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Critical Care Air Transport Teams (CCATTs) have evolved as a vital component of the U.S. Air Force’s aeromedical evacuation system. Previous epidemiological research in this area is limited. The objective of this commentary is to highlight the importance of obtaining robust epidemiological data regarding patients transported by CCATTs. A limited epidemiological analysis was performed to describe CCATT patients transported during Operation Enduring Freedom and the waning months of Operation Iraqi Freedom. CCATT transports for the calendar year 2011 were examined as recorded in the U.S. Transportation Command Regulating and Command and Control (C2) Evacuation System database. As many as 290 CCATT primary patient transport records were reviewed. Of these, 58.6% of patients had multiple injuries, 15.9% of patients had traumatic brain injury, 7% had acute coronary syndromes, and 24.8% of all transports were for nonbattle-related injuries. The most common International Classification of Disease, 9th Edition, Clinical Modification coded injury was bilateral lower extremity amputation (40%). Explosive blasts were the top mechanism of injury for patients requiring CCAT. The distribution of injuries and illnesses requiring CCAT appear to have changed compared to previous conventional conflicts. Understanding the epidemiology of casualties evacuated by CCATT during modern warfare is a prerequisite for the development of effective predeployment training to ensure optimal outcomes for critically ill and injured warriors. INTRODUCTION Critical Care Air Transport Teams (CCATTs) are an essential component of the United States Air Force (USAF) aeromedical evacuation system, facilitating transportation of critically ill and injured patients. The capability to transport the critically injured patient in the early days after injury has altered the entire structure of the military medical system, minimizing forward deployed medical resources and allowing transfer to definitive care outside the theater of conflict. Understanding the epidemiology of casualties evacuated by CCATT in modern warfare is essential for developing effective predeployment training and choosing the appropriate equipment to ensure optimal outcomes for critically ill and injured warriors. The post–Cold War environment was characterized by an increase in the scope and complexity of worldwide military operations necessitating “. an agile medical system that could deploy and redeploy rapidly” with a reduced medical footprint. Attaining this capability required an organizational change in the Joint Service casualty management system resulting in the establishment of the USAF CCATT program in 1994. These teams are composed of three specially trained critical care providers: a critical care physician, a critical care nurse, and a respiratory therapist. The critical care physicians’ primary specialty training may be emergency medicine, surgery, anesthesiology, and/or pulmonary medicine, and the nurses may practice in medical, surgical, and/or cardiac intensive care units. CCATTs are tasked to simultaneously manage multiple high-severity casualties, and each team is trained to manage multisystem trauma, burns, shock, respiratory failure, and other serious illnesses and injuries. CCATTs are a high-demand, low-density resource designed for utilization within a full spectrum of operations, including disaster response, small-scale contingencies, homeland security, and major theater war. Limited published data exist regarding the epidemiology of patients transported by CCATTs. Mason et al reported on 133 patients transported from Balad Air Base, Iraq, over a 1-year period. One of the startling findings from this study was a high prevalence of burns (21%), considerably higher than the prevalence of 2 to 10% reported in previous wars. In 2009, Bridges and Evers performed the largest retrospective epidemiologic analysis of CCATT patients to date, reporting on 1,418 patients from Operation Iraqi Freedom/ Operation Enduring Freedom (OIF/OEF). This analysis revealed a high prevalence of traumatic brain injuries, soft *Divisions of Trauma Anesthesiology, Department of Anesthesiology, Program in Trauma, Shock Trauma Center, University of Maryland School of Medicine, T1R83, 22 South Greene Street, Baltimore, MD 21201. †Divisions of Critical Care Medicine, Department of Anesthesiology, Program in Trauma, Shock Trauma Center, University of Maryland School of Medicine, T1R83, 22 South Greene Street, Baltimore, MD 21201. ‡Program in Trauma, Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201. §Center for Sustainment of Trauma and Readiness Skills (CSTARS), United States Air Force, 22 South Greene Street, Baltimore, MD 21201. kAir University, Maxwell Air Force Base, Montgomery, AL 36112-6335. ¶En Route Care Research Center, U.S. Army Institute of Surgical Research, Fort Sam Houston, TX. doi: 10.7205/MILMED-D-13-00474 MILITARY MEDICINE, Vol. 179, June 2014 612 D ow naded rom http/academ ic.p.com /m ilm ed/article-ab/179/6/612/4160803 by gest on 15 M arch 2020 tissue trauma, and burns. Because of this analysis, several troop surges have occurred, and mortality and morbidity rates have changed. The epidemiology reported in these studies suggests different injury patterns compared to previous wars. This is likely due to the changing nature of contemporary warfare, but may also be because of sampling during different stages in an ongoing armed conflict. As the role of CCATTs evolves, continual refinement of predeployment training is vital. The principal aim of this commentary is to use a limited epidemiological analysis of patients transported by CCATTs during OEF, and during the waning months of OIF to understand the distribution of injuries and illnesses and “lessons learned” throughout this period of intense operations. An examination of CCATT data has direct implications for clinical training and medical planning for future conflicts. Understanding the concurrent epidemiology of contemporary utilization may affirm current curricula or provide the impetus for revisions in an effort to improve patient outcomes. METHODS The epidemiology of CCATT patients transported during OIF/OEF was examined using a case series study design that included all transports during the calendar year 2011. All CCATT patients had “stabilizing” treatment in a forwarddeployed medical facility before transport. Definitive treatment was deferred in most cases in accordance with the CCATT paradigm, which is to deliver critically ill patients to definitive care. The primary data source was the U.S. Transportation Command Regulating and Command and Control (C2) Evacuation System (TRAC2ES). TRAC2ES is a web-based system that coordinates the Department of Defense’s movement of sick or injured Service members worldwide. For every patient, TRAC2ES contains data regarding primary and secondary diagnosis codes, as categorized according to the International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM). The ICD-9CM is an adaption of the generalized ICD system used for inpatient data and includes additional morbidity data and procedure codes. In the USAF CCATT program, these codes are assigned to the patient in TRAC2ES before transport. In addition, a mandatory text field is required for CCATT patients containing additional information regarding the patient’s condition, age, gender, mechanism of injury, and in-flight critical care requirements. TRAC2ES data were only examined for the calendar year 2011. Secondary sources were reviewed and data abstracted to compare injury patterns throughout OEF and OIF. Descriptive statistics were calculated. Percentages for the leading causes of injuries were calculated and compared. Means (with standard deviation) and medians (with interquartile ranges) were calculated based on the nature of the data. No inferential statistics were performed. All statistical analyses were performed in Stata Version 11.2 (Stata Corporation, College Station, Texas). The University of Maryland School of Medicine Institutional Review Board determined that this research activity qualified as an exempt study and waived additional review. RESULTS Final analysis of 2011 TRAC2ES data identified 396 CCATT patient transports, representing 290 patients after duplicate transports were removed (patients with multiple CCATT transports). Patients were counted twice only if the primary and secondary ICD-9-CM codes differed from the preceding transport. Median age was 25 years (interquartile range: 22 to 33) and casualties were predominantly male (97.6 %). Table I lists the demographics for this cohort. Army (N = 121) and Marine Corps (N = 79) casualties were the most frequently transported. The 15 most common ICD-9-CM diagnoses in 2011 are listed in Table II. One hundred twenty cases had a single ICD9-CM diagnosis, whereas the remaining 170 cases had multiple ICD-9-CM diagnoses. The most common ICD-9-CM diagnosis TABLE I. Demographic Information for Casualties Evacuated by CCATTs During 2011 (N = 290)