191

The Aeromedical Evacuation

Chapter 13

THE AEROMEDICAL EVACUATION

ALAN L. PETERSON, PhD, ABPP*; KELLY R. MCCARTHY, MA†; DANIEL J. BUSHEME, MA, LCDC‡; RICK 

L. CAMPISE, PhD, ABPP§; and MONTY T. BAKER, PhD¥

INTRODUCTION

EVOLUTION OF MILITARY MEDICAL EVACUATION

A Brief History of Military Medical Evacuation

Aircraft Used for Aeromedical Evacuation

THE DEPARTMENT OF DEFENSE PATIENT MOVEMENT SYSTEM

Aeromedical Evacuation Movement Precedence

Patient Classification Codes for Aeromedical Evacuation

Completion of Patient Movement Records

AEROMEDICAL STAGING FACILITIES

Contingency Aeromedical Staging Facilities

The Ramstein Air Base Contingency Aeromedical Staging Facility

The Andrews Air Force Base Aeromedical Staging Flight

AEROMEDICAL EVACUATION OF PATIENTS IN SUPPORT OF OPERATION ENDURING FREEDOM AND OPERATION IRAQI FREEDOM

BEHAVIORAL HEALTH CONSULTATION FOR MEDICAL PATIENTS

SUMMARY

*Professor, Department of Psychiatry, Mail Code 7792, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, 

Texas 78229; formerly, Chair, Department of Psychology, Wilford Hall Medical Center, San Antonio, Texas

†

Captain, Nurse Corps, US Air Force; Historian, Peterson Air Force Base, 150 Vandenberg, Suite 110S, Peterson Air Force Base, Colorado 80914; formerly, 

Chief, Behavioral Health Nursing Management, Life Skills Center, United States Air Force Academy, Colorado Springs, Colorado

‡

Lieutenant Colonel, Nurse Corps, US Air Force; Chief, Mental Health Nursing, US Air Force Medical Operations Agency, 485 Quentin Roosevelt 

Road, Suite 400, San Antonio, Texas 78226-2017; formerly, Deputy Squadron Commander and Inpatient Mental Health Flight Commander, Travis 

Air Force Base, California

§

Colonel, Biomedical Sciences Corps, US Air Force; Commander, 559th Medical Group, 1920 Biggs Avenue, Lackland Air Force Base, Texas 78236; 

formerly, Commander, 1st Medical Operations Squadron, Langley Air Force Base, Virginia

¥

Major, Biomedical Sciences Corps, US Air Force; Director of Clinical Research, Warrior Resiliency Program, San Antonio Military Medical Center, 

2200 Bergquist Drive, Suite 1, Lackland Air Force Base, Texas 78236; formerly, Element Leader, Mental Health Clinic, 59th Military Health System, 

Lackland Air Force Base, Texas
192

Combat and Operational Behavioral Health

INTRODUCTION

Aeromedical evacuation is the movement of patients under medical supervision to and between 

medical treatment facilities by air transportation.1

 The 

global war on terror has been the largest sustained 

combat operation by the US military since the Vietnam 

War. Almost 2 million US military personnel have 

deployed to support Operation Iraqi Freedom (OIF) 

and Operation Enduring Freedom (OEF). The current 

aeromedical evacuation system used in support of 

OIF/OEF is one of the factors that is credited for the 

greatly improved survival rate for combat-wounded 

personnel in Iraq.2 The current survival rate is approximately 90%, and it is the highest in recorded history; it 

is a significant increase from the 74% to 75% survival 

rate of wounded personnel in the wars in Korea, Vietnam, and the Persian Gulf.2

This chapter will review the aeromedical evacuation 

of patients from military battlefield locations and other 

operational locations, to include the types of aircraft 

used, the functioning of contingency aeromedical staging facilities (CASFs), guidelines and principles for 

evacuation of medical and psychiatric patients, and 

the pertinent military regulations and instructions that 

guide the evacuation process. A particular emphasis 

of the chapter is on aeromedical evacuation in support 

of OIF and OEF.

