The Role of Critical Care Air Transport

In this episode of Frontline Surgery: Mastering Military Trauma Care, host Dr. Joshua Dilday and Dr. Rachel Russo are joined by Dr. Valerie Sams and Dr. Geoffrey Anderson to discuss Critical Care Air Transport Teams (CCAT) and their essential role in moving critically injured casualties across the theater of operations and back home. From the origins of the CCAT concept to its evolution through the global war on terror, the episode covers how a small team delivers full-spectrum ICU care, including ECMO and continuous renal replacement therapy, at altitude and across oceans.

The conversation tackles the realities of sustainment and readiness for both active duty and reserve CCAT teams, the physiologic and operational stressors of flight that no simulation can fully replicate, and how task saturation demands flexibility from every member of the team. With LISCO on the horizon and evacuation timelines expected to lengthen in contested environments, the episode makes clear that CCAT is not simply transportation. It is an extension of the trauma care system itself, and understanding it is essential for every military surgeon preparing patients for the next phase of survival.

Transcript

SPEAKER_04 0:01

It's uh a three-person team that's 30,000 feet above the Atlantic Ocean with no way to call a consult sometimes, but has to be able to do that with limited resources with some of the sickest patients.

SPEAKER_02 0:12

When the situation dictates that you need to make some operational decisions, then you know that's a negotiated conversation between the CCAT team and the uh team in the uh the Ford Surgical Facility.

SPEAKER_00 0:27

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Stay prepared and stay sharp with Frontline Surgery, where every episode provides key insights into mastering military trauma care.

SPEAKER_01 0:59

Welcome back to another episode of Frontline Surgery, Mastering Military Trauma Care. I'm Joshua Dilday. I'm joined by my co-moderator, Dr. Rachel Russo. We've got a couple episodes on these together, Rachel. So thank you so much for joining us. And I'm excited about this one that kind of fits close to home with your background on this episode.

SPEAKER_05 1:16

Yeah, thank you so much. This CCAT episode is gonna be really exciting, so I can't wait to get it started.

SPEAKER_01 1:23

Absolutely. You know, just to review, this series is designed to prepare those early career military surgeons for the realities of deployed trauma care and the systems that support it. And one of the systems is key for critical care evacuation. And that's exactly what we focused on today's episode. Today we're gonna focus on Critical Care Air Transport Team, or CCAT, which is a highly specialized team responsible for moving critically injured patients across the theater of operations and beyond, even to get them back home safely. CCAT has transformed combat casualty care, really highlighted during the global war on terror, by allowing severely injured casualties to survive the transport that previously would not have been possible. And since we're talking about that, we've got a couple experts in that field joining us. We're joined today by Dr. Valerie Sams, a physician with extensive CCAT experience and leadership, and Jeff Anderson, who himself has coordinated care between forward surgical teams and aeromedical evacuation platforms within the CCAT space. Dr. Sams, Dr. Anderson, thank you so much for joining us today on Frontline Surgery.

SPEAKER_04 2:26

Thanks for having us. This is great.

SPEAKER_02 2:28

Yeah, great to be here. Thanks, guys.

SPEAKER_05 2:30

All right, so I want to begin just with a scenario so that our listeners can get into the mindset of when CCAT might be helpful. So let's imagine we're at a roll-to facility at three o'clock in the morning. We have sustained combat operations with multiple casualties. We're dealing with one that has severe blast injuries and has just undergone damage control surgery with massive transfusion and has a temporary abdominal closure. The patient's still on the ventilator, they're sick on pressors and critically unstable. We really need to get them out of here so we can make some room for some new patients coming in. There's weather delays and we're in a contested airspace, so our evacuation timeline is pretty prolonged. Going by ground doesn't seem viable. We hear a CCAT team is inbound, which is going to help transport the casualty to higher levels of care. And so you know the next several hours of transport may determine whether this patient survives. Let's start then with Val. Can you tell us a little bit about what CCAT is and why it has become such a critical component of combat casualty care?

