Airmen prepare for a new era of medical evacuation in the Pacific

ANDERSEN AIR FORCE BASE, Guam — The U.S. Air Force is rethinking how it would medically evacuate thousands of wounded American troops from the Pacific in a matter of weeks if the military sustained high casualties in a war with China.

Such a conflict would force the military’s flying ambulances to reckon with thousands of miles of open ocean, a lack of full-service health facilities and the logistical challenges of transporting and cooling medical supplies across the region, airmen told Air Force Times during a exact visit to Guam.

To save the lives of their fellow service members, they said, medevac units will need to fly longer, triage more injuries and illnesses in midair and work more closely with their international partners than ever before.

“It’s the readiness factor, ensuring that we’re not just mission-capable [in] how they have been doing aeromedical evacuation as they always have,” said Lt. Col. Stephanie Ellenburg, who sets the standard for patient care across nearly three dozen medevac units as commander of the 375th Aeromedical Evacuation Squadron at Scott Air Force Base, Illinois.

“Are they truly Getting ready [for] what potentially is out there?” she asked.

Medics from the U.S. Air Force and six allied countries sought to answer that question last month at Mobility Guardian, the Air Force’s two-week, biennial training exercise for its airlift and aerial refueling units.

Their efforts will shape a new framework for aeromedical evacuation at Air Mobility Command, the branch of the Air Force that manages medevac units.

The initiative is part of AMC boss Gen. Mike Minihan’s push to transform his command for major operations in the Pacific, after the Pentagon named China as America’s top competitor in military strength, technology development and global influence.

Minihan warned airmen in a memo earlier this year to prepare for a potential war with China as early as 2025.

Lt. Col. Stephanie Ellenburg, 375th Aeromedical Evacuation Squadron commander, speaks to the AE crew during joint medical training on a Royal Air Force A400M Atlas over the Indo-Pacific region July 14 during Mobility Guardian 2023. (Staff Sgt. Devin Rumbaugh/Air Force)

If the U.S. responds to a Chinese attack on Taiwan — the democratically self-governed island that maintains military and trade ties with the United States but is claimed by China — Air Force medics could face an onslaught of combat wounds and a limited number of aircraft on which to treat them.

The Center for Strategic and International Studies, a Washington think tank, has estimated that 6,900 to 10,000 U.S. troops would be killed, wounded or missing in a conflict with China. Those killed in action could comprise around half of the casualties.

“In three weeks, the United States will suffer about half as many casualties as it did in 20 years of war in Iraq and Afghanistan,” the think tank said in a Jan. 9 report.

That volume of casualties would put immense pressure on military medevac to carry as many troops to safety as possible.

Officials say that requires a shift in the Air Force’s current aeromedical evacuation enterprise, on which the military relies to move patients between major bases and hospitals around the globe.

In a typical medevac, troops would call for help and wait for air planners to assign medics and an aircraft to pick up a wounded or ill patient. But in the Pacific, vast distances and schedule demands — and potentially, combat losses — mean the coalition may not have the luxury of waiting for on-call units from nearby bases to arrive.

Reorganizing those teams can help. At Mobility Guardian, small medical crews armed with large backpacks of supplies traveled with airlift squadrons to respond to simulated emergencies on the spot. Airmen had to use their own judgment and prioritize treatment for those with the highest chance of survival, the Air Force said in a July 20 release.

That approach also helps keep missions moving if a unit can’t speak to troops on the ground or receive orders from higher headquarters.

The Air Force should be able to tack more airmen and equipment onto those basic teams, depending on the situation, Ellenburg added. For instance, a unit may need to pick up pediatric supplies or a respiratory therapist in Guam.

Aeromedical evacuation teams will also need to keep patients stable in flight for longer periods of time, as they hop between facilities that provide lower-level care on their way back to major military hospitals in the U.S., like Hawaii’s Tripler Army Medical Center. That will require airmen to balance the amount of equipment they carry on flights with the need to travel light on aircraft full of other cargo.

Royal Canadian Air Force and U.S. Air Force aeromedical evacuation personal work on simulated patients during Mobility Guardian 23 at Andersen Air Force Base, Guam, July 10. (Tech. Sgt. Sean Carnes/Air Force)

Those teams could start small and localized on aircraft like the C-130 Hercules cargo plane, which can land on austere outposts with dirt strips instead of full-fledged runways. Later, they could hand off patients to teams on faster C-17 Globemaster III airlifters, which have more room for people and supplies.