EVOLUTION OF MILITARY MEDICAL EVACUATION

A Brief History of Military Medical Evacuation

Throughout history many different approaches 

have been used to evacuate combat casualties from the 

battlefield to receive medical care. In the United States, 

the earliest recorded reports of the need for a military medical evacuation system occurred during the 

American Revolutionary War.3

 In April of 1777, the US 

Congress passed a bill recommending that “[a] suitable 

number of covered and other wagons, litters, and other 

necessaries for removing the sick and wounded, shall 

be supplied by the Quartermaster or Deputy Quartermaster General; and in case of their deficiency, by the 

Director or Deputy Director General.”3(p36) However, 

there are no records that indicate that any such vehicles 

were actually built or supplied at that time. 

The first reports of the actual use of a medical 

evacuation system occurred during the American Civil 

War,4 which resulted in many battle-injured patients 

who challenged the military medical community.5 As a 

result, significant changes were made in how soldiers 

were evacuated. During this time, at least 10 different 

designs were proposed for ambulance wagons that 

were to transport sick and wounded military personnel. Dr Jonathan Letterman was the first to create an 

organized system of medical evacuation during the 

Civil War. His pioneering work formed the basis for the 

present military medical evacuation system. President 

Lincoln commissioned railroads and riverboats during 

the Civil War for the medical transport of patients.6

The invention of automobiles was followed shortly 

thereafter by the invention of motorized ambulances 

to transport emergency medical patients.7,8 More 

than 2 years prior to the United States’ formal entry 

into World War I, teams of US military surgeons and 

their support personnel had already been deployed 

to France.9

 The collaboration of military and civilian 

surgeons at the Ambulance Americaine in Paris led 

to the use of ambulances to evacuate injured military 

personnel throughout Europe during World War I.

The invention of aircraft led to evolutionary changes 

in the medical evacuation of military patients throughout the 20th century.10 The potential use of aircraft for 

the medical evacuation of injured military personnel 

was conceptualized in the early 1900s.11,12 Marie Marvingt, a French nurse, was one of the most influential 

and effective proponents for the use of aircraft to 

evacuate the wounded in combat settings.13 In 1913, 

Colonel Samuel F Cody demonstrated the potential 

use of a biplane as an air ambulance at Farnborough, 

England.14 The initial conversion of military aircraft 

into air ambulances by the US Army occurred during 

the period from 1918 to 1924.15 However, the concept 

of aeromedical evacuation of military medical patients 

did not gain widespread acceptance until World War 

II.16 At that time, naval vessels were the most common 

form of transport for movement of military personnel 

to and from the war zone. Ships were also the most 

common means of transporting casualties to the United States for more definitive medical care. However, 

transport by ship could take weeks; there was a need 

to provide faster medical evacuation for more seriously 

injured military personnel. Subsequently, extensive 

use of military aircraft for patient evacuation began 

during 1945 when approximately 625,000 casualties 

(25% of all patients) were aeromedically evacuated to 

the United States.16

The first widespread use of helicopters for aeromedical evacuation occurred during the Korean War.17

Use of helicopters was instituted because of the necessity to move patients rapidly from the battle area over 

rugged and inhospitable terrain. Helicopter evacuation 
193

The Aeromedical Evacuation

led to the successful transport of nearly 22,000 patients 

and is attributed to a reduction in the casualty mortality rate.17 The combat experiences of the United States 

in Korea, the British in Malaya, and the French in Indochina proved that rotary-wing aircraft were invaluFigure 13-1. The UH-60 Black Hawk. The UH-60 Black 

Hawk can hold up to six litters for patient transport and is 

the Army’s front-line helicopter for aeromedical evacuation 

in Iraq and Afghanistan. 

Reproduced from: US Air Force Link photo library. 

www.af.mil/shared/media/photodb/photos/030822-F7709W-005.jpg.

Figure 13-2. The CH-46 Sea Knight. The CH-46 can accommodate up to 15 patients and was used extensively by the 

Marines during the battle of Fallujah in November 2004. 

Here, Marine Reserves—the “Moonlighters” from Marine 

Medium Lift Helicopter Squadron 764, based at Edwards 

Air Force Base, Calif—pause for refueling and servicing by 

the US Navy flight deck crew aboard the USS New Orleans, 

participating in a nine-country training excercise called 

Partnership of the Americas, July 3, 2010. Photographer: 

MSgt Peter C Walz.

Reproduced from: US Marines Web site. www.marines.mil/unit/marforsouth/PublishingImages/

NewsStoryImages/2010/100703-M-3168W-008.jpg.

Figure 13-3. The C-9 Nightingale. The C-9 is the only military 

aircraft that was specifically designed for the aeromedical 

evacuation. Nicknamed the “Cadillac of Medevac,” the C-9 

was the workhorse of medical evacuation. It was phased 

out in 2003. 

