to perform live-saving missions in the world’s most remote areas (Pararescuemen Overview, 2017). This training is covered in an extensive 22- week course taught at Kirkland Air Force base in New Mexico and gives PJs the training to manage trauma patients prior to evacuation and provide emergency medical treatment
(Pararescuemen Overview, 2017). Despite their very applicable training PJs do not execute nearly as many MEDEVACS as Coast Guard aircrews. This is primarily due to the fact that most remote towns/villages are located in coastal regions rather than in the interior of Alaska.
There have been a select few missions where PJs have flown on Coast Guard aircraft to support a
MEDEVAC mission but under normal circumstances there does not exist enough time to retrieve a PJ from their base in Anchorage and place them on a Coast Guard aircraft in time to execute the MEDEVAC within the time window prescribed by the Coast Guard flight surgeon.
The MOU’s that exist with the Air Force in Alaska and the positive working relationship the Coast Guard shares with the Air Force are perfect assets to possibly exploit in identifying alternative ways for the Coast Guard to increase the level of in-flight care in Alaska. The Air
Force has repeatedly offered its services in order to ensure these missions run more smoothly for all components involved.
ADVANCING IN-FLIGHT MEDICAL CARE 20
Civilian Air Ambulance Capabilities
Below are itemized lists of the capabilities of each of the civilian air ambulance companies that service Alaska. The information listed outlines crew makeup, area of operation, and type/types of aircraft used. Largest differences between civilian air ambulance companies in comparison to the Coast Guard are aircraft used and medical experience of crew. All civilian air ambulance crews strive to provide an RN for most flights and will travel with nothing less than a paramedic. (MEDEVAC/MEDICO, 2017).
-Airlift Northwest:
• Can provide RN’s on most flights.
• Weather permitting can service most if not all of Southeast Alaska.
• Utilizes one Learjet based in Juneau and one Learjet based in Seattle. Both with
1,500NM range.
-Life Med Alaska:
• Crews normally consist of two RN’s or, one RN and one paramedic.
• Weather permitting can service most of Alaska.
• All aircraft based in Anchorage. Two Learjets with 2,000NM range. One KingAir with
1,400NM range. One Cessna Caravan with 860NM range. Two helicopters with 150NM
range.
-Guardian Flight:
• Most prominent civilian air ambulance service in Alaska.
• Crews normally consist of an RN and paramedic. Can place multiple RN’s and doctors
on board if needed.
• Weather permitting can service most of Alaska. ADVANCING IN-FLIGHT MEDICAL CARE 21
• Aircraft are based in several locations around Alaska. Three Learjets with 2,000NM
range. Six KingAirs with 1,400NM range. One helicopter with 150NM range.
-Life Flight:
• Normal crew will consist of two RN’s or, one RN and one paramedic.
• Weather permitting can service most of Alaska.
• Aircraft based in Anchorage. On KingAir with 1,400NM range.
-Harris Air:
• This is not a technical air ambulance company but they do provide charter aircraft to
move patients when needed. Normally chartered by Mount Edgecumbe Hospital in
Juneau or Sitka Community Hospital.
• Charters available weather permitting. Only services Southeast Alaska. Utilizes two
Piper Chieftains and several smaller aircraft with floats in order to reach extremely
remote villages. Ranges vary.
Recommendation
This creative project has been developed to provide a practical and executable recommendation to the command cadre of D17 in order to successfully advance and increase the level of in-flight medical care currently provided by Coast Guard units operating within Alaska.
The project will consist of eight subsections, all focusing on one particular area that is crucial to the formulation and implementation of the overall plan, which will systematically increase the level of in-flight medical care provided by the Coast Guard in Alaska. The project will discuss and review all pertinent information outlined in the literature review and will evaluate the implications of suggested policy changes or additions. ADVANCING IN-FLIGHT MEDICAL CARE 22
While reviewing the creative project it is important to remember that the recommendation outlined within is not a sanctioned or actionable decision by D17. This project is designed to present a recommendation only to the commander of D17, and if agreed upon, this project can be implemented with minimal complication and cost to the service at large. Detailed below are this project’s specifications.
