Medical care on the fly

RAMSTEIN AIR BASE, Germany - The huge KC-135 air-refueling tanker touched down here about 7 a.m. and was immediately greeted - not by fuel trucks but by ambulances.

At the plane's side door, an elevated platform called a K-loader moved into place, and medical technicians began emerging with litters of wounded and injured soldiers from Afghanistan.

"Most of them are going home, and they're happy," said Air Force Maj. Barry Van Sickle, a flight nurse who accompanied seven patients on the KC-135, which had been converted into a flying hospital.

"Some are wounded; some have been hurt in accidents," said the Stevensville, Mont., resident. "We give them fluids and pain meds and keep them comfortable."

The scene - late last month - plays out every day at Ramstein as the number of casualties from Afghanistan increases. Their movement is carefully choreographed by members of the nearby 435th Contingency Aeromedical Staging Facility, a key stopover on a medical lifeline that spans continents and has important links to runways and operating rooms in Philadelphia and its vicinity.

Air Force Capt. Dave Gaulin of Cherry Hill, who flies giant C-17 cargo jets out of McGuire Air Force Base in South Jersey, feels a special sense of mission when his orders are to transport wounded service members.

"Sometimes I'm carrying cargo and I'm told, 'You've been re-cut to carry patients,' " said Gaulin, who has flown the wounded from Afghanistan and Iraq about a half-dozen times.

When that happens, "everyone moves with an additional sense of urgency and purpose. Now, we're dealing with human lives, wounded warriors. You want to get them to a place of care as fast and safely as possible."

The aeromedical staging facility at Ramstein serves as a terminal for patients waiting to take flights or transportation to another hospital. Its 98 active-duty airmen, reservists, and guardsmen also move patients to and from transport aircraft, including converted C-17 cargo planes.

The C-17s are especially suited to hospital conversions. They are so roomy that they can easily accommodate up to 36 patients. They are also equipped with electric plugs for oxygen and medical equipment, and litter stanchions along the fuselage that can hold three patients and IV bags.

Sandra Archer, a spokeswoman for the 435th Air Base Wing at Ramstein, longs for slow days at work. "I'm always glad if there aren't many patients," she said. "Things have shifted. We're getting more patients now from Afghanistan than Iraq. You sometimes see kids with no arms, no legs."

Two litter-bound and five ambulatory service members - all from the Army or the Marines - were taken from the KC-135 to ambulances that carried them to nearby Landstuhl Regional Medical Center for treatment.

Many are still alive because of surgical procedures pioneered by C. William Schwab, chief of trauma surgery at the Hospital of the University of Pennsylvania.

As drug violence flared in Philadelphia in the late 1980s and early 1990s, Schwab began experimenting with a phased operating procedure in which he and other surgeons stabilized multiple-gunshot victims, deferring further surgery to repair their serious wounds until their bleeding had been stanched and their vital signs restored. In the past, advances in trauma surgery honed on the battlefield found their way to civilian hospitals back home. Now, Schwab's procedures - developed in response to Philadelphia's drug wars - are saving lives in Iraq and Afghanistan.

Schwab served as a senior visiting surgeon at Landstuhl in 2006, the first surgeon to take part in a volunteer effort organized by the American Association for the Surgery of Trauma and the American College of Surgeons' committee on trauma.

The aeromedical staging officials here have arranged the movement of more than 12,000 patients from Afghanistan and Iraq in the last 12 months. About 2,400 have stayed briefly at the unit's 100-bed facility during that period.

Since 2003, more than 50,000 patients have gone through the staging area, part of a medical pipeline unknown in previous American wars; injured service members are moved to the States within 72 to 96 hours of injury. Soldiers previously languished for weeks in field hospitals before being transported out of the combat zone.

"We hear there may be more [casualties] with the offensive" expected against the Taliban, said Air Force Capt. Iriz Yazno, an aeromedical staging administrator. "We are expecting more injuries."

But the facility is ready, she said. "We are a 24/7 operation. Our mission is to provide a continuity of care. We recover patients from the plane, take them to Landstuhl, and provide outpatient care for follow-up appointments."

The facility often has patients awaiting flights to Andrews Air Force Base near Washington and a transfer to Walter Reed Army Medical Center or other Stateside hospitals.

In the staging area, "we have patients that don't require much medical care," Yazno said. "Some are patched up and returned to duty."

The staging area's busy tempo comes as U.S. deaths in Afghanistan have increased dramatically: from eight in the first two months of last year to 29 during the same period this year after ramped-up winter operations against the insurgency.

President Obama has announced the deployment of 17,500 additional troops to bolster the record 38,000 already in the country as the United States draws down its forces in Iraq.

Part of the increase in deaths is due to the increased number of troops. In early 2008, about 27,000 were in the country.

The wounded are flown from Afghanistan and Iraq in cargo and tanker planes that are outfitted like hospitals with beds and medical monitoring equipment.

A doctor puts in a patient-movement request that shows up on an electronic mission board in a staging-area command center. The board tells planners where the patient is coming from and when he or she will arrive at Ramstein.

Then, based on the patient's requirements, medical personnel assemble the litters, monitors, and medicines needed for transport.

"I make a list of all the requirements for each patient," said Air Force Capt. Joseph Melder of Elmer, La. "We have all the equipment here."

"When our patients come in, they're disappointed" because of their injuries and absence from comrades, added Yazno. "We try to provide comfort and encouragement."

The patients have access to computers, televisions, games, and phones in a USO at the staging area. Last month, Steven Lincoln, 19, an Army private from Pawtucket, R.I., was working online while waiting for a transfer. "I came from Iraq, and I'm on my way to Fort Sam Houston," said Lincoln, whose hand was burned in an accident.

At his desk in a nearby multipurpose room, the chaplain, Air Force Maj. David Reynolds of Frederick, Md., made himself available to patients who needed other kinds of healing. "I'm here for whatever spiritual and emotional needs they have," he said.

In Iraq and Afghanistan, surgical units using Schwab's phased approach are much closer to the front lines than in past wars. And survival rates have never been higher.

Since the war in Iraq began producing large numbers of wounded service members in 2003, according to the Pentagon, only about 10 percent have died of their injuries - down from about 24 percent in Vietnam.

And while it took an average of 45 days to transport a wounded service member from a field hospital in Vietnam to a medical center in the United States, now that trip to Iraq and Afghanistan can take fewer than four days, thanks to the Air Force tankers and airlifters at McGuire and other bases.

"Our mission here is important," said Maj. Mark Knitz, the staging area's flight commander, "and the people here are great."