C-17s, seen as the gold standard for aeromedical missions because of their built-in power supply, lighting and square footage, could then ferry their patients to their final destination.

Ideally, Ellenburg said, the U.S. and its allies will standardize their teams, processes and lingo so that injured troops receive the same level of care, regardless of who picks them up.

That means American medevac teams need to be jacks of all trades like their foreign counterparts, and less beholden to checklists that can be thorough but cumbersome.

Interoperability is made easier when countries fly the same aircraft, like the C-17s the U.S. shares with Australia or the C-130s it has in common with Japan.

On a July 10 training sortie, American airmen joined their Australian counterparts on a Royal Australian Air Force C-17 to go through the motions of loading litter-bound patients onto the plane and checking their vitals in flight.

Royal Australian Air Force aviators, assigned to the 3rd Aeromedical Evacuation Squadron, and U.S. airmen, assigned to the 375th AES, conduct joint medical training July 10 on a RAAF C-17 Globemaster III over Andersen Air Force Base, Guam, for Practice Mobility Guardian 23. (Staff Sgt. Devin Rumbaugh/Air Force)

In the belly of the jet, medics wove multicolored tubes and cords through the skeletons of metal litter racks that would hold four patients — plastic dummies adorned with faux gashes and burns.

Four airmen, one for each handle on a litter, began the carefully choreographed steps to bring victims up the ramp: squat, lift, forward.

Leading Aircraftwoman Rachel Koch, an Australian medical technician, barked directions. “Prepare to rack. Rack!”

Two Australians and two Americans slid a patient into place on the shelf.

Staff Sgt. Audrey Allen, an American technician with the 375th AES, offered Koch tips to secure the patients as they strapped three other dummies to the floor.

“They’re very similar, but in learning the different team dynamics, it helps us understand how we’re going to integrate together if we’re going to fly AE missions together,” Royal Australian Air Force Flying Officer Alyssa Collins, officer in charge at the 3rd Aeromedical Evacuation Squadron, said in a public affairs video July 11.

Medical training dummies wait at the bottom of the ramp of a Royal Australian Air Force C-17 Globemaster III July 10 during Practice Mobility Guardian 23 on Andersen Air Force Base, Guam. (Staff Sgt. Devin Rumbaugh/Air Force)

Still, coalition air forces faced other logistical hurdles that may require further policy tweaks.

Some biomedical cargo was stuck on the flight line because of inspection processes that crews hadn’t anticipated, Ellenburg said. And units may have to find a way to support heating-and-cooling equipment so medicine doesn’t go bad in the field.

Ellenburg said Mobility Guardian highlighted the “struggles that it’s going to take” to redesign aeromedical evacuation, but praised the seven-member coalition’s effort to figure it out for a new generation of airmen.

“I’ve had the greatest opportunities to work with lots of different international partners,” she said. “Not all of their U.S. forces have. … It’s opening their eyes [to] really, truly, what they can do.”

Rachel Cohen joined Air Force Times as senior reporter in March 2021. Her work has appeared in Air Force Magazine, Inside Defense, Inside Health Policy, the Frederick News-Post (Md.), the Washington Post, and others.

New Medicare proposal would cover training for family caregivers

Even with extensive caregiving experience, Patti LaFleur was unprepared for the crisis that hit in April 2021, when her mother, Linda LaTurner, fell out of a chair and broke her hip.

LaTurner, 71, had been diagnosed with early-onset dementia seven years before. For two years, she’d been living with LaFleur, who managed insulin injections for her mother’s Type 1 diabetes, helped her shower and dress, dealt with her incontinence, and made sure she was eating well.

In the hospital after her mother’s hip replacement, LaFleur was told her mother would never walk again. When LaTurner came home, two emergency medical technicians brought her on a stretcher into the living room, put her on the bed LaFleur had set up, and wished LaFleur well.

That was the extent of help LaFleur received upon her mother’s discharge.

She didn’t know how to change her mother’s diapers or dress her since at that point LaTurner could barely move. She didn’t know how to turn her mother, who was spending all day in bed, to avoid bedsores. Even after an occupational therapist visited several days later, LaFleur continued to face caretaking tasks she wasn’t sure how to handle.

“It’s already extremely challenging to be a caregiver for someone living with dementia. The lack of training in how to care for my mother just made an impossible job even more impossible,” said LaFleur, who lives in Auburn, Washington, a Seattle suburb. Her mother passed away in March 2022.