Planning
In order to accurately compile all required information and formulate this plan, D17 will have to identify all key entities in the MEDEVAC system within Alaska, both civilian and military. After being identified, each entity’s full capabilities and roles must be outlined, discussed, and fully understood. With an updated and current outline of the SAR system within
Alaska it will be much easier to gain command approval to advance the level of in-flight medical care provided by Alaska-based units.
To complete the project as required, external participants to the Coast Guard will have to be identified as well as a project staff internal to the Coast Guard. The command cadre will not approve the project unless there is general consensus amongst all Coast Guard components having a role with SAR in Alaska. Flight corpsmen, rescue swimmers, flight surgeons, command center personnel, and senior leadership all must agree that increasing in-flight medical care is in the best interest of Coast Guard personnel as well as those being transported by the service. In the end, it comes down to a simple question of risk vs. gain. This project will be successful if it reduces risk and increases gain for the Coast Guard and for patients. It is important to remember that if gain increases for the patient but risk increases for the Coast Guard it generally will create problems in the long run for the service, which is why the Coast Guard ADVANCING IN-FLIGHT MEDICAL CARE 23 will try to avoid situations with that potential. Current operations are beginning to head in that direction, hence the need and importance of this project.
The methods utilized to create this project will incorporate a thorough review of current policy, extensive discussions with D17 search and rescue units (SRUs), and input from state and local SAR partners. These reviews and discussions will be conducted to ensure practicality, fluency, and accuracy. All required materials will be itemized and included in the project plan.
A detailed timeline will also be created to provide a visual to the command cadre. The timeline will display the project’s life from the point of approval to the tentative arrival of the first qualified paramedic at a given air station. Amplifying information will be provided on the implementation process to ensure physical requirements are known and understood in order to avoid unnecessary delays should the command cadre decide to advance the level of medical care.
With the project plan laid out, an assessment will be included to itemize both immediate and future impacts of the project. Honest input on potential complications and set-backs will also be included in the assessment. Measures will be recommended to avoid these potential set- backs and delays. Should the command cadre approve the project it will be ready for immediate implementation.
Participants
In order to advance the level of in-flight medical care provided by the Coast Guard in
Alaska from the current EMT-II level to the paramedic level, several key players have to be involved. Internal to the Coast Guard, three primary groups have to be involved: air stations
Kodiak and Sitka, all D17 flight surgeons, and the D17 command center. These three Coast
Guard components will provide an accurate assessment of past case history where the level of care was called into question, the willingness of current flight corpsmen and rescue swimmers to ADVANCING IN-FLIGHT MEDICAL CARE 24 pursue and maintain a paramedic level of certification, and the impact to operations once members begin holding and maintaining the higher level of training.
Input from the air stations and their personnel is extremely valuable to the project because, more than any other component, the impacts of this project and the advancement of care will be most intrusive to them. The air stations are home to both the flight corpsmen and rescue swimmers, and ultimately it is these personnel that will have to expend the time and effort to obtain these newly required certifications and put them into practice. If the burden of this project is too much for these members to incur, then the project fails. Changes in policy should advance
Coast Guard personnel, not hinder them. D17 flight surgeons will be able to provide detailed policy outlining the increased level of care to be provided with paramedics present onboard.
These medical policies will clearly delineate what medical cases/conditions Coast Guard SRUs will accept or deny. Elevating care to the paramedic level does not dissolve all past MEDEVAC concerns. Often, medical personnel holding a paramedic certificate operate under the supervision and mentorship of a physician. D17 flight surgeons will be the physicians working directly with flight corpsmen and rescue swimmers during these missions. Currently, D17 flight surgeons provide a recommendation (time window) for movement and tasking to aircrews for in- flight care of patients. For this project, flight surgeons, flight corpsmen, and rescue swimmers will have to come to a consensus as to the expectation for care provided by Coast Guard paramedics. D17 will ensure policy and MOUs are drafted to civilian partners to ensure there is no misunderstanding between the civilian expectation for air MEDEVACS and the military expectation. Lastly, D17 command center personnel will have to edit policy and procedures accordingly to facilitate the increased level of care provided. Interactions with state medical clinics/hospitals and civilian air ambulance companies will all have to be modified as to avoid ADVANCING IN-FLIGHT MEDICAL CARE 25 any interruptions or delays to operations. Involving these three components internal to the Coast
Guard ensures a fluid transition from the bottom up.
