When I met Army private Jamie Salvedo he was being loaded onto our C17 cargo plane at Joint Base Andrews (near Washington D.C.). It had been nearly two weeks since he was injured and almost killed in Afghanistan. This was the last leg of his journey home. He gave me a smile and thumbs up as I introduced myself and did a quick assessment. He had three wound vacs, one each to the amputated stumps of his legs and right forearm. He also had a peripheral IV, epidural PCA, IV PCA, NS infusing through a pump, and a Foley catheter. I asked how he was doing and he struck me completely speechless when he said with a wink "my feet are kind of hot".
Our day begins several hours before flight. Our five-person crew (2 nurses and 3 med techs) will brief on the mission and get the number and type of patients. Based on the patient load we create a positioning plan that is tailored for each flight. After briefing we load our sizeable pile of equipment (about 800 pounds of ACLS and nursing supplies) onto a truck and head to the hospital where the patients are being housed. There, we get patient report, pick up narcs, and head out to the plane to set up. We hustle to put up the stanchions that hold the litters, electrical systems, oxygen lines, and all of our own flight emergency gear. When the patients arrive, they are loaded, secured, and briefed.
Jamie was on patrol with his unit in Afghanistan when he stepped on an IED (improvised explosive device). The explosion blew off both his lower legs and right hand, and peppered him with shrapnel. Jamie was treated in the field by US Army medics who put him in spinal immobilization, placed tourniquets, and started IVs. He was choppered to a field hospital at a US base for emergency surgery. He was then flown to Germany for more surgery and stabilization. After nine days there, he was heading home.
Aeromedical Evacuation (Air Evac) is a large, complex system designed to bring American casualties back to the US and take them anywhere the US military operates. Run by the US Air Force, it transports service members from all branches of the military, their family members, US military contractors, and occasionally foreign nationals. These patients all require in-flight nursing care that is delivered by Air Force flight nurses, flight med techs, and Critical Care Air Transport (CCAT) teams. (A CCAT team has a physician, nurse, and respiratory therapist. They transport ICU patients on the ground and in the air.)
Once our patients have been loaded and assessed for safety and pain levels, they are prepared for flight and all equipment is secured. We give them a briefing similar to that received by anyone who has taken a commercial airline flight. Jamie's PCA pumps are operating normally and his pain levels are acceptable. I know I will need to check his pulse ox especially once we reach altitude. Based on the patient report we received prior to the mission, we have affixed an electrical outlet and an oxygen regulator to the stanchion where Jamie is loaded.
Flight nursing care has a number of considerations not found in most nursing environments. Air Evac utilizes cargo aircraft, which are not ideal for transporting people. They are noisy, hot on the ground, cold in the air, and are by no means considered a "clean" environment. They operate at high altitude, which can significantly reduce available oxygen. Privacy is difficult to provide and resources that are normally taken for granted like medical supplies, oxygen, electricity, and medications, are all in a limited supply. Additionally we have to always consider mission security, manage the patients' luggage, and assist passengers.
Flight nursing training focuses on these "stresses of flight". They are; decreased oxygen, decreased barometric pressure, temperature changes, decreased humidity, noise, vibration, fatigue, and G-forces (AFI 41-307, 2011). These factors impact patients with respiratory issues, cardiac problems, pain medications, closed head or eye injuries, burns, fractures, TBIs (traumatic brain injuries) and others.
As expected, once we reach altitude, I check Jamie's pulse ox and find it to be 81% with him dozing lightly and easily arouseable. I place him on 3L O2 via nasal canula and he is fine at 91%. We now have to complete assessments, take vitals, document, administer pain meds, give scheduled meds, and provide food, water, and toileting. In short- typical nursing care.
In addition to Jamie we have 7 other litter patients, (2 of whom are intubated and cared for by a CCAT team), 11 ambulatory patients, 2 family members accompanying 2 of the patients, 1 medical attendant accompanying a psych patient, and 22 passengers, some of whom are children (the aircraft is not exactly child-proof and we must watch them for safety). It can get pretty hectic, like any nursing shift anywhere.
During flight, one of Jamie's wound vacs is alarming because it has become unplugged and the battery is dying. I can't hear the alarm over the engine noise but I see it during an assessment and plug it in. I reposition him twice during the four-hour flight, empty his Foley and help him eat. He insists on opening his water bottle without assistance using his teeth to hold the cap.
At our first stop in California we off-load about half our patients and take on one new one, but Jamie is continuing on to Washington State. During our stop, with the engines off, I'm able to talk with him more and he tells me about his injury. Newly a triple amputee at 22 years old, I was again humbled by his amazing attitude and outlook. He feels lucky that he will still be able to go fishing, one of his favorite things to do.
After an uneventful flight to Washington State we off-load our patients, give report, secure our gear, and check into a hotel. We will fly back the next day, restock, recharge, and repeat in a few days.
Nursing in flight is full of challenges. One of the biggest is that you can't just head to the supply closet if you need something. If you didn't bring it, you don't have it. It can be as simple as a power cord for a pump. Planning ahead and being meticulous are two important skills. Keeping organized is a constant challenge when you don't even have a flat surface to write on.
The best thing about this job is that these wounded warriors are the most amazing patients! I respect them so much for volunteering to serve their country. They are polite, tough, don't complain, and looking forward to be going home. Most of them display either quiet strength or a bit of bravado, like Jamie. It is truly an honor to take care of them.
(Details have been changed to protect patient privacy but represent real events.)
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