Baron Larrey and the evolution of medical transport
The fascinating history of transporting the injured can be traced to innovators such as Baron Dominique-Jean Larrey, the prominent French surgeon who established the “Flying Ambulance” organization during the early Napoleonic Wars.¹ Larrey developed his Flying Ambulance unit for what was then a novel purpose: rapidly transporting injured soldiers from the battlefield to a more secure location, where they could receive medical care for their wounds.

He realized that this could be accomplished only through preparedness and organization, and so he devised a fleet of lightweight, functional wagons that were pulled by horses (Figure 1). In one of the earliest examples of triage in practice, his medics were directed to attend first to the most grievously injured soldiers, regardless of rank, who were placed in the wagons and carried from the scene of the fighting to safety. When horses and wagons were unavailable, Larrey used great ingenuity for transport and at times used camels, or even wheelbarrows, for his wounded.

America’s ‘Father of Battlefield Medicine’ and medical director of the Union’s Army of the Potomac, Dr. Jonathan Letterman adopted Larrey’s principles of triage and transport when he organized medical support for the northern soldiers during the Civil War. Among Dr. Letterman’s many reforms, he instituted an ambulance system that was responsible for triaging and evacuating thousands of wounded troops from the front lines, saving numerous lives.² 

As technology has evolved, so has emergency transport of the war’s wounded. The horse-drawn wagons and carriages have been replaced by automobiles, trains, ships, and, ultimately, airplanes and helicopters. During World War II, which saw hundreds of thousands of wounded over a large geographic spread, medical transport became essential, and the C-47 Skytrain was the workhorse of that conflict. In the wars of Korea and Vietnam, helicopters ferried casualties to hospitals or aid stations in record time, significantly reducing the percentage of soldiers who succumbed to their wounds and hugely impacting the prosecution of those engagements (Figure 2). Following Vietnam, the US military’s ability to transport large numbers of wounded would not be tested on a large scale until the present conflicts in Afghanistan and Iraq, which began shortly after September 11, 2001.

Dr. Paul Carlton and the CCATT
One Air Force surgeon, in particular, had much to do with envisioning and organizing the military’s current methods of transporting the wounded. In 1982, Paul K. Carlton, MD, was stationed in Wiesbaden, Germany, as a young lieutenant colonel. He realized that no effective, formal plan existed to facilitate medical transport in the event of an emergency. The procedure at that time was to appropriate aircraft of opportunity and dispatch small medical teams where needed, but there was no established organization or dedicated equipment. Instead, military physicians, nurses, and medics were assigned in a somewhat random fashion to carry out missions throughout Europe and Africa, retrieving sick and injured soldiers and conveying them to a US military hospital in Germany.

Determined to change this haphazard system, Dr. Carlton lobbied to secure dedicated medical equipment, which was pre-positioned and at the ready on pallets. He fought for the establishment of organized, trained teams that were always prepared to be dispatched to rescue patients in need.  Dr. Carlton originally named this new organization the Flying Ambulance Surgical Trauma (FAST) Team, in honor of Larrey and his historic Flying Ambulance.

Over the years, as Dr. Carlton rose in rank and assumed greater responsibility, he continued to work on the issue of medical evacuation, always refining and improving his ideas. In 1999, Dr. Carlton was appointed Surgeon General of the US Air Force and was positioned to implement the well-researched aerovac program that he had formulated over the years, and which had been organized in the late 1990s as the Critical Care Aeromedical Transport Team (CCATT).

A basic CCATT is comprised of one physician, at least one critical care nurse, and a pulmonary specialist. The CCATT physician must be either a surgeon or a critical care specialist. All members of a CCATT undergo a training program that lasts several weeks, and those who successfully complete the program earn the right to wear the unique CCATT emblem on a shoulder of their flight suit. These specialized teams are noted for their members’ professionalism and can-do attitudes.

Each CCATT is supplied with state-of-the-art medical equipment, such as lightweight, reliable ventilators; infusion machines; pulse oximeters; high-quality monitors; and basic laboratory kits. After acquiring patients, the CCATT need only ensure that the patient is physically stabilized, although perhaps not medically stable, before taking to the skies. After all, the airplane has been transformed into a flying intensive care unit, where damage control is the rule and ‘care in the air’ is the mantra.