The U.S. Air Force will play a significant role in this project. Specific points of contact
(POC’s) at the Pararescue School House at Kirkland AFB, NM will have to be established to create a venue for joint service training. Paramedic training within the civilian sector as described in the literature review is a robust course of study requiring a considerable amount of time for training and vetting. Due to the frequency of operations within the military and high turnaround need for qualified personnel, the civilian course of study would not be appropriate for the Coast Guard’s needs. The civilian course for training would be too costly in terms of time.
The Air Force curriculum for paramedic training is no less extensive than the civilian training; however, the time for training is considerably condensed. Students within the Air Force program must possess a high aptitude for advanced course work/academics. Flight corpsmen and rescue swimmers are personnel considered to be of some of the highest performing personnel within the
Coast Guard. The initial group of preliminary Coast Guard students will be extensively screened and evaluated prior to selection and the beginning of advanced training. No time in service requirement will be necessary. Aptitude to perform of at the paramedic level will be the ultimate decision criteria. Academic and performance aptitude is paramount in these specialty ratings and meets the requirements for the member to be successful during the condensed 22-week paramedic course taught by the Air Force at Kirkland AFB. The course curriculum and schedule benefit the Coast Guard in terms of time, but more importantly, the ability to train jointly with another service is cost effective for the Coast Guard and serves as a platform to improve joint service operations. ADVANCING IN-FLIGHT MEDICAL CARE 26
Lastly, state and local MEDEVAC entities will have to be involved to provide professional insight on how an increase in Coast Guard in-flight medical care may or may not affect their operations. The civilian air ambulance companies of Airlift NorthWest, Life Med,
Guardian Flight, Life Flight, and Harris Air will be the assessed civilian air ambulance companies. By law, the Coast Guard is not to compete or take business away from civilian services and an increase in medical care by the Coast Guard could be perceived as a move to accomplish just that. Civilian partners would have to be involved from the infancy of the project to avoid possible complications such as this. The experience civilian air ambulance companies have of already maintaining a higher level of care while in flight will also be beneficial for this project in establishing a best practices outline.
Project communication is quintessential to success. The involvement of these key entities by the Coast Guard will effectively eliminate major obstacles by ensuring all pertinent parties and information are included and appraised.
Staff Development
This project will have a project staff of four from the D17 District Response
Management Branch (DRM). Staff positions will consist of a project manager, policy expert, command center representative, and operations expert. Collectively, this staff will be able to collect, evaluate, and present all pertinent information in an effective manner that will ultimately result in the project being presented to the command cadre of D17.
The project officer will be ultimately responsible for the overall progression, organization, and completion of the project. The project officer will compile all required information and organize all material as to be easily referenced and evaluated by other staff members, outside entities, and command cadre personnel. The creation and adherence to the ADVANCING IN-FLIGHT MEDICAL CARE 27 time line will also be a primary responsibility of the project officer. For this project adequate time must be set aside to ensure proper discussion and evaluation of newly required training and the proposed implementation process. At minimum, the project officer will be a lieutenant (O-3) assigned to D17 DRM and have comprehensive knowledge of MEDEVAC operations within
Alaska.
The policy expert on staff will be the D17 SAR Expert. This position is normally held by a civilian employee (GS-13). The SAR Expert is the leading resource in regards to all pertinent policies both local and national that pertain to SAR missions within Alaska. As new policies and training recommendations are created by this project, the policy expert will be able to provide guidance on recommendations that may possibly collide with or contradict standing policy. If standing policies need to be changed, removed, or amended, the policy expert will serve as the lead in drafting and gaining approval for those changes. The policy expert will also ensure no breaches in MOU’s with civilian air ambulance companies will occur as a result of the proposed increase in in-flight medical care. Ultimately, the policy expert will help ensure success of the project both on paper and physical execution.