Reproduced from: US Air Force Link photo library. 

www.af.mil/shared/media/photodb/photos/021202-O9999G-007.jpg.

Figure 13-4. The KC-135 Stratotanker. The KC-135 is used primarily for air refueling, but it can be configured with patientsupport pallets and used for aeromedical evacuation. 

Reproduced from: US Air Force Link photo library. www.

af.mil/shared/media/photodb/photos/ 060613-F4192W-808.jpg.

able in reducing battlefield death rates.18 During the 

Vietnam conflict helicopters were firmly established 

as an essential component of aeromedical evacuation 

on the modern battlefield.18 Operations Desert Shield 

and Desert Storm involved the deployment of 1,950 

aeromedical evacuation personnel to support medical 

airlift.19 Aircrews were deployed to 17 locations in the 

region and more than 12,500 patients were successfully 

airlifted using converted cargo aircraft.19 The majority 

of these patients were general medical patients and not 

battle-related injuries.
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Combat and Operational Behavioral Health

Currently, the military uses a variety of vehicles 

for transport of patients to include medical ground 

vehicles, nonmedical ground vehicles, watercraft, rail 

transport, and sometimes whatever vehicle of convenience is available.20 However, today virtually 100% 

of casualties requiring transport away from areas of 

insurgent activities or out of the war zone are moved 

by aircraft. 

Aircraft Used for Aeromedical Evacuation

Rotary wing aircraft are the primary vehciles used 

for casualty evacuation from the battlefield. These 

aircraft, in addition to improved body armor and advancements in casualty care, are thought to contribute 

to the increased survival rate that has occurred during 

the military actions in Iraq and Afghanistan.2

The Army and Marines operate most of the rotary 

wing aeromedical evacuation aircraft. The UH-60 Black 

Figure 13-5. The C-17 Globemaster III. The C-17 is the most 

commonly used fixed-wing aircraft for aeromedical evacuation out of the combat theater to military medical centers. 

Reproduced from: US Air Force Link photo library.

www.af.mil/shared/media/photodb/photos/091118-F3431H-513.jpg.

Figure 13-6. KC-10A Extender. The KC-10A is another air 

refueler that can be configured for aeromedical evacuation 

when loaded with patient-support pallets. 

Reproduced from: US Air Force Link photo library. 

www.af.mil/shared/media/photodb/photos/091013-F3140L-112.jpg.

Hawk (Figure 13-1), the Army’s front-line utility helicopter, is used for air assault, air cavalry, and aeromedical evacuation. The UH-60 can hold up to six litters for 

patient transport. UH-60s can travel at high speeds, 

land on rough terrain in remote locations, and evacuate 

most injured patients for emergency department care 

within one hour—“the golden hour”21 of critical importance to casualty survival. The CH-46 Sea Knight (Figure 13-2) is a larger twin-engine heavy-lift helicopter 

similar to the CH-47 Chinook and can accommodate up 

to 15 litters. CH-46s and CH-47s are vital aircraft durFigure 13-7. The C-130 Hercules. The C-130 is the most 

versatile fixed-wing aircraft used for aeromedical evacuation. It can carry up to 70 litters and can operate in austere 

locations.

Reproduced from: US Air Force Link photo library. www.

af.mil/shared/media/photodb/photos/031030-F-9629J-005.

jpg.
195

The Aeromedical Evacuation

ing intense offensive military assaults when potentially 

large numbers of casualties need aeromedical transport 

during a short period of time. The AH-1W Cobra is an 

attack helicopter that often provides in-flight protection 

for rotary wing evacuations.

Fixed-wing aircraft are the primary means of aeromedical evacuation out of theater and from outside the 

continental United States (OCONUS) to the continental 

United States (CONUS) medical facilities. These are 

controlled by the Air Force. The C-9 Nightingale was 

introduced in 1968 and is the only military aircraft that 

was specifically designed for the aeromedical evacuation (Figure 13-3). However, the C-9 was phased out in 

2003 and all medical evacuations now utilize “aircraft 

of opportunity.” The development of patient-support 

pallets has increased the ability of alternative aircraft 

to be used for aeromedical evacuation. PSPs are built 

on a standard cargo pallet that can be loaded onto a 

variety of mobility aircraft. They provide support for 

six litters or a combination of three airline seats and 

three litters. The KC-135 Stratotanker (Figure 13-4) and 

KC-10A Extender (Figure 13-6) are aircraft used for air 

refueling that can be configured for aeromedical evacuation when loaded with patient-support pallets.

