Dec. 1, 2004

When the UN’s Baghdad offices were car bombed in August 2003, a quick-reacting Air Force medical group was among the first to reach the scene. The gruesome attack claimed the lives of 22 persons, but USAF surgeons and staff saved many others. Such feats have taken place numerous times in violence-wracked Iraq.

This was the product of a new type of medical concept called EMEDS, for Expeditionary Medical Support. Unlike the acronym MASH (Mobile Army Surgical Hospital), the term EMEDS may not ever make it to the silver screen, but it is becoming as well-known to today’s forces as MASH units were to Korean War troops.

As of last April, say Air Force officials, USAF’s expeditionary medics have treated more than 171,000 casualties, comprising those injured in combat and those suffering from noncombat injuries and disease. There are EMEDS operating in Iraq and 11 other countries.

EMEDS is a concept by which the Air Force Medical Service provides health care to US forces in a deployed environment. It is a building-block approach and is modular in nature.

“That allows you to plug and play different elements as necessary, depending on the health care requirements at a given location,” said Capt. Michael Bruhn, chief of ground medical unit type code management at Air Combat Command, Langley AFB, Va.

The EMEDS program is managed largely from the ACC command surgeon’s office, which is responsible for all of the Air Force’s ground-deployable medical assets.

High Marks

In Congressional testimony, Lt. Gen. George P. Taylor Jr., Air Force surgeon general, gave the EMEDS units high marks for their work in Afghanistan and Iraq. Taylor credited lessons learned in Afghanistan with proving the modular approach. By the time of the war in Iraq, the six-year-long conversion of the Air Force’s “large footprint” field medical facilities into small, rapidly deployable EMEDS units was complete.

Said Taylor, “Our performance in Iraq validates [the claim] that the EMEDS concept works. It saves lives.”

The EMEDS approach began to emerge after Operation Desert Storm in 1991. In that war, Air Force officials discerned a need to get medical services closer to the combat zone than had been possible at that time.

In those days, explained Bruhn, the Air Force standard medical configuration was the 25-bed air transportable hospital, which was a far more elaborate setup. It confronted Air Force medical officials with many problems.

Moving that hospital required the loading of about 55 pallets and sustained use of three C-17 transports. By contrast, EMEDS can be loaded on only 25 pallets and transported for the most part on a single C-17 aircraft.

“Before, we had an extremely large footprint and would go in with an extremely heavy capability,” said Bruhn. In the interim, he noted, “we created a lighter, leaner yet more efficient deployable medical capability.”

Airlift requirements are critical because of the many demands on this capability. To get space on a transport, medical equipment and personnel must compete with combat troops.

Logistics wasn’t the only problem that the old concept generated for the Air Force. It was also inflexible. USAF could not take anything less than a full facility to the front.

“The air transportable hospital was not tailorable,” said Bruhn. “It could not be modularized, as the EMEDS is now. … That made it difficult to get to the warfighter.”

He said that the EMEDS construct has different scaleable modules.

First Responders

The first two EMEDS “building blocks” are the preventive aerospace medical (PAM) teams and mobile field surgical teams (MFSTs). According to Taylor, the PAM teams are “first-in, last-out” medics, who “are inserted with the very first troops and are capable of providing health care, on location, before the first tent stake is in the ground.”

A PAM team can include an aerospace medicine physician, bioenvironmental engineer, public health officer, and an independent duty medical technician. The team’s primary role, said Bruhn, is to work “preventive medicine issues, from occupational health to water sampling to food sources to disease factors.” The physician and technician also provide primary and emergency medical care.

Following closely behind a PAM team is an MFST with five team members, each carrying a 70-pound, specially equipped backpack of medical and surgical equipment. The MFST comprises a general surgeon, orthopedic surgeon, emergency medical physician, an anesthesia provider, and an operating room nurse or technician. These five surgical team members, said Taylor, can perform up to 10 emergency, life-or-limb-saving surgeries with the materials they carry on their backs.

The next module, called EMEDS Basic, adds 17 more personnel, including medical, surgical, and dental. This element brings enough tents and supplies to support four in-patient beds. It would be used to support a small air base.

For a somewhat larger base, USAF can lay in what is called “EMEDS Plus 10.” This expands EMEDS Basic and provides additional personnel and another 10 beds to support the air base.

The largest model is EMEDS Plus 25, with additional beds and the medical capabilities that would go with them.

“We lay in the amount of medical capacity necessary to support the population,” said Bruhn. “That is totally different from what we used previously, when we had one big hospital that would go for everything.”

The EMEDS concept has helped the Air Force to not only shrink deployed hospital facilities but also slim down and smooth out the vital records-keeping function. Storage space that once required several large filing cabinets now is provided by a single laptop computer.

This is what the Air Force calls GEMS, for Global Expeditionary Medical System. According to Bruhn, GEMS is an electronic patient record system that collects and sorts all kinds of patient information. It is used to track an entire theater’s injury scenarios and other medical problems. The data are used for medical surveillance and are fed into a larger Defense Department system.

While EMEDS ground units provide the first-line care, they do not accompany patients on air evacuation missions. Another part of the EMEDS capability—aeromedical evacuation with a different complement of medical personnel—takes over to move the more serious cases to larger facilities. USAF also has updated its medevac system.