SPEAKER_04 3:30

Yeah, thanks, Rachel. You know, Critical Care Transport is a specialized team that really was recognized several decades ago by leaders like Don Jenkins and CK Carlton and Warren Dorlack and Shay Joe Hanneman. They said, we need to do better by our patients. So we save their lives on the battlefield. We still got to get them home. And they recognize the need to really establish this highly trained team that could do that. And we are the only training in the Air Force that actually requires you to be verified to do this mission. It's not a participation trophy. You can't just show up and complete the training, you actually get scored and you have to pass. So that's how seriously we take it because it's uh a three-person team that's 30,000 feet above the Atlantic Ocean with no way to call a consult sometimes that has to be able to do that with limited resources with some of the sickest patients. So that is a team of a physician, usually critical care, critical care adjacent, mostly our emergency medicine anesthesia and our variety of critical care physicians fill that role. Then we have critical care and emergency medicine nurses and registered respiratory care practitioners. So that makes up the three-person community. And their mission scope since their inception was to be able to take care of up to six patients, three of them can be critically ill. So and it really started, the training really started in the early 2000s.

SPEAKER_01 4:51

So, Dr. Anderson, you you've been involved in some of these and you've had multiple deployments across a variety of spectrums, pre-hospital, up to CCAT. What's really the role currently with CCAT in this combat casual D care? We just heard about the history of it and its evolution, but how does this bridge the gap between a far forward surgical asset and getting that patient safely to another area?

SPEAKER_02 5:14

Yeah, I think that CCAT is kind of your is the is the way of getting those critically injured patients back to a higher level of care. It does a few things. One, it allows for a specialized team to transport these patients safely to get them to a higher level of care. It also allows decompression, like in this scenario here, decompression of a forward hospital that may have uh ongoing uh casualties coming in. You need to decompress so that you can get those, so you can keep the capabilities of those um forward surgical hospitals running. So you get the critical patients out, you get patients where they need to go to the next level of care. This is kind of within theater and then intra-theater as well. So CCAT teams can be involved in transporting patients from kind of a forward surgical hospital to an in-theater or higher level of care.

SPEAKER_05 6:02

Thanks. So now we have heard a little bit about what CCAT is and how it helps with transport. Thinking about how to prepare a patient to be transported. What types of things does that team on the ground need to know or need to do to improve the patient's chances of success with CCAT?

SPEAKER_04 6:21

I'll take a stat at this one because we do, we think about this all the time, especially when we're thinking about how we're going to plan for Wisco. You know, historically, you know, patient movement has been non-contested over the past couple of decades, and you can spend time to assess, optimize, you know, as how to scoop and run mission. We've really been able to get the patient the best possible physiologic state to move them. Um we know that may not be the case in a Wisco or a future event. So we are always thinking about how do we, number one, how do we uh mitigate the risk as the critical care providers on the back of the plane with these really sick patients, but also how do we teach those ground teams to best prepare those patients? And some of those things really is just about uh if if they're not doing well on the ground in in some area or in some organ, they're gonna do worse in the air. So if we can, you know, do things on the ground to better optimize them for that patient movement, uh that that will only help us because we don't really have anywhere else to go once we get up there. Diversion is is rather difficult depending on where we are in the world um and where you can safely divert to if you have to get on the ground quickly. That being said, you know, I I talked about these critical care teams being specialized and trained, and most people think, well, it's just ICU in the air, you just take an ICU team out of the ICU and putting them on the back of the plane. But there are lots of things about the physiologic effect of not just the transport for the patient, but the the team. You know, the team that's carried for the patient and all those physiologic stressors of flight, the operational environment, you know, how do you handle electrical and oxygen and and how do you set up all the equipment? It's a very operational environment. So that training is pretty complex and probably as important, if not more important, than the clinical training that we do at the studies. So I'll pause there and see if Jeff has anything he wants to add to that.

SPEAKER_02 8:14

Yeah, I'd agree with what uh Dr. Sam's is saying. It's the key considerations are you know making the patient as stable as you can prior to transport, because yes, we can do the things that would be done in normally in the ICU in the air, but things like procedures are hard. We can do them and we have critical care physicians up there to do those things, but in the back of an aircraft, flying up at altitude can be tough. Um, so keep that in mind. The other thing though is that as Dr. Sam has mentioned, this is a field that's evolving, right? If if the operational considerations are absolutely important for decisions on transport. So it's things that you don't kind of consider in civilian transport or, you know, in peacetime military uh CCAT transport, right? When you have non-operational considerations, you can make a patient as stable as you want and you can just wait until they are stable to transport. But when the situation dictates that you need to make some operational decisions, then you know that's a negotiated conversation between the CCAT team and the uh team in the uh the forward surgical facility. So that's those those are conversations you can have to determine the best place and the best way to evacuate those patients.