The C-17 Globemaster III (Figure 13-5) is the newest and most flexible long-range mobility aircraft. It 

was designed to support aeromedical evacuation as 

a secondary mission. The operational and tactical capabilities of the C-17 aircraft have led it to become the 

primary aircraft for airlift out of Iraq and Afghanistan. 

The design of the C-17 allows it to land on austere airfields. It can take off and land on runways as narrow as 

90 feet and as short as 3,000 feet. It can be configured 

to carry 48 litters and 40 ambulatory patients. The 

C-17s are used to transport patients from theater to 

Landstuhl Army Regional Medical Center in Germany 

to Andrews Air Force Base in Washington, DC. 

The C-130 Hercules (Figure 13-7) is a four-turboprop 

aircraft. First used by the Air Force in the 1950s, it is 

the oldest aeromedical evacuation aircraft. Its versatility, reliability, and capability of operating from rough, 

dirt strips make it an invaluable resource in deployed 

settings. Within theater, the C-130 Hercules can carry 

70 all-litter loads, or a combination of 50 litters and 27 

ambulatory patients. In Iraq, C-130s are often used for 

intratheater missions to Qatar and Kuwait.

The mission of the Department of Defense Patient 

Movement System is to transport US military casualties and other medical patients from combat zones to 

field hospitals or other fixed medical treatment facilities located in or out of the combat theater.22 Medical 

evacuation of military personnel injured in combat 

begins on the battlefield. Patients are assessed and 

treated across echelons of care. After combat life-saving 

care or forward surgical team intervention is provided 

at the initial injury site, the next echelon of care is often 

at an Army combat support hospital or an Air Force 

theater hospital. Navy medical hospital ships, such as 

the USNS Comfort (T-AH 20) or USNS Mercy (T-AH 

19), are also sometimes available as a first echelon of 

care in deployed locations. Patients not expected to be 

able to return to duty within 7 days (or the established 

combat theater evacuation policy standard) will normally be evacuated to the next level of care once they 

are approved for aeromedical evacuation. 

If patients require further evacuation, they are transported by fixed wing aircraft, rotary wing aircraft, or 

ground vehicle to a CASF, where they are prepared for 

aeromedical evacuation out of theater. Table 13-1 includes a summary of primary aeromedical evacuation 

instructions, regulations, and reference guidelines. 

Patient movement is tracked through a computerized system at entry and during transit, and completed 

at exit from the aeromedical evacuation system. Patient 

movement requirements (PMRs; also called “patient 

movement requests” and “patient movement records”) 

are medical requests to transport a patient to a higher 

echelon of care. The US Transportation Command is 

responsible for intertheater patient movement. Patients 

who require intertheater aeromedical evacuation 

are entered into the US Transportation Command 

Regulating and Command and Control Evacuation 

System (TRAC2ES), which allows their movement to 

be tracked by various facilities and the Joint Patient 

Movement Requirement Centers. The Global Patient 

Movement Requirements Center (GPMRC) is an 

organizational element of US Transportation Command that manages patient movement. The GPMRC 

integrates intertheater and CONUS medical regulation 

services, mission requirements, clinical validation, 

and related activities that support patient movement 

requests. Using TRAC2ES, the GPMRC and the Theater Patient Movement Requirements Center receives, 

consolidates, and processes PMRs to coordinate aeromedical evacuation requirements with available airlift 

operations, health service support capabilities, and 

available bed space. 

Aeromedical Evacuation Movement Precedence

When a patient requires aeromedical evacuation, the 

attending physician is responsible for determining the 

THE DEPARTMENT OF DEFENSE PATIENT MOVEMENT SYSTEM
196

Combat and Operational Behavioral Health

Title Publication Date Brief Description

Air Force Policy Directive 41-3 

Worldwide Aeromedical Evacuation

July 29, 1994 Establishes responsibilities and authorities for aeromedical 

evacuation with the Air Force Surgeon General, Air Mobility Command, Air Combat Command, and the surgeon generals of the US Air Force Reserves and National Guard.

Air Force Instruction 41-301 

The Worldwide Air Medical Evacuation 

System

August 1, 1996 Provides an overview of the entire aeromedical evacuation 

process. 