A new proposal from the Centers for Medicare & Medicaid Services addresses this often-lamented failure to support family, friends, and neighbors who care for frail, ill, and disabled older adults. For the first time, it would authorize Medicare payments to health care professionals to train informal caregivers who manage medications, assist loved ones with activities such as toileting and dressing, and oversee the use of medical equipment.

The proposal, which covers both individual and group training, is a long-overdue recognition of the role informal caregivers — also known as family caregivers — play in protecting the health and well-being of older adults. About 42 million Americans provided unpaid care to people 50 and older in 2020, according to a much-cited report.

“We know from their research that nearly 6 in 10 family caregivers assist with medical and nursing tasks such as injections, tube feedings, and changing catheters,” said Jason Resendez, president and CEO of the National Alliance for Caregiving. But fewer than 30% of caregivers have conversations with health professionals about how to help loved ones, he said.

Even fewer caregivers for older adults — only 7% — report receiving training related to tasks they perform, according to a June 2019 report in JAMA Internal Medicine.

Nancy LeaMond, chief advocacy and engagement officer for AARP, experienced this gap firsthand when she spent six years at home caring for her husband, who had amyotrophic lateral sclerosis, a neurological condition also known as Lou Gehrig’s disease. Although she hired health aides, they weren’t certified to operate the feeding tube her husband needed at the end of his life and couldn’t show LeaMond how to use it. Instead, she and her sons turned to the internet and trained themselves by watching videos.

“Until very recently, there’s been very little attention to the role of family caregivers and the need to support caregivers so they can be an effective part of the health delivery system,” she told me.

Several details of CMS’ proposal have yet to be finalized. Notably, CMS has asked for public comments on who should be considered a family caregiver for the purposes of training and how often training should be delivered.

(If you’d like to let CMS know what you think about its caregiving training proposal, you can comment on the CMS site until 5 p.m. ET on Sept. 11. The expectation is that Medicare will start paying for caregiver training next year, and caregivers should start asking for it then.)

Advocates said they favor a broad definition of caregiver. Since often several people perform these tasks, training should be available to more than one person, Resendez suggested. And since people are sometimes reimbursed by family members for their assistance, being unpaid shouldn’t be a requirement, suggested Anne Tumlinson, founder and chief executive officer of ATI Advisory, a consulting firm in aging and disability policy.

As for the frequency of training, a one-size-fits-all approach isn’t appropriate given the varied needs of older adults and the varied skills of people who assist them, said Sharmila Sandhu, vice president of regulatory affairs at the American Occupational Therapy Association. Some caregivers may need a single session when a loved one is discharged from a hospital or a rehabilitation facility. Others may need ongoing training as conditions such as heart failure or dementia progress and new complications occur, said Kim Karr, who manages payment policy for AOTA.

When possible, training should be delivered in a person’s home rather than at a health care institution, suggested Donna Benton, director of the University of Southern California’s Family Caregiver Support Center and the Los Angeles Caregiver Resource Center. All too often, recommendations that caregivers get from health professionals aren’t easy to implement at home and need to be adjusted, she noted.

Nancy Gross, 72, of Mendham, New Jersey, experienced this when her husband, Jim Kotcho, 77, received a stem cell transplant for leukemia in May 2015. Once Kotcho came home, Gross was responsible for flushing the port that had been implanted in his chest, administering medications through that site, and making sure all the equipment she was using was sterile.

Although a visiting nurse came out and offered education, it wasn’t adequate for the challenges Gross confronted. “I’m not prone to crying, but when you think your loved one’s life is in your hands and you don’t know what to do, that’s unbelievably stressful,” she told me.

For her part, Cheryl Brown, 79, of San Bernardino, California — a caregiver for her husband, Hardy Brown Sr., 80, since he was diagnosed with ALS in 2002 — is skeptical about paying professionals for training. At the time of his diagnosis, doctors gave Hardy five years, at most, to live. But he didn’t accept that prognosis and ended up defying expectations.

Today, Hardy’s mind is fully intact, and he can move his hands and his arms but not the rest of his body. Looking after him is a full-time job for Cheryl, who is also chair of the executive committee of California’s Commission on Aging and a former member of the California State Assembly. She said hiring paid help isn’t an option, given the expense.

And that’s what irritates Cheryl about Medicare’s training proposal. “What I need is someone who can come into my home and help me,” she told me. “I don’t see how someone like me, who’s been doing this a very long time, would benefit from this. They caregivers do all the work, and the professionals get the money? That makes no sense to me.”

Judith Graham is a columnist for KFF Health News.