CCATTs have distinguished themselves on the battlefields of Afghanistan and Iraq by successfully retrieving thousands of wounded. It has been remarkable to see how well the CCATTs have performed and how thoroughly Dr. Carlton’s ideas have been validated.

Rescuing the U.S.S. Cole victims  
• Terrorists attack—An early test of the CCATT occurred in response to the bombing of the U.S.S. Cole. Thursday, October 12, 2000, was a beautiful autumn day in Landstuhl, Germany, where several CCATTs were based. Landstuhl is home to a regional US military hospital, which even in 2000 had a busy patient load, although it was not the hot bed of activity it has since become. Landstuhl Regional Medical Center currently serves as the European center of patient care for those wounded in the Iraq and Afghanistan conflicts.

The U.S.S. Cole is a navy destroyer, and on that day in October, it had approximately 200 sailors aboard (Figure 3). In the early afternoon, personnel at Landstuhl received word that the U.S.S. Cole had been attacked by suicide bombers while refueling at Aden Harbor in Yemen. As always happens when such catastrophes occur, we began receiving conflicting reports on the number of deaths, extent of injuries, and the degree of damage. Some reports turned out to be correct, some incorrect. Eventually, it was confirmed that 17 sailors had died from the bombing and another 39 were injured. While the ship had a medic and an aid station, it had no physician. However, all the Cole’s survivors actively tended to their injured compatriots even as they struggled valiantly to keep the ship from sinking.

We received an immediate request to get a CCATT ready to proceed to Yemen and retrieve our injured sailors, many of whom had been taken to local hospitals in Aden, where sophisticated medical care was lacking. Fortunately for our sailors, the French military had established a modern hospital about 200 miles away, across the Strait of Aden, in the little country of Djibouti. On their own initiative, the French flew a C-160 Transall to Yemen and evacuated the 11 most seriously wounded patients to the Djibouti hospital, where they were cared for most professionally.

• Planning the MedEvac missions— Because the patients were now separated into two different groups in two different countries, planners at Ramstein Air Force Base (AFB) decided to dispatch two MedEvac missions to ferry all the injured back to Germany. Each plane was to have an augmented CCATT to deal with the high number of casualties.

Each mission involved a C-9 Nightingale, which until its recent replacement by the C-17, was the aerovac airplane of choice for many years (Figure 4). It is a twin-engine jet, the military equivalent of the DC-9, and specifically designed for MedEvac missions. The aircraft is plumbed and wired to care for multiple casualties; features such as suction, oxygen, and litter stanchions are built into the plane. A side door on the Nightingale folds outward to become a ramp, which makes on- and off-loading patients faster and more efficient.

The first mission, 10E1, flew from Ramstein AFB to Cairo, and then on to Aden. The second mission, 10E2, went from Ramstein AFB to Cairo to Djibouti (Figure 5); one of the authors, Dr. David Welling, was a member of the CCATT on 10E2. Because of international aviation restrictions, the need to obtain clearances from foreign governments to traverse their airspace, and the “fog of war,” the missions did not leave Ramstein AFB until early in the morning on October 13, a full day after the attack. While the CCATTs were prepared to leave 12 hours earlier, the tremendous planning and coordination the missions required took half a day to accomplish. This detailed planning was to pay dividends later. For example, on the way to their respective destinations, each mission had a scheduled stop in Cairo, Egypt, to refuel. Planners ensured that ‘fresh’ pilots were staged in Cairo so that the C-9 Nightingales could make the roundtrip without violating crew-rest restrictions.

• At the French military hospital in Djibouti—The Republic of Djibouti is a poor Muslim country in eastern Africa. We arrived there in the afternoon of October 13, in brutally hot and humid weather. The plane taxied into a secure, fenced area, patrolled by French soldiers with automatic weapons and dogs. Some concern existed about whether we, too, might become terrorist targets.

The French military hospital was approximately 5 miles away, and we drove there in vans, forming a military convoy. On arrival, we visited the 11 patients with haste. We found 2 who were critically injured and on respirators; the other 9 had major fractures and various severe injuries. We determined that the patients’ conditions were stable enough for us to take all 11 back to Landstuhl with us.