The Command Center Chief, which is always a lieutenant commander (O-4), will serve as the staff member responsible for ensuring continuity within the command center. The D17 command center located in Juneau, AK is the centralized hub through which all Alaska-launched
MEDEVACs are coordinated. Command center personnel are expected to be subject matter experts and extremely proficient with assessing, triaging, and running all variations of
MEDEVAC missions. The Command Center Chief will be critical in ensuring minimal lapses or delays in operations as the transition process occurs once approved. Additionally, any possible complications the project may create for command and control functions will be brought up and ADVANCING IN-FLIGHT MEDICAL CARE 28 addressed by the Command Center Chief. Lastly, the Command Center Chief will serve as the direct liaison to the air stations and their operations officers. The line of communication established between these two parties will be essential in addressing any new concerns or input put forth by flight corpsmen and rescue swimmers during the transition process.
The Lead SAR Controller is a civilian employee (GS-12) and is arguably the most seasoned and experienced command center watchstander. This staff member will serve as overall quality control for the project. They will fulfill an advisory position on the project and will ensure the project and final recommendations are reasonable, executable, and do not detract from Coast Guard capabilities in any way. Their extensive experience with MEDEVAC missions will help ensure fluency throughout the entire life of the project.
Methods
In order to complete this project in totality an agreement must be reached with Air Force counterparts to establish a joint service training program at the Pararescue School House located at Kirkland AFB. Being able to utilize and train with the pararescuemen paramedic school provides D17 and the Coast Guard the ability to establish a stronger working relationship with the Air Force as well as provide flight corpsmen and rescue swimmers with the advanced training they require to fulfill the needs of this project. D17 will work closely with service partners at the 11th Air Force Head Quarters at Joint Base Elmendorf/Richardson, Anchorage,
AK to establish this connection with the school house. 11Th Air Force representatives have continually expressed a willingness to assist D17 forces in advancing their mission capabilities.
Time is one if not the largest hurdle for this project. Even by utilizing the Air Force’s consolidated 22-week paramedic program, the Coast Guard has to budget at least six months to train a member to the paramedic level. Currently within D17, flight corpsmen and rescue ADVANCING IN-FLIGHT MEDICAL CARE 29 swimmers have three-year billets. If the paramedic program were established, their time serving within D17 would be reduced to two and a half years. This project will have to obtain approval for a reduced tour length or foster conversations entertaining the idea of increasing tour lengths for these members to four years to guarantee at least three and a half years of service within D17 holding a paramedic qualification. In the interim, as newly qualified members are being trained, the current standard of maintaining an EMT-II qualification for flight corpsmen and rescue swimmers will continue uninterrupted in order to ensure operational effectiveness throughout the
AOR. Tour lengths and service requirements will not change for members not specifically designated as participants in the new training program. Once an agreement is reached with the
Air Force to allow Coast Guardsmen to train at their school house, then negotiations can be had with Enlisted Personnel Management Branch (EPM) and the rating chain master chiefs for both
Health Service Specialists (flight corpsmen) and Aviation Survival Technicians (rescue swimmers) to determine the appropriate tour length for personnel holding a paramedic qualification within Alaska.
With the training and tour length particulars shortened the official memorandum requesting permission to enact the project to the D17 command cadre can be drafted. The memorandum is more than just a request for permission on paper. The command cadre will request excessive documentation of all materials that lead to the creation of the project and reasoning for existence. Multiple presentations will have to be made to adequately brief the project and forums must be made available to entertain questions/requests from the command.
After the command cadre has submitted their input, time must be delegated to revise and alter the plan to meet the needs of the command cadre. The command cadre is responsible for ensuring the integrity of the Coast Guard as a whole. Decisions made within D17 have to reflect ADVANCING IN-FLIGHT MEDICAL CARE 30 positively on the service nationally and keep the service’s intentions and key missions in perspective. Again, if the project poses minimal risk with positive gain and provides a benefit to members the command is more likely to approve it.
Materials
Below is an itemized list of required materials to enact this project.