SPEAKER_01 9:28

That's a huge point. And both of you, Dr. Sam's and Dr. Anderson, have have highlighted the training, and you had mentioned the certification required for this. As we prepare for these new geopolitical climates in Lisco, with both of you hit on, one of the common themes is readiness. So how do you keep these CCAT teams ready? Are these all at military hospitals? Do you just wait for the next conflict? How is this extensive training and validation system always, as we say in frontline surgery, staying sharp, staying ready to make sure that it's ready to go when needed?

SPEAKER_04 10:00

Yeah, this is a challenge, just like any other readiness platform, you know, sustainment is a problem. It's a gap across the military health system in terms of the military health system is not serving as that sustained platform as it should be. And then you take something that's as operational as critical care air transport, and it's even less relevant in that garrison environment. You know, what it's particularly, and and Jeff can probably comment on this, it's particularly challenging for our garden reserve units, which make up a good number of our CPAT teams, because this requires home unit sustainment training, hands-on with the equipment. This is not your standard ICU equipment. You have to know how to how it works, how to set it up, how to break it down, how to change it out, how to troubleshoot it. Whether it's the ventilator, the monitor, the pumps, the litter with the stanchions and all those things. So if you don't have a good home unit sustainment program, then that is gonna be difficult when you come through to re-verify. It's a it's a re-verification course. So you're gonna come through and verify the first time, and then every three years on active duty, you're gonna come through and verify again just to show us that you're sustaining those skills. And then for Garden Reserve, it's every four because of funding issues. So it is something that we recognize has tremendous skills attrition, and we're not gonna be able to get people more than every three years. What does that mean? Is that when you go back home to your unit, you can't just put that skill up on a shelf and take it out in three years and be able to do it. And we only have you for a limited period of time in the formal training pipeline to get you spun back up on that stuff. So if you don't come clinically sharp and you've let your clinical skills get rusty and you've let your operational skills get rusty, it it's a real challenge. And we're seeing that, and we're seeing uh we're we're finding new ways to help uh with the sustainment part so people come to us a little more prepared and we're doing some multimedia tools. We were able to get some extra funding to get guard and reserve some uh equipment sets to their units, and you know, but it at the end of the day, it comes down to uh service leadership has to allow that training to take place, and it's only gonna get harder as we're less operationally busy. We do a lot of training flights just like pilots do, as we're able. Uh we participate in all the exercises that we can. Uh every exercise there's gonna be CCAT teams out there playing. We also have the ECMO program down in San Antonio, which actually is a big sustainment platform for CCAT. And actually, when you add up all the CCAT missions for that unit in San Antonio, the ECMO team does more than the CPAT unit itself does. So that's another it's but that's only good for San Antonio. So um, you know, these are these are skills that are susceptible to attrition just like any other skill set.

SPEAKER_02 12:38

Yeah, the reserve side's a little bit different. You know, I have, for instance, some of my teams that I have out here in California, and then I came from a unit in Massachusetts. We had physicians, nurses, and RTs who were, you know, working at level one trauma centers in their civilian job that were pretty high um acuity, so had were great on the clinical side. But, you know, in the reserves, we drill one week in a month. So keeping up those military skills, getting hands on the actual equipment that you're gonna use in the and the this the setup and the working in back aircraft was less less common. We found ways to work around that. One is, you know, getting the equipment at your unit, or if you're not at a unit that has like the CCAT equipment, finding a neighboring unit and drill and doing some uh joint drills. And we did that with like some guard units around the region that didn't have us a uh equipment set out. They would come out to our uh base and drill with us in kind of joint mini exercises that we would do. Uh, we got our command to agree to quarterly drills. So instead of going one weekend a month, we went we go for a week every three months, and that allows us to do a lot more sustainment training during those drill weekends because we're there for a whole week. Uh getting on all the exercises you can get on, going to the classes. There's a sustainment unit up in Minnesota for the reserves that does a lot of kind of continuous training that units can be involved with. So there's a lot of ways in keeping up that skill set, but it's it's an active process. It has to be kind of thoughtful and deliberate to maintain those skills.

SPEAKER_05 14:15

Thank you. I think both of you kind of hit on something that was really relevant for me during my CCAT training. And it's that you have to sustain both that operational skills of being able to do the critical care in the air and a broad skill set of critical care expertise, which is more than just trauma care, because it will extend also into that medical ICU component, particularly for contractors and uh local nationals who may end up needing transport. But with that small team of just a doctor, a nurse, and a respiratory therapist, it was easy for one person, particularly the ICU nurse, to become task saturated. And so the biggest learning curve for me was learning how to do the nursing job and learning how to do that RT job, which is outside of what I would ordinarily be doing at a level one trauma center. So I was hoping maybe you guys could comment on that part.