Several on our team were able to converse with our hosts in French, and this facilitated better planning and patient care. Some of us also knew French surgeons known to the physicians at Djibouti, which established common ground and put everyone at ease. The visit illustrated the significant benefits of international cooperation and studying foreign languages. It must be stated that the French physicians did a marvelous job treating our patients and deserve tremendous credit for their initiative and excellent work.

• Transporting survivors to Germany— Once our rounds had been completed and our plans were set, we commandeered every ambulance in Djibouti to caravan our patients back to the airplane. It was dark by the time everyone was loaded securely aboard and we were prepared to take off, at 6:29 pm. The effort had left us soaked with perspiration, and we relished the modern jet’s air-conditioned coolness. The smell inside the aircraft was unforgettable: a pungent mixture of sweat and  draining wounds. The trip itself was also memorable. We were surrounded by brave and wonderful young people who, despite having undergone a traumatic experience that had left them badly injured, were as eager to help us as we were to help them. Those who were awake did their best to assist us in moving and repositioning them, and although some sailors were grieving over friends who had died in the explosion, they endeavored to comfort their surviving shipmates.

One patient began showing signs of sepsis after the plane got underway, so several internal medicine physician members of our CCATT inserted a central line and initiated antibiotic treatment. Most of our 11 patients were on oxygen; many had open, draining wounds. The most critically injured patient had nearly 11 broken bones, bilateral pneumothorax, and a ruptured stomach. He was being ventilated, and we were able to keep him stable throughout the trip. A young woman with pulmonary burns was also on a ventilator. Because of a lack of equipment, the Yemeni doctors had been unable to perform endotracheal intubation and ventilation, and she was found in extremis by the French doctors, who quickly realized her desperate situation, intubated her, and put her on a respirator, thereby saving her life.

Mission 10E2 again stopped to refuel in Cairo, Egypt. After takeoff from Cairo, we continued up the Mediterranean towards southern Italy. It became apparent that our liquid oxygen supplies were getting dangerously low, so we diverted to Sigonella, Sicily, where we took on more fuel and replenished our oxygen reservoir. We then proceeded to Ramstein AFB; the atmosphere was foggy, but we had just enough visibility to land “at minimums” at 7:15 am on October 14, 2000, less than 24 hours after being dispatched. We felt great relief as all 11 patients were carried safely up the hill to the hospital at Landstuhl, where we were greeted by an enthusiastic team of rested colleagues. They assumed responsibility for our patients at that point and subsequently gave them the best of care.  

Mission 10E1 had arrived at Ramstein AFB several hours before 10E2, just before midnight on October 13, but the plane was diverted to Frankfurt, Germany, because of the impenetrable fog. The medical team and its multitude of patients made the hour-long journey from Frankfurt to Landstuhl by bus and arrived early in the morning on October 14.

• After Action Report—All of our 11 patients recovered, most without any long-term health complications. The damaged U.S.S. Cole was hauled on the back of a heavy Norwegian transport ship named the Blue Marlin to Pascagoula, Mississippi, where it was repaired and put back into service.

The Air Force selected the combined missions of 10E1 and 10E2 as “Mission of the Year” for 2000 and awarded the prestigious MacKay Trophy to the 39 crew and CCATT members who were present on the two flights. Dr. Carlton attended the ceremony and expressed his pride in the team members “for their professionalism and skill in bringing back our wounded warriors.” The MacKay Trophy rests in the Smithsonian Air and Space Museum in Washington, DC.

CCATTs are still performing magnificently, and the lessons learned from the U.S.S. Cole rescue mission have been applied repeatedly in transporting large numbers of critically injured troops from Iraq and Afghanistan. The principles of Larrey’s Flying Ambulance continue to soar.  

This article contains the opinions of the authors and does not necessarily reflect the doctrine of the United States Department of Defense or the Uniformed Services University.

References
1. Burris DG, Welling DR, Rich NM. Dominique-Jean Larrey and the principles of humanity in warfare. J Am Coll Surg. 2004; 198(5): 831-835.

2. Gillet MC. Army Historical Series—The Army Medical Department 1818-1865, Center of Military History United States Army, Washington DC, 1987, p. 228.