Air Force Instruction 41-303 

Aeromedical Evacuation Dietetic Support

March 27, 1995 Provides guidance and procedures for dietetics departments 

in medical treatment facilities that feed patients in the aeromedical evacuation system during peacetime and contingency operations. 

Air Force Instruction 41-305 

Administering Aeromedical Staging 

Facilities

December 1, 1997 Delineates requirements to set up and operate a contingency 

aeromedical staging facility including staffing and equipment lists. 

Air Force Instruction 41-307, Attachment 6 

Aeromedical Evacuation Patient Considerations and Standards of Care

August 20, 2003 Provides information on nursing care requirements and 

general guidelines for aeromedical evacuation of psychiatric 

patients. Includes descriptions of flight-specific medical 

issues, such as Boyle’s Law. Outlines the special considerations for psychiatric patients. 

Air Force Instruction 41-309 

Aeromedical Evacuation Equipment 

Standards

November 1, 

2001

Provides a listing of approved Air Force Research Laboratory 

and US Army Aeromedical Research Laboratory medical 

equipment, which can be used on fixed and rotary wing 

aircraft. 

Air Force Joint Instruction 41-315

Patient’s Regulated to and Within the 

Continental United States

March 30, 1990 Prescribes uniform procedures and establishes responsibilities during peacetime and contingencies for regulating the 

transfer of patients from overseas to the CONUS, the transfer of patients between uniformed services, VA, or civilian 

medical treatment facilities within the CONUS, and the assignment of beds in VA Medical Centers for members of the 

uniformed services who will require further hospitalization 

or nursing home care after separation or retirement from all 

military services.

DoD Directive 4500.9E 

Transportation and Traffic Management

February 12, 2005 Establishes DoD policy for transportation and traffic management. States that DoD transportation resources should be 

used for official purposes only. DoD transportation resources may be used to move non-DoD traffic only when the 

DoD mission will not be impaired and movement of such 

traffic is of an emergency or life-saving nature, specifically 

authorized by statute, in direct support of the DoD mission, 

or requested by the head of an agency of the government. 

DoD Directive 6000.12 

Health Services Operations and Readiness

January 20, 1998 Establishes patient movement policy and assigns the Commander, US TRANSCOM responsibilities as the DoD single 

manager for patient movement, other than intratheater 

patient movement. The Commander, US TRANSCOM is 

responsible for establishing and maintaining a system for 

medical regulating and movement.

DoD Regulation 4515.13-R 

Air Transportation Eligibility

April 9, 1998 Implements DoD policies governing the use of DoD-owned 

or DoD-regulated aircraft and establishes criteria for passenger and cargo movement. Chapter 5, “Aeromedical 

Evacuation” of DoD Regulation 4515.13-R is used to determine eligibility for patient movement. 

TABLE 13-1 

AEROMEDICAL EVACUATION PUBLICATIONS

(Table 13-1 continues)
197

The Aeromedical Evacuation

DoD Instruction 6000.11 

Patient Movement

September 9, 

1998

Establishes procedures for the movement of patients, medical attendants, and related patient movement items on 

DoD-provided transportation. Addresses the evacuation 

of patients through the Air Force fixed-wing aeromedical 

evacuation system and the medical regulating of patients 

to appropriate locations of care. Establishes aeromedical 

evacuation patient priorities that are used by competent 

medical authorities to classify a patient as a candidate for 

patient movement. 

Joint Pub 4-02.2 

Joint Tactics, Techniques and Procedures 

for Patient Movement in Joint Operations

December 30, 

1996

Delineates requirements and considerations for joint patient 

movement planning. Includes special aspects of special operations and military operations other than war. Describes 

doctrine of the exercise of command and control by joint 

force commanders engaged in all types of operations and 

exercises.

Army Technical Manual MED 289 

Aeromedical Evacuation: A Guide for 

Health Providers (also known as 

Armed Forces Pamphlet 164-4)

November 1, 

1991

Provides guidance to physicians and other healthcare providers who select and prepare patients for transport on all 

types of aeromedical evacuation aircraft. It applies to all 

DoD facilities using the aeromedical evacuation system, 

including Air National Guard and Air Force Reserve units 

and members.

