Air Transport of the Critically Injured Patient: Controlling Pain during Transport and Flight

Contemporary warfare has brought both advancements and new challenges for acute pain management in the combat setting. Although survivability has increased secondary to improvements in body armor, the necessarily exposed limbs of soldiers have become even more vulnerable to progressively more destructive explosive devices. The lethality of improvised explosive devices, explosively formed penetrators, and other weapons has clearly increased during the course of the current conflict. Rapid patient evacuation out of the battlefield, farforward advanced surgical capabilities, and rapid air evacuation of combat wounded to critical care facilities outside of the war theater are the key factors resulting in a less than 10% died-of-wound rate. Historically, the relatively austere medical environment of the US Air Force (USAF) evacuation aircraft (Figure 29-1) made the management of acute pain in multitrauma patients particularly difficult. Today, the ability to evacuate patients from the battlefield has evolved into the most efficient transport and medically capable system in history. At the core of this system lies the USAF aeromedical evacuation system (AES). With the inclusion of the critical care air transport team (CCATT), the AES has been described as a 6,000-mile-long intensive care unit in the sky, stretching from staging areas in the Middle East to the continental United States. Although CCATTs focus on the critical care patient, the majority of injured soldiers require AE transport without mechanical ventilation, inotropic medications, or other measures typically associated with critical care. However, these patients often have sustained massive injury, such as multiple amputations of limbs and complicated orthopedic injuries. Although “hemodynamically stable,” these patients still have acute needs for in-flight monitoring and aggressive pain management. The US military experience with evacuating casualties by air dates to World War I. Until recently, advances in pain management during evacuation have not kept pace with advances in casualty resuscitation and transport. This chapter will address the historical casualty transport capabilities of the military, advances in patient care enroute, and the addition of advanced pain management during evacuation. Specific challenges encountered in patient care while traveling for hours for thousands of miles on military aircraft will also be addressed.