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"We were really lucky in that one of our helicopter pilots was a pharmacist who also had some prehospital experience. Before we deployed, he taught several classes on some of the meds we were going to use and was available for any questions while we were deployed. "In Afghanistan, we were doing the tradi- tional flight medic job but were also doing critical care transports from the forward surgical teams (FSTs) on 60–90 minute, or longer, flights with multiple medication drips. The FSTs had a couple of surgeons, a couple of nurses and a few operating room techs. The patients were usually flown out within hours of injury by helicopter to a combat support hospital (CSH) in Bagram or Kandahar. The CSH was the Army equivalent of a Level 1 trauma center. The FSTs did the lifesaving surgery to stabilize patients until they could get to the surgeons at the CSH." In what would later become a key element to show the Army the benefit of paramedic- level training, the flight medics of C-1/168 developed a robust charting system. "We all thought we wouldn't have to deal with charting in Afghanistan and would just do our medical care," Park says. "However, our NCOIC, Rob Walters, insisted upon good charting. We wanted to be able to do QI on our missions. We pulled together the best parts of several different charts to make one that met our requirements and condi- tions. It started out as a paper chart and then became electronic. One of our guys was really good with computers and was able to use an Army system to create an electronic patient care report (PCR). We would do chart reviews of medication usage, medical care, and difficult or challenging patients. It kept us honest. It also stayed in the patient's record so the receiving medical staff knew what care occurred en route." The flight medics in Afghanistan were no longer just treating young soldiers with traumatic injuries. They were treating older contractors with health problems such as diabetes and heart attacks; sick and injured children and elderly civilians; and critically injured patients just out of surgery, on ven- tilators and with multiple intravenous fluids and medications. They were also transport- ing these patients over great distances and caring for them for up to two hours. Lt. Col. Robert Mabry, MD, was a bat- talion surgeon for a special forces battalion that was deployed to Afghanistan in 2005. "I was a paramedic before I became an doctor," Mabry says, "so I knew the level of care in civilian f light programs was very high. That planted a seed that I thought we needed to upgrade the training of the Army flight medics. I went to the doctors in charge of the Army flight medic program and they said there was no evidence there was any- thing wrong with what we were doing." "I was told about an Army National Guard air ambulance unit that had mostly civilian paramedics for its flight medics. The unit was C-1/168. Using their patient care reports, I developed a study to show the outcome dif- ferences when the flight medics were also civilian paramedics. I looked at all the out- comes of the severely injured patients who arrived by helicopter at the large trauma hospitals in Bagram and Kandahar and their survival rate up to 48 hours. "I compared the patient outcomes for the air ambulance unit that served the year before C-1/168, while C-1/168 was in coun- try, and the unit that served after C-1/168 rotated home. The study showed a 66% less chance of dying with the civilian paramedics of C-1/168. That is a big number. I expected maybe a 15% difference, not 66%. This gave the Army the data it needed to make a change in the training levels for flight medics." Upgraded Training The U.S. Army Medical Corps decided to upgrade the training of all current and new f light medics to NREMT-Paramedic and add a critical care transport EMT-P course as well. The new training program began in 2012 and is broken down into three phases. Each phase corresponds to a civilian level of prehospital training using the U.S. Department of Transportation curriculum. Phase 1 is five weeks at Fort Rucker, AL, home of U.S. Army aviation. The medic leaves as a certified Emergency Medical Technician-Basic. They use UH-60 Black Hawk trainers to practice their skills inside the vehicle they will be using. They also use a special tower for hoist training. Phase 2 is the paramedic training. It is a 27-week course through the University of Texas Health Science Center (UTHSC) in San Antonio, TX. It includes 1,054 hours of training with 300–500 hours of clinical time with real patients. It is taught by civil- ian instructors. Phase 3 is an eight-week critical care para- medic (CCP) course. The curriculum is based on the University of Maryland, Baltimore CCP program. It consists of three weeks of didactic training at UTHSC and five weeks of clinical time. The students do their clinical time either at UTHSC or Brooke Army Medi- cal Center (BAMC). Rotations include the operating room for airway procedures, vari- ous intensive/critical care wards, the burn unit, cardiac catheterization lab, neonatal intensive care unit and pediatric intensive care unit, and obstetrics for delivering babies. This phase emphasizes development of criti- cal thinking skills. The final part of the CCP course inte- grates how medics fit into the military medical care system with the protocols they will use in theater for patient care. They also include a veterinarian clinic, since they will be caring for injured military working dogs. The challenge for the Army flight medics versus civilian flight medics is the civilians C O V E R R E P O R T 48 MARCH 2015 | EMSWORLD.com