SPEAKER_04 15:10

Yeah, I love that you brought that up, Rachel, because I was looking for a way to slide in what we're doing with this next evolution because the CCAT concept has evolved over the past 20 years as we've learned what the mission require. And as we look forward to Lisco, we know that past saturation, we haven't really been pushed to the level that Lisco is going to push our teams. Um, when you look at nursing ratios and the civilian ICU, you know, two to one at most, uh, we're talking three to one baseline. And now we're gonna go to three to one double because what we're gonna do is add an extra nurse to the team so we can take up six critical patients with one doc, one nurse, two nurses, and one RT. Um but you're right, the test saturation is real. Uh, the more critical these patients are, they've got six or seven drips running, they're on the ventilator, they've got um uh the monitor, that maybe an EVD, maybe they're pneumonia, maybe they're a seizure patient. 50% of what we do is medical, uh, not even trauma care. So you're right, the breadth is pretty immense. And I I would say that for the the cross covering, that's a real thing in all small teams, I think. And it's it's as true in CCAT as it is for any other small team, is you're gonna have to be able to flex and have a little bit of scope expansion to get through that fast saturation. Because you know, trauma surgeons are notorious for just standing at the door and being being the go get me person and putting their hand out. But uh, you know, these teams all have to be firing on all cylinders in their core job, and they also have to have a little bit of capability to flex and help in those task saturation times. And Jeff, I'll toss it over a year.

SPEAKER_02 16:40

Yeah, totally agree. The nurse for sure has the hardest job and they will get task saturated first. The way we handled that, um, a couple of different ways. One, the doc can learn to do a few of the tasks. I would suggest mastering a few of those and not you don't have to, you're not gonna learn all the things that a nurse can do, a critical care nurse, but you can help out with a few of those things, especially during critical phases. So when you're um loading the patient, when you're getting ready to transport off the aircraft, for instance. Uh, it's good to be able to know how to run the pumps, manage some sedation, et cetera. So some of the hang uh hang some fluid. Knowing a few of those critical tasks that are gonna uh offload your nurse is is um is a great strategy. You know, Dr. Sands mentioned the kind of changing complement of the CCAT teams. I can tell you that's happening downrange already, kind of organically. On my last deployment, we had some patients that needed some specialized nursing care. And we had, you know, we had to transport an ECMO patient. So we plused up the CCAT team with an extra nurse to help run that. Same with a patient who's on uh continuous renal replacement therapy. We had uh we plused up the nursing staff for those flights to make it a little bit easier for the whole team.

SPEAKER_04 17:52

Yeah, because the other thing is, you know, these missions, it's kind of like when when I had uh my boss in my last deployment when I was in thromazar. So, well, you know, this only lasts like 20 minutes. I don't know why you guys are so stressed and tired in the morning because he didn't need see the whole process. And CCAT is a process. I mean, it's like the mission planning, then you got to go get the patient, then you gotta package the patient, then you gotta load the patient, and then you gotta take care of the patient and however long that flight is, could be anywhere from a couple hours to 12, 17, 20 hours. Um, and then you gotta offload that patient, hand that patient off uh at the next location. And um, so this turns into like a very, very long mission. We don't get through rest, uh, you know, being on the flight and the physiological stress of the flight, you gotta have the right team compliment to be able to get through that um and be able to sell them.

SPEAKER_01 18:35

And I just want to clarify, because I keep we keep using the term critical care, but you've talked about renal continuous renal replacement therapy. You guys have probably ECMO both times. That is capable, that is within the full capability. I mean, this is not just critical care watered down in the air. This is true critical care capabilities. Is that is that what you guys are describing? There's someone who can go from almost point of care injury, at least close enough, and go back across an ocean with a full critical care in flight.

SPEAKER_04 19:03

We can't do it if we have the plane and the equipment. I will say not all critical care teams are trained in CRRT. You know, that's uh that's kind of a specialized thing. All ECMO teams are. The ECMO teams also are critical care, and the burn flight team, even the Army burn flight team is critical care, air transport trained. So I wouldn't say it's 100%, but um, you have to really organize your mission based on the needs of those patients and make sure you have those capabilities with you. But yeah, we've done renal replacement therapy across the ocean and uh ECMO across the ocean. And uh, you know, we're historically used to going to the ends of the earth with whatever capability it took to get a patient home. And that's what we want to be able to continue to do regardless of the threat.