Streamlining Medevac

Taylor said the service has seen a “significant advancement” in the ability to take advantage of so-called “back-haul” aircraft.

Recently developed patient support pallets (PSPs) make it easy to transform any USAF mobility aircraft into an aeromedical evacuation platform. A PSP is a collection of specially packed medical equipment units that can be installed in cargo and transport aircraft within minutes.

USAF has deployed 41 of these special pallets to strategic locations around the world.

Taylor told lawmakers last spring that an Air Force medevac team used one of the PSPs to convert a Greek aircraft “within an hour” into a critical-care transport to take a five-year-old “deathly ill” Iraqi girl to Greece to receive care.

Similarly, he said, USAF can quickly convert a “plane that just landed to deliver weapons” to one that can transport critically wounded airmen, soldiers, sailors, and marines.

As one medic put it, “If it flies, and we have elbow room, we can do our thing.”

Taylor said that development and deployment of PSPs “has tremendously accelerated the aeromedical evacuation process.” Previously, patients might have to “wait days for a designated C-9 or C-141 aeromedical evacuation mission to pass through their area,” he said.

“We are the only country in the world that can do this on a regular and sustained basis for our military personnel,” said Taylor.

The Air Force considers the EMEDS construct to span the range of functions, from its first response preventive and surgical teams through aeromedical evacuation. As Bruhn explained, “If you look at it as an overall medical response of the Air Force, we have the ability to treat patients from the point of entry through the air evac system to a higher echelon of care.”

The New NBC Threat

EMEDS also is prepared to meet dire threats. Taylor told a Senate panel that, shortly before the start of combat operations in Iraq, USAF added its EMEDS Supplemental NBC (nuclear, biological, and chemical) Treatment Modules.

Each module, loaded on a pallet, contained 25 ventilators and medical supplies to care for 100 radiological, biological, or chemical casualties.

Even as these pallets provided the tools to treat NBC casualties, EMEDS’ “hardened” tents and infrastructure offered a protective shelter in which medics could carry on their work.

Each of these shelters can be equipped with special liners and air-handling equipment that overpressurizes the interior. Clean, filtered air is pushed in, and contaminated air is kept out.

Protected water distribution systems work the same way; they make sure that the EMEDS team has safe, potable water even in contaminated environments.

“So, when our patients come into an EMEDS that is collectively protected,” said Bruhn, “there is an assurance that they will be safe inside these tents to be treated.”

EMEDS would also play a major role in protecting troops in the field. Bruhn said, “We have specific antidote capabilities that deployed members are required to take, and they are used if they feel that they are in an environment where they have been exposed to some kind of an agent.”

EMEDS teams are made up of many types of specialists, said Maj. Gen. Barbara C. Brannon, assistant surgeon general for nursing services and medical force development.

According to Brannon, the wars in Afghanistan and Iraq saw deployments of 725 nurses and 1,603 medical technicians within a total of 24 EMEDS units. Five of these deployed units have been equipped with chemical and biological protection to counter potential threats.

In one year, six nurses were deployed as EMEDS commanders in charge of deployed wing medical facilities in such places as Saudi Arabia, Romania, the United Arab Emirates, Bahrain, and Diego Garcia.

Many of the medics are reservists, though you could not distinguish them from active duty members. “They train the same way,” said Bruhn. “They attend the same courses. Certain courses they attend are certified the same way the active duty courses are, and we all deploy, so, when you are in the field, there is no way to determine whether this is a Guard or Reserve or an active duty person.”

Staying Sharp

EMEDS training entails in-house courses and cooperative arrangements with civilian institutions. “Air Force medics could not succeed in our expeditionary deployments without targeted training to ensure clinical currency,” said Brannon.

A Readiness Skills Verification Program helps keep personnel trained in needed wartime skills.

Centers for Sustainment of Trauma and Readiness Skills (C-STARS) programs allow the Air Force to partner with civilian academic centers to immerse nurses, medical technicians, and physicians in all phases of trauma care. This takes place at three locations: the Shock-Trauma Center in Baltimore, University of Cincinnati Medical Center, and Saint Louis University Hospital in St. Louis.

While it moves to make medical facilities smaller and more maneuverable, the Air Force also is exploiting new developments to make them more effective. Taylor specifically noted the development of modern, high-technology medical equipment.

“During operations in Iraq,” he said, “we have relied on technical marvels [such as] a laptop-sized ultrasound machine, a ventilator unit the size of a football, and a chemistry analyzer that, during Desert Storm, required its own tent; now it fits into the palm of your hand. Our people are saving lives with these technologies around the globe.”

Bruhn noted other examples: a new mobile oxygen-generation system and self-contained water distribution system. They are designed to travel light and move into war zones in time to treat the first battle casualties.

The primary job of the Expeditionary Medical Support operation is to keep Air Force troops healthy and provide treatment when they are sick or wounded. EMEDS, as Bruhn sums it up, allows the Air Force to do this “on time, efficiently, and with a small footprint.”

Bruce D. Callander is a contributing editor of Air Force Magazine. He served tours of active duty during World War II and the Korean War and was editor of Air Force Times from 1972 to 1986. His most recent article for Air Force Magazine, “Poles Apart,” appeared in the November issue.