ALPENA COMBAT READINESS TRAINING CENTER, Mich. — Helicopter-driven winds beat the outside of the tent as another influx of patients is assessed in lines of military green litters. Inside the tent, healthcare providers rush around their already established patients, gauging needs, ordering care and making space for the new
inflow.
Over the frantic murmurs, crosstalk and the roar of fading helicopter blades, one piqued voice carried over it all.
“That’s my decision?!”
When faced with making the decision to continue possible life-saving treatment by using valuable medical supplies on a single patient, or order morphine and comfort and allow those supplies to put several other service members back into the fight, the Michigan Air National Guard nurse – and other medical group Airmen like her – experienced firsthand the massive transformation to peer and near-peer warfare that was the focus of Northern Strike 2019.
“In a peer, near-peer environment, we don’t own the sky,” said Michigan Air National Guard Col. Sid Martin, Air National Guard Assistant to the United States Air Forces in Europe – Air Forces Africa Surgeon General. “These folks — which include Michigan, Minnesota and Oklahoma medical groups — are beginning to write the book on what patient care and movement is going to look like in this environment, where casualties, no kidding, really overwhelm the system and where people begin to have to make decisions about care based on survivability. In these crisis standards of care, people will begin to have to make very conscious decisions about where we’re going to apply resources because there simply will be more patients that need resources than there are actual resources.”
Northern Strike 19 is a National Guard Bureau-sponsored exercise uniting more than 6,000 service members from more than 20 states, multiple service branches and seven coalition countries during the last two weeks of July 2019 at the Camp Grayling Joint Maneuver Training Center and the Alpena Combat Readiness Training Center, both located in northern Michigan and operated by the Michigan National Guard.
The exercise integrated medical patient movement by adding more realistic wartime stress to the usual casualty care and patient movement system, which included significant capability degradation, crisis standards of care and critical-thinking expansion.
“In the medical community, we’ve gotten used to the fact that things run on a schedule, paperwork is always in-hand, the patients always meet the regulatory definition of what an aeromedical evacuation patient is ...” said Oklahoma Air National Guard Col. Keith Reed, 137th Special Operations Medical Group (137th SOMDG) commander. “Some of the harsh realities of war come to play in that peer or near-peer environment.”
Those harsh realities of war include more casualties, more critical patients, less resources, and facilities that are closer to the warfront and less advanced than those in more established NATO areas. It also requires a stronger focus of resources on returning more service members to the fight, not home.
“In 2007, if you came to us as an American service member alive, you had a 98 percent chance of leaving our facility alive,” recalled Martin.
“Everybody still expects that 98 percent, but when I was briefing the team for this, I said, ‘Twenty percent might be good enough,’” continued Minnesota Air National Guard Col. Matt Peterson, Air National Guard Assistant to National Guard Bureau Joint Surgeon. “That sucks.”
“We’re still going to try to save as many people as we can,” continued Peterson. “That’s our nature. It’s what providers do. But at the end of the day, it’s ‘How many people can I get back into the fight?’ Because it’s that big of a fight.”
The overall casualty care and patient movement system, which is end-to-end, starts downrange at the point of injury (or POI) and continues into a Role 4 medical facility stateside.
“So let’s say at the POI, a Soldier, Airman, Marine, what have you, is injured,” explained Oklahoma Air National Guard 1st Lt. Sarah Willhight, 137th SOMDG medical administrative officer and En Route Patient Staging System planner for Northern Strike 19. “That’s considered Role 1, where you’re doing Self Aid Buddy Care or initial life-saving measures. Then, you would want to get them to a Role 2, which is like your field hospital.”
Next, the patient would ideally be treated and stabilized, properly documented and then put into the system to be medically evacuated or casualty evacuated to a staging area, called the En Route Patient Staging System, or ERPSS.
“At ERPSS, usually you’ll have a stable patient,” continued Willhight. “We receive them, we take care of their paperwork, their personal effects, make sure that they don’t have any weapons hidden, give them something to eat and then load them onto a plane for Aeromedical Evacuation Teams to take them to a Role 3, which is still usually a hospital not within the United States.”
ERPSS is an active duty-funded personnel package that acts as a sort of hold-over for patients awaiting evacuation to a higher level of care. The 137th SOMDG is assigned the ERPSS 10, which is made up of 13 personnel and designed to care for 10 patients for two to six hours, 40 patients a day, for seven days before needing a resupply. The highest echelon of care is nursing.
Despite its design, the scenarios of Northern Strike sent 50 in-bound and unregulated patients to the ERPSS within a 45-minute window, forcing the medical teams to scramble and stretch not just the capabilities of ERPSS, but also the limits of the Airmen.
“What was the most challenging during this three-day exercise for us was the actualization that even though we were set up as an ERPSS-10 package, we were still receiving patients we didn't have the capability of saving,” said Oklahoma Air National Guard Airman 1st Class Misha Claytor, 137th SOMDG medical technician. “If you think of real-world situations, it's actually very sad. I learned that even though some or even most can't be saved, as a medic, you have to move on and keep trying for the next person. Emotions need to be set aside for the entire time you work.”
For the 137th SOMDG, the ERPSS personnel package contains the only deployable positions within the unit, outside of the first sergeant and superintendent, which means it requires unique training that extends past the usual physicals and immunizations for which most Airmen know medical groups at Guard bases.
“To be a part of ERPSS for us is an opportunity to deploy, because we don’t get a lot of those opportunities,” said Willhight. “Our primary mission is to make sure the members of our base have their medical readiness items taken care of. So ERPSS is what we can do to feel like we’re a more integral part of the war fight. The need for us out there is hard to see when we’re not actually exercising our clinical skills.”
“We are the expeditionary ERPSS,” said Willhight. “It’s a modular system, so we’re normally first on the ground, on a bare base.”
As an expeditionary system, the ERPSS was setup right off of major airways — such as the Army Airfield at Grayling and near bare-bones field hospitals while deployed — where medical helicopters coast nearly to the front tent opening to offload patients. While training for ERPSS, Airmen even learn night-vision driving and loading and offloading patients to buses, ambulances, aircraft, Humvees and two-ton trucks.
“Your ERPSS people are in the fight,” emphasized Martin. “This is not in-garrison operations. They are training to go to war and they are as critical a piece of the puzzle as any of the things that go ‘bang’ or ‘boom’ in the night. We need Oklahoma, including the ERPSS, to continue to play a part outside the state to help us develop what the future looks like.”
**This story originally appeared in Vol. 5, No. 1 of the Air Observer, a digital publication, Sept. 14, 2019.