§ Summarized review of all current/applicable Coast Guard SAR policies to include but not
limited to:
- Air Operations Manual, COMDTINST M3710.1F
- Management and Administration of Aviation Incentives Pays, COMDTINST
7220.39
- Seventeenth District Search and Rescue (SAR) Plan, (2014). Seventeenth District
Instruction 16104.1
- United States Coast Guard Addendum to the United States National Search and
Rescue Supplement (NSS) to the International Aeronautical and Maritime Search
and Rescue Manual (IAMSAR), COMDTINST M16130.2E
§ Position Paper summarizing the results and findings of the 2017 Alaska SAR Leadership
Conference. (Conference Dates April 3-7). Conference participants include Alaska State
Troopers, National Park Service, United States Air Force, United States Coast Guard,
North Slope SAR, Alaska Department of Health and Social Services, Alaska National
Guard, and Alaska Division of Homeland Security and Emergency Management.
§ Memorandums from both air stations Kodiak and Sitka stating support for the increased
in-flight medical care provided by Coast Guard aircrews within Alaska. ADVANCING IN-FLIGHT MEDICAL CARE 31
§ Memorandum from the D17 Command Center stating support for the increased in-flight
medical care provided by Coast Guard aircrews within Alaska.
§ Memorandum of Agreement between United States Air Force Battlefield Airmen
Training Squadron – Pararescue & Combat Rescue Officer School, Kirkland Air Force
Base and United States Coast Guard Seventeenth District.
§ Policy Paper confirming tour lengths for Health Service Specialist serving as flight
corpsmen within Alaska and Aviation Survival Technicians stationed in Alaska.
§ Updated Coast Guard policy on new training requirements for Alaska billeted flight
corpsmen and rescue swimmers. (The project is designed specifically for Alaska-based
flight corpsmen and rescue swimmers only due to the large amount of NON-MARITIME
MEDEVACs the Coast Guard executes in D17. No other district executes near the same
amount of shore based medical missions, as do units based in Alaska).
§ Updated Memorandums of Understanding with civilian air ambulance providers and the
State of Alaska defining new level of care provided by Alaska-based Coast Guard forces.
Timeline
§ 2017
- April 3-7: Alaska SAR Leadership Conference
- April 10: Summary of conference findings submitted.
- April 16: Project Submission Date
- May 1: Start of Coast Guard approval process.
§ 2018
- January 1: Approval of project and receipt of memorandums from Air Stations,
D17 Command Center, and Air Force Pararescue School. ADVANCING IN-FLIGHT MEDICAL CARE 32
- April 1: Selection of 8 preliminary petty officers for initial training.
- May 1: Updated policies received for tour lengths and training requirements.
- June 1: Preliminary students begin paramedic program at Kirkland AFB.
- December 1: Preliminary students report to assigned air station. Probationary
period begins.
§ 2019
- December 1: Probationary period ends.
§ 2020
- January 1: Evaluation period begins.
- April 1: Evaluation period ends. Final recommendation for full implementation
submitted.
- June 1: Command decision made on full implementation.
Implementation
The implementation process for this project will span a three to four year period to allow time for proper vetting and a probationary period to evaluate the results of the paramedic training program with the Air Force. If the program is approved within the next six months, the first group of preliminary students could hypothetically begin training with the Air Force during summer 2018. This preliminary group of students would consist of eight petty officers with new permanent change of station (PCS) orders to both of Alaska’s air stations. Of the eight students, four (two flight corpsmen/two rescue swimmers) will be from Air Station Kodiak and the other four (two flight corpsmen/two rescue swimmers) will be from Air Station Sitka.
These students will be enrolled and complete the 22-week training curriculum at the
Pararescue School House located at Kirkland, AFB. A one year probationary/evaluation period ADVANCING IN-FLIGHT MEDICAL CARE 33 will commence for each student upon arrival to their air station from paramedic training. This probationary period will be utilized to evaluate the benefits of having a paramedic as part of the aircrew during MEDEVAC missions. Number of missions run, types of patients assisted, execution time for missions, patient loses, and feasibility of maintaining qualifications/proficiencies will all be assessed.