United States Naval Flight Surgeon 

Handbook

1998 (2nd ed) Provides a brief summary of aeromedical evacuation as 

it applies to Navy medical personnel. It includes details 

on patient movement, patient classification, movement 

precedence, and special in-flight considerations regarding 

physicians and patients.

Table 13-1 continued

movement precedence, in accordance with the urgency 

for transport, to the destination medical facility. 

Urgent. The urgent precedence applies when immediate aeromedical evacuation is required to save life, 

limb, or eyesight or prevent complications of serious 

illness. The attending physician is required to coordinate with an accepting physician at the destination 

facility for urgent patients. 

Priority. A priority precedence is used when there 

is the need for prompt medical care not available locally. Similar to urgent cases, the attending physician 

must coordinate directly with the accepting physician 

for priority patients and the goal is to transport the 

patient within 24 hours. 

Routine. The routine precedence applies to all other 

patients. 

Patient Classification Codes for Aeromedical 

Evacuation

A patient classification code is used as a management tool to track types of aeromedical evacuation 

patients. Table 13-2 includes the patient classification 

codes for aeromedical evacuation. Mental health patients are classified in several different categories based 

on their diagnosis and risk prior to being manifested 

on an aeromedical evacuation flight. Attachment 6 of 

Air Force Instruction 41-307, Aeromedical Evacuation 

Patient Considerations and Standards of Care,

23 outlines 

the aeromedical evacuation psychiatric categories. The 

psychiatric patient categories include:

	 •	 Category 1A. This category is for the severely ill 

psychiatric patient who requires close supervision during the entire aeromedical evacuation process. Category 1A patients should 

be transported wearing hospital clothing or 

physical training gear. They should be chemically sedated and restrained on a dressed litter 

during the flight. These patients are required 

to have a medical attendant with a minimum 

rank of E-5 (sergeant). To help ensure patient 

safety, medical attendants for category 1A 

patients must be trained in neurological and 

circulatory checks and the proper use of restraints.

CONUS: continental United States

DoD: Department of Defense

MED: medical

Pub: publication

TRANSCOM: US Transportation Command

VA: Veterans Affairs
198

Combat and Operational Behavioral Health

TABLE 13-2 

AEROMEDICAL EVACUATION PATIENT 

CLASSIFICATION CODES

Code Classification

1 (Psychiatric)

1A Severe psychiatric patient

1B Intermediate psychiatric patient

1C Moderate psychiatric patient

2 (Litter)

2A Immobile patient

2B Mobile patient

3 (Ambulatory)

3A Nonpsychiatric, non–substance-abuse 

patient going for treatment

3B Recovered patient returning home

3C Drug or substance abuse patient going 

for treatment

4 (Infant)

4A Infant or child under 3 years old in bassinette or car seat

4B Recovered infant or child requiring seat

4C Infant in incubator

4D Child under 3 years old on a litter

4E Outpatient under 3 years old

5 (Outpatient)

5A Ambulatory, nonpsychiatric, or substance abuse outpatient going for 

treatment

5B Ambulatory, psychiatric, or substance 

abuse outpatient going for treatment

5C Psychiatric outpatient going for treatment and/or evaluation

5D Outpatient on litter for comfort and/or 

safety going for treatment

5E Outpatient returning on litter for comfort and/or safety

5F All other returning outpatients

6 (Attendant)

6A Medical attendant

6B Nonmedical attendant

	 •	 Category 1B. Category 1B is for moderately to 

severely ill psychiatric patients. These patients 

also should be chemically sedated, wear hospital clothing or physical training gear, and be 

transported on a litter. However, restraints are 

not routinely applied for Category 1B patients. 

A set of restraints must be readily available 

during the aeromedical evacuation flight and 

should be secured to the litter or maintained 

by the patient’s attendant.

	 •	 Category 1C. Cooperative, reliable, and moderately severe psychiatric inpatients traveling in 

ambulatory status are placed in Category 1C. 

These patients may wear their military uniforms and may have a medical or nonmedical 

attendant. They may administer their own 

medication based on the evaluation by the 

mental health provider and flight surgeon.

	 •	 Category 3C. This category is for ambulatory 

patients who are being evacuated for inpatient 

treatment for substance use disorders. These 

patients wear their military uniforms during 

aeromedical evacuation. A nonmedical attendant usually accompanies them.

	 •	 Category 5B. Ambulatory patients evacuated 

for outpatient treatment for substance use disorders are placed in Category 5B. A nonmedical attendant usually accompanies them.