SPEAKER_02 19:43

Yeah, the CCAT teams can do a pretty wide range of critical care. But as Dr. Sam's mentioned, there are some like sub-specialized critical care teams. So you can ask for the burn team, you can ask for the ECMO team, you can ask for the pediatric team. So there's some, you know, sub-specialization even within CCAT if you need those extra resources.

SPEAKER_05 20:01

So you guys have both touched a little bit on environmental stressors and the stressors of flight. Now, I remember that there is a certain kind of stress to doing a prolonged transport in an adult onesie. But with all seriousness, like what are the environmental stressors and challenges of flight that affect both the crew and also the patients that may be a little bit different than when you're delivering care on the ground? Go ahead, Jeff. I'll let you go first.

SPEAKER_02 20:25

Yeah, there's um several things that come to mind immediately. Fatigue is one. Was mentioned before, these are long missions. So, you know, uh, I can tell you on my last deployment mission set would be, you know, several hours of mission planning, then taking off, flying to the place where the patient is, then packaging them, getting them on the taking them to the airfield, getting them on the aircraft, flying all the way back from where you came from, uh, and then doing the whole thing in reverse. And then you're just stuck somewhere and you're not, your day's not done. You actually got to get home. So these can be marathon days. So just the fatigue of that entire process is real. I think underappreciated before you actually get to do a mission, how long these things actually take. There's temperature considerations. It can get really hot or really cold, depending on where you are and what uh not even just the type of aircraft, but the individual model of that aircraft. That individual airframe can get some of some, like for instance, some C-130s, the heater works really well and some of them it doesn't. And so that's a real consideration for you and for your patients for sure. And if you're talking about critically injured trauma patients, noise. You can't hear anything in the back of the aircraft. Um, so that is just one of your senses that's gone from your assess patient assessment and your ability to communicate with your team. We have, you know, communication systems to communicate uh amongst our team, but those aren't you know foolproof and do break down. And plus, it just is another barrier to uh patient care is that communication. You only have what you brought with you. So you're used to if you're used to working. An ICU and you can, you know, just go to the other floor to get something, you can't do that when you only have what you brought with you. So that's another consideration. Yeah. So lots of things, but the the the the temperature, the fatigue, the noise, those are some of the big ones that and then and then the restricted amount of gear that you have with you. Those are some of the big ones that I think about.

SPEAKER_04 22:21

Yeah, and you know, I talk about all the time. You know, the one thing we can't simulate in the training is the duration of the flights. You know, we only have one three. We can we can't do that to them during the training. We'd never it would take us weeks to get through training. Um and the other thing we can't really simulate, we do take them on a live training flight and try to do that on every class. Um, but you know, for those simulations that they do and they get verified on, we can't really simulate we can simulate the noise in the light, which we do, but we can't simulate that vibration. And that constant vibration on the megaplane is shown to induce a significant amount of fatigue and you're crossing all these time zones and you're up for days sometimes. So you gotta think about that when you're planning these long missions and how how much how many resources you need to take with you.

SPEAKER_05 23:02

Well, I wanna thank you guys both for joining us. Thanks, Val. Thanks, Jeff. It's apparent from this conversation that CCAT is more than just transportation, it's really an extension of the trauma care system itself with the best critical care and critical care capabilities, including ECMO and uh CRRT. And what we've found is that its success is going to depend on an integration between those medics and Ford surgical teams and these in-route care teams, AE teams, and the various evacuation platforms, all the way through to that receiving hospital. So when we think about future conflicts, it is likely that the CCAT teams are going to face even greater operational challenges as these evacuation timelines lengthen and contested environments become the norm.

SPEAKER_01 23:43

Absolutely. And Rachel, we are we are so excited to highlight this uh this avenue of combat casualty care on front lane surgery. We just want to thank Dr. Anderson and Dr. Sands for taking part in this conversation and have showing us how CCAT teams have fundamentally changed the survivability of modern battlefield by bringing high-level, full spectrum, sub-specialized ICU care into the air. Understanding their role helps every military surgeon better prepare patients for the next phase of survival in whatever political or geopolitical climate that may be. And so, as we always say to close out the podcast, until next time, stay sharp and stay ready.

SPEAKER_03 24:20

Thank you for tuning into this episode of Frontline Surgery. We hope today's discussion has provided valuable insights into military trauma care.

SPEAKER_00 24:28

Be sure to join us next time for more expert perspectives and battlefield ready knowledge. Until then, stay ready.