Assessment
Once all eight preliminary students have completed their first year as a paramedic at their prospective air stations a two to three month review period will be conducted at the D17 headquarters in Juneau, AK. The assessment team will consist of the D17 Commander, D17
Response Management Chief, D17 Command Center Chief, both air station operations officers,
D17 flight surgeons, and the original project team. They will ultimately determine the practicality of continuing to require paramedic qualifications for Alaska-based flight corpsmen and rescue swimmers. If still deemed a worthwhile endeavor, a final recommendation will be made to the D17 commander. With command approval, 2020 is a plausible fiscal year to see full implantation of new policy requiring an increased level of care for Alaska-based SRUs.
Summary
This research project stemmed from my involvement with the SAR system here in Alaska, and a genuine desire to make it better. Our nation’s military has remained the world’s leading military force for the last century because it is comprised of members that continually innovate and ask how the service can complete its missions more accurately and efficiently. This culture of leaving things in a better state than when one found them is why this project came to life. The
Coast Guard is the leading maritime SAR entity in the world, but despite it being the standard bearer it still has immense potential for improvement. Since the earliest involvement of Coast ADVANCING IN-FLIGHT MEDICAL CARE 34
Guard units in Alaska, SAR has been a main focus and remains one of the largest challenges the service faces within this highly diverse and unique operating environment. Something as seemingly simple as increasing the level of medical qualification for our members who are intimately involved with the transportation of patients in Alaska, can have huge positive impacts operationally for the Coast Guard, and locally for the communities in which we serve here in
Alaska.
Over the last three years, I kept noticing a trend in terms of added logistics and mission delays that occurred when the Coast Guard was requested to move a patient with an advanced medical condition that exceeded the scope of care our flight corpsmen and rescue swimmers could provide. When faced with this challenge, mission planners and flight surgeons were forced to look outside the Coast Guard and identify capable and readily available civilian personnel that could provide the level of care required. These added layers to the mission added in new complexities, safety concerns, and a number of other difficulties as described in this paper. Increasing the level of in-flight medical care provided by Alaska-based Coast Guard units seemed like a highly logical and pragmatic solution to a problem that has been frustrating air crews and mission planners for years.
One of the greatest difficulties with this project was addressing how to physically provide the training to flight corpsmen and rescue swimmers to increase their level of training from the
EMT II level to the paramedic level. Presently the Coast Guard does not have the ability to train or qualify personnel to the paramedic level. Within the civilian sector there exists substantial avenues to exploit, in terms of paramedic training and certification, but the skill level is obviously advanced and the civilian courses are lengthy and not necessarily conducive to Coast
Guard tour lengths and training agendas. Finding a way to bridge this gap was not easy. ADVANCING IN-FLIGHT MEDICAL CARE 35
Thankfully, the U.S. Air Force has been qualifying its pararescuemen as paramedics for some time now, and has developed and maintained its own paramedic school at Kirkland, AFB.
This discovery helped propel the main objective of this project completely into the realm of achievability. The military loves inter-military training. Anytime multiple services can jointly train and learn from one another, it is highly encouraged. Again this goes back to maintaining military superiority. The more fluid the nation’s services are with working with one another, the higher the likelihood of success when called upon to work cohesively during a time of national crises or defense. A willingness by the Air Force to train Alaska-based flight corpsmen and rescue swimmers to the paramedic level, allows the Coast Guard to invest in a cost effective and time effective mode of training. The 22-week curriculum allows for a viable training solution that fits cohesively with tour lengths and mission objectives within Alaska.
The other challenge for this project was identifying a recommendation that did not adversely increase the mission load for the Coast Guard or detract business away from any of the civilian air ambulance companies that operate in Alaska. The utilization of the Coast Guard for
MEDEVAC purposes anywhere in the world the Coast Guard operates is and should always remain a last resort for those requesting that assistance. Civilian air ambulance companies and their aircraft are specifically designed, built, and manned to transport medically advanced and critical patients. Coast Guard aircraft are specifically designed, built, and manned to be multi- mission military platforms. The level of care in a Coast Guard aircraft will always be lower than the level of care provided by a civilian air ambulance. This project had to evaluate the probability of a transport request increase once the level of in-flight medical care was advanced, and what the impact of a potential increase would do to asset availability, mission planning, and crew fatigue. More than anything it had to be established that an increase in the level in-flight ADVANCING IN-FLIGHT MEDICAL CARE 36 medical care would not detract or hinder the Coast Guard from completing any of its other mission responsibilities in terms of national defense, law enforcement, marine environmental and resource protection, and Arctic domain awareness.
Consideration also had to be paid to insuring that the Coast Guard did not become a competitor in business to the civilian air ambulance companies. Military entities, such as the
Coast Guard when operating within the domestic sector of the U.S. cannot outright compete or detract business away from civilian entities that can provide the same service. MEDEVACs conducted by the Coast Guard are attractive because they come at no cost to the patient, since it is a federal service mandated by the Constitution. However, the government has a conscious role to play in maintaining the integrity and strength of our economy in terms of free enterprise.
Though the ultimate goal is to provide a critical service to citizens in need, the Coast Guard must be a responsible party and not justify its means by hindering those of another. It is a delicate balancing act, but this project put forth a proposal that avoids this situation. The missions that have generated the need for this project are missions civilian air ambulance providers are physically incapable of executing due to weather extremes and FAA regulations. This project highlighted that increasing the level of in-flight medical care within Coast Guard aircraft only improves the mission effectiveness for the Coast Guard and the chance of survival for the patient while in transport.
One of the largest recommended improvements for this project would be for the D17 to host a meeting in Juneau with key representatives from the Air Force and Alaska-based civilian air ambulance companies. Despite having the Alaska SAR Leadership Conference in April, this meeting would provide a venue to discuss this topic solely with all key entities. Though the conference in April is designed to improve SAR effectiveness and improve SAR coordination ADVANCING IN-FLIGHT MEDICAL CARE 37 within the state, the topics discussed over the week are much broader than the focus of this project. An individual discussion forum hosted by the Coast Guard would be extremely beneficial to the members of this project team; it would provide a venue to ensure all pertinent information was disseminated properly, and any concerns or suggestions by involved organizations could be heard and vetted. Inner organizational communication for a project such as this is essential to ensure a smooth and cooperative transition. A meeting such as this would also allow for senior leadership to vocalize any concerns and receive direct answers from other agencies and organizations that will be impacted or involved with the process. Obviously with a suggestion of creating a joint service training opportunity with the Air Force MOUs would have to be drafted and agreed upon and policies within the Coast Guard would have to be changed and amended to accommodate the new training requirements. Senior leadership possess the influence in larger scale projects like this to make or break the entire endeavor, allowing their involvement and input is a very tactical and necessary component.
In relation to assessing the project plan, the assessment team will be separate from that of the assessment team mentioned previously. The assessment team mentioned within the Creative
Project portion is designed to evaluate the practicality of a full implementation of the project beyond the first preliminary eight students and their probationary period. The assessment of the project proposal, plan, and implementation project is divided into three parts. The first portion of the overall project assessment has already been completed. The initial assessment consisted of concurrence and approval from the D17 SAR Expert and the D17 Command Center Chief in identifying the subject of this project as needed and worth evaluation. The secondary assessment will come at the conclusion of the CAPSTONE course and the acceptance of the project by the
MSTEM faculty at California State University Maritime Academy. This acceptance of the ADVANCING IN-FLIGHT MEDICAL CARE 38 project will signal to D17 leadership that the project is of sound academic weight and has been edited and discussed thoroughly at the academic level. With thoroughness and validity of the project no longer a source of questioning, the third and final assessment will begin with D17 leadership in Juneau, Alaska. A thorough review of the project will be conducted and discussed and decision by the D17 Commander will initiate the project into actuality or condemn it.
However, with concurrence on the merit of the project from the previous two assessments there should exist very little reason to not proceed with the project as outlined.
ADVANCING IN-FLIGHT MEDICAL CARE 39
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