	 •	 Category 5C. This category is for outpatient 

mental health patients evacuated for evaluation or treatment of psychiatric disorders. This 

category is rarely used when transporting a 

patient from the area of responsibility. It is 

more common when patients are transferred 

from Germany (OCONUS) to CONUS locations.

Completion of Patient Movement Records

The Aeromedical Evacuation Patient Record (Air Force 

Form 3899) is used for the initiation of an aeromedical 

evacuation. In most deployed locations, the PMR is 

completed in a handwritten format. A sample PMR is 

included in Exhibit 13-1. The Air Force Form 3899 includes information pertaining to treatment, diagnosis, 

medication, status as an inpatient or an outpatient, and 

the attending physician. Although PMRs are required 

to be signed by an attending physician, in many deployed locations where a psychiatric patient requires 

aeromedical evacuation, a mental health provider will 

complete a draft of the PMR and have it cosigned by 

the attending physician. 

An electronic version of the PMR has recently been 

developed. This form was previously only available on 
199

The Aeromedical Evacuation

exhibit 13-1

sample patient movement request
200

Combat and Operational Behavioral Health

paper, which sometimes resulted in clerical errors or 

loss of information. The electronic version of the PMR 

developed at Landstuhl is automatically populated 

with data from the European Composite Health Care 

System on a daily basis. All aeromedical evacuation 

personnel working at the first geographic CONUS 

sites encountered in patient transport (eg, Andrews 

Air Force Base, Landover, Maryland; the National 

Naval Medical Center [known locally as “Bethesda”], 

Bethesda, Maryland; and Walter Reed Army Medical 

Center, Washington, DC) can access a real-time version 

of the electronic PMR. 

AEROMEDICAL STAGING FACILITIES

Aeromedical staging facilities (ASFs) are medical 

facilities similar to a medical passenger terminal that 

are used to stage patients prior to aeromedical evacuation. Some ASFs are permanent facilities that operate in 

peacetime as well as times of military conflict (eg, ASF 

at Andrews Air Force Base). Contingency aeromedical staging facilities (CASFs) are temporary facilities 

placed at strategic locations to facilitate the aeromedical evacuation of patients. The mission of a CASF is the 

safe medical airlift of combat- and noncombat-related 

casualties from deployed locations to a higher echelon 

of medical care. CASFs operate around the clock to reassess, stabilize, stage, and transport US military medical patients. Other patients are sometimes transported 

through CASFs, including coalition military personnel, 

Department of Defense civilians, and patients engaged 

in humanitarian missions. 

The typical staffing composition of a CASF includes 

60 military medical personnel: 45 nurses, 2 flight surgeons, 6 administrative personnel, 3 mental health 

staff, and 1 individual from each of the logistics, bioenvironmental engineering, pharmacy, and nutritional 

medicine specialty areas. The CASF mental health team 

includes one officer and two enlisted mental health 

technicians. The officer position is usually filled by 

a psychiatric nurse or advanced practice psychiatric 

nurse. However, the specific staffing composition and 

requirements may be modified depending on the location and mission of the CASF. 

Aeromedical evacuation personnel provide medical care and treatment to patients during aeromedical 

evacuation flights according to published guidelines. 

Prior to cosigning the PMR and writing medication 

orders, a flight surgeon must ensure the patient is 

physically stable for flight. The aeromedical evacuation of psychiatric patients includes additional medical 

and logistical issues that must be considered for the 

safety of patients and aircrew members.24 Psychiatric 

patients should be given special consideration and 

attention during all phases of the aeromedical evacuation to safeguard their personal dignity and to help 

ensure respect for cultural, psychological, and spiritual 

values. The overall goal is to use the safest and least 

restrictive measures to control behavior of psychiatric 

patients during aeromedical evacuation. However, 

some psychiatric patients may place the aircraft, crew, 

and other patients at risk. The use of in-flight restraints 

is sometimes necessary for patients who present a clear 

risk to flight safety.23 A physician’s order is required for 

restraints and their use should be limited to cases in 

which there is a clear indication of a flight safety risk. 

Restraints should not be used merely for the convenience of the aeromedical evacuation crew. 

Mental health staff members play an important role 

in advising the flight surgeon regarding the patient’s 

mental health diagnosis, prognosis, and the need for 

aeromedical evacuation for psychiatric reasons. When 

a patient is manifested for aeromedical evacuation, