Mobile Medics
Written by Brendan P. Rivers
The ambulance variant of the MRAP
provides protection as well as treatment
for the threats of Iraq and Afghanistan.
When a soldier gets injured during combat, the fastest way to get him off the battlefield and into medical care quickly is usually by medevac helicopter. However, in the current combat situations in Iraq and Afghanistan, this solution is sometimes problematic, with the helicopter under threat of attack by rocket-propelled grenades and often up against an enemy that—let’s face it—isn’t necessarily going to respect the big red cross painted on the chopper.
Enter the combat ambulance—in particular, the recently deployed ambulance variant of the mine resistant armor protected (MRAP) vehicle. Two variants of the vehicle have been produced and fielded in support of both Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom: a smaller, fourwheeled Category I (CAT I) MaxxPro Plus by Warrenville, Ill.-based Navistar and the larger, six-wheeled Category II (CAT II) RG-33 heavy armored ground ambulance (HAGA) by BAE Systems’ Arlington, Va.-based Land and Armaments Group that some have dubbed “rolling ERs” or “ERs on wheels.”
Both are equipped with a medical equipment set (MES), which on the larger HAGA consists of 96 items that come “combat configured” to make it easier for the medic to use.
“It’s ready to go,” said Jaime Lee, a program manager with the U.S. Army Medical Materiel Development Activity (USAMMDA). “Before, medics would get stuff in packets, and they would be configured by the individual medics. Now they don’t have to do that, because they like the way we’ve configured it.”
According to a spokesperson with the MRAP Joint Program Office (JPO), which is responsible for HAGA acquisitions for the Army, U.S. Marine Corps and Special Operations Command, the major subcomponents of the MES are an oxygen-delivery system using oxygen concentrators, an adjustable suction device and a vital-signs monitor. The MES is also split into four categories:
• Care under fire: dismount bags designed and equipped to provide the medic with essential lifesaving capabilities while dismounted from the vehicle and exposed to hostile fire (tourniquets, topical hemostatics, surgical cricothyroidotomy kit and more).
• Tactical field care: an en route care panel onboard the vehicle that provides the medic additional capabilities to address wounds and injuries that aren’t inherently lethal, such as a hypothermia prevention and management kit, sterile dressings and slings.
• Trauma management: a panel that provides the medic higher-level management tools that may be needed during extended evacuation times, including burn-management tools, a hand-operated resuscitator and spinalimmobilization tools.
• Resupply: extra stores of some of the aforementioned equipment.
AT THE CORE
Interestingly, while the MRAP vehicle itself was designed with the threat of improvised explosive devices (IEDs) and explosively formed projectiles (EFPs) in mind, according to Michael Bate, BAE Systems’ acting program manager for the RG-33 CAT II and HAGA, the medical equipment itself has not really been tailored with those sorts of threats in mind, at least not in terms of actually treating the sorts of wounds typically caused by such devices. However, the oxygen-delivery system was changed in response to the IED/EFP threat, going from the older oxygen bottles to the Eclipse 2 oxygen concentrator, developed by San Diego, Calif.-based SeQual. The change was made in part as safety precaution to help reduce the chances of a secondary explosion (oxygen being extremely combustible) in the event of an IED/EFP attack on the ambulance, said USAMMDA’s Lee.
Weighing in at about 17 pounds, the portable Eclipse 2 system works by pulling oxygen from the surrounding air and delivering it in nearly pure form to a patient who is having difficulty breathing. The wheeled unit is also rugged enough to operate in extreme temperatures and environments and needs only its own battery or power supplied by the vehicle to provide a patient with the needed oxygen. The oxygen-delivery system is actually in its second iteration (hence, the 2) because as BAE Systems’ Bate explained, the original “wasn’t robust enough.” According to the MRAP JPO spokesperson, this is also the first time the Army Medical Department (AMEDD) has employed the Eclipse 2 system on its ground ambulances.
Another device that helps form the core of the MES is the Model 326 portable aspirator and suction device, produced by Impact Instrumentation of West Caldwell, N.J., according to Tony Altamore, a sales and marketing coordinator with the company, who said that the device can provide “continuous and programmable intermittent suction.” Built around a small, lightweight vacuum pump, the Model 326 can be used for wound drainage and for thoracic or abdominal decompression procedures. The 12-pound unit can operate off of vehicle power or by using its rechargeable internal batteries for several hours of transport or as an emergency backup.
The third part of the MES’s core triad is the vital-signs monitor (VSM), which the JPO refers to as the Physiological Status Monitor. USAMMDA’s Lee said it “acts as an extra medic in some ways,” allowing the actual medic to tend to other patients until being alerted that his attention is needed elsewhere. Each litter in the MRAP ambulance has its own dedicated VSM, provided by Welch Allyn of, Skaneateles Falls, N.Y., to keep track of non-ambulatory patients’ heart rate, temperature, respiration and so on. The VSM is integrated with the Eclipse 2-based oxygen-delivery system and the Model 326 aspirator and suction device, said BAE Systems’ Bate.
MOVE OUT
Two of the more interesting pieces of equipment are actually in the dismount bags carried by the medics themselves: the Combat Application Tourniquet (or C-A-T), produced by Composite Resources of Rock Hill, S.C., and the QuikClot Combat Gauze, developed by Z-Medica of Wallingford, Conn. In fact, when asked to identify what he would consider to be the real “gee whiz” technologies in the MES, these were the two to which USAMMDA’s Lee pointed.
Composite Resources, along with its distribution partner North American Rescue of Greer, S.C., provides the C-A-T, which, Lee said, is carried not just by medics but soldiers in the field as well. They real key to the C-A-T is that it can be applied with one hand, so a soldier with a wounded arm is able to apply the tourniquet to that arm. It uses a windlass system with a free-moving internal band to provide circumferential pressure to the arm or leg. Once it’s placed on the extremity in the necessary spot and tightened enough, the windlass is locked into place, and a strap is applied to secure the windlass in place to maintain pressure to stop bleeding.
According to Composite Resources, this securing system avoids the use of any additional screws or clips that could be difficult to use under stressful combat situations. The company also touts a 2004 study by the U.S. Army’s Institute of Surgical Research (USAISR) that reportedly showed the C-A-T to be 100 percent effective in occluding blood flow to an extremity in cases of traumatic injury with significant hemorrhaging and to be lighter (at slightly more than 2 ounces) and less painful than eight other battlefield tourniquets tested as part of the USAISR study.
And while a tourniquet may be necessary in extreme situations, Z-Medica’s QuikClot Combat Gauze, USAMMDA’s Lee said, can stop most bleeding without a tourniquet on any part of the body, including (unlike a tourniquet, for obvious reasons) the head, neck and chest. For its part, the company said its Combat Gauze—intended specifically to address the needs of military medical personnel and developed in association with the Office of Naval Research, the U.S. Marine Corps Warfighting Laboratory, and the U.S. Marine Corps Systems Command—uses a special inorganic hemostatic agent, a granulated mineral substance, capable of stopping bleeding in seconds. It works by absorbing water molecules in the blood, leaving the larger platelets and the molecules responsible for clotting in a highly concentrated form, thereby promoting swift clotting and preventing severe blood loss. It is also said to be pliable enough to fit any size or shape of wound, including penetrating wounds, and able to be easily removed once clotting has taken place.
BRING ’EM BACK
Of course, once the immediate needs of the wounded soldier are tended, it’s time to get him off the battlefield and back to base, where he can receive full treatment, or at least be better stabilized and evacuated further. First, though, you’ve got to get him into the ambulance.
Steve Shrout, a contractor supporting the MRAP JPO as a logistician, noted that, at least in the case of the RG-33L, BAE Systems came up with a unique configuration of steps in the rear of the HAGA that allow it to be converted into a ramp for easier access. That’s all well and good if you can actually get up the ramp or steps on your own. For those that are unable to do so, however, each vehicle includes a litter-lift system used for the non-ambulatory that was developed under the now-canceled Future Combat Systems program, according to USAMMDA’s Lee. Both variants employ powered litter lifts that aid the medical crew by mechanically raising and lowering the upper lifter berths.
As Paul Mann, program manager for the MRAP JPO pointed out, “By the time we understood the requirements for a HAGA in Iraq, a lot of the technical work had been done, and there was a lot of information.” Once onboard, the question becomes how to fit as many patients as possible and still carry the necessary equipment and crew. As the MRAP JPO’s Mann noted, “Space, power and weight were key.” The solution for both the MRAP ambulance variants was a reconfigurable litter system in the rear of the vehicle to accommodate varying numbers of litter casualties and ambulatory casualties.
According to the MRAP JPO spokesperson, the Navistar MaxxPro Plus ambulance can be configured by a trained medic to handle one or two litter casualties along with one ambulatory, or it can carry three ambulatory patients, whereas the BAE Systems HAGA can be configured to accommodate up to three litter casualties, or up to six ambulatory; it can also be configured for one or two litters and three ambulatory patients.
A TRUE ROLLING ER?
With all of this equipment, some of it cutting edge, in the MES for the MRAP ambulances, some people refer to the vehicles as rolling ERs. But though they are clearly proud of the MRAP ambulances, government officials generally describe the vehicles more modestly.
“The moniker is earned simply by the fact that ‘protected’ medical care can now be provided at or near the point of an incident,” a spokesperson from the MRAP JPO said. Also, “If the employing unit chooses to staff and equip the ambulance at a higher capability than its intended mission profile, it may in fact be an ‘ER on wheels.’”
The point mostly is one of personnel and doctrine.
“‘ER on wheels’—not sure how it got that name,” USAMMDA’s Lee said. “If the vehicle had a doctor onboard, it has that capability, but that’s not currently the standard operating procedure.” Lee added, however, that “it is much better than a standard ambulance.”
Some Things MRAP Ambulances Carry
• AAA batteries (four packages)
• Oxygen cylinders (four)
• Sodium chloride (one package)
• Bandages, 37 inches x 37 inches x 52 inches (28)
• Bandage kits (22)
• Gauze bandages, 4.1 yards (48 rolls)
• Isopropyl alcohol pads (one package)
• Surgical sponges (two packages)
• Vital signs monitor
• Stethoscopes (two)
• Cricothyrotomy sets (five)
• Oximeter pulse fingers (two)
• Universal splints (eight)
• Blood-fluid warmer (one)
• Easy suction catheter (one)
• Adult sphygmonameters (two)
• Combat tourniquets (14)
• Irrigating syringes (four packages)
• Spineboards (two)
• Oral airway (one package)
• Oxygen concentrators (two or three)
• Survival blankets (six)
Source: U.S. Army
Successor to the M113 Ambulance?
Beyond the ambulances based on the mine resistant armored vehicle (MRAP), might we soon see one based on the Bradley? If Arlington, Va.-based BAE Systems Land and Armaments has its way, we will. The company has developed an ambulance variant of the Bradley, dubbed the Armored Medical Evacuation Vehicle (AMEV), that BAE hopes can replace the M113 ambulances in the U.S. Army’s heavy brigade combat teams (HBCTs).
Several years ago, the U.S. Army Medical Department (AMEDD) had a validated requirement for a Bradley-based ambulance and more recently announced that it was retiring its M113 fleet, some of which are currently serving as medevac vehicles.
BAE Systems has spent its own internal research and development (IRAD) funds to develop a Bradley-based replacement to the M113, which, since the HBCTs already heavily employ Bradleys, would have 77 percent commonality with the units, according to Rick Burtnett, the company’s program manager for the Bradley family of vehicles.
The Bradley AMEV provides 532 cubic feet of mission space, some of which is gained by raising the “back deck” of the Bradley so that a medic can stand up in the rear of the vehicle. Burtnett said that this modified Bradley increases available space by 60 percent over the M113. The company’s current configuration would also allow 28 inches between litters “to allow the medic to get in there and work on patients,” he said, adding that “older ambulances can’t do that.”
As for outfitting the vehicles, Burtnett said much is government-furnished equipment, including the litter-lift system. There’s also what Burtnett called an “enhanced medical package, based on what’s on the M113.” He said the Bradley AMEV is currently equipped with three vital-signs monitors, but he claimed that it could handle four. He also added that two oxygen concentrators are currently part of the prototype mission package.
Paul Mann, program manager for the MRAP Joint Program Office noted that “the need for ambulances is clearly going up.” But an Army source speaking on background added that, operationally, heavier vehicles have worked great in Iraq, where much of the combat is urban, with a solid road system. But with less maneuverability, such heavy vehicles have been more difficult to employ in Afghanistan, where the terrain is rougher and there is less of a transportation infrastructure. ♦
Hope for More Stryker MEVs
Among the 10 different types of Stryker combat vehicles is the Medical Evacuation Vehicle (MEV), which manufacturer General Dynamics Land Systems describes as “either a mobile aid station that keeps pace with the rapid movements of today’s modern forces, or as an armored ambulance that uses its mobility and survivability to whisk casualties to advanced medical clinics.”
Mobility is a key attribute: the MEV can reach speeds of 60 mph or more. Also important is ease of access to equipment inside the vehicle, as well as ease in loading and transferring patients. For example, the MEV features the same type of litter as that used in UH-60 Black Hawk medical evacuation helicopters, “so a wounded soldier can be easily transferred from the Stryker to the helicopter in the same litter, and an empty litter from the helicopter put into the Stryker MEV,” the company noted. An automatic lift system can let medics lower the top litter to load a patient, then move it upward, making the process of loading smoother and less traumatic for the patient.
While Stryker ambulances are being acquired as replacements for older ambulances in the Army’s heavy combat brigades, 118 members of Congress earlier this year in a joint letter sought to persuade the House defense appropriations panel to include funding in the latest supplemental war funding bill of more than the 225 MEVs already funded by lawmakers, The Hill reported. In response to requests that the Army acquire more MEVs, Army Secretary Pete Geren said at the time that it would “consider” the request. Spokespeople for Geren did not response to a request for comment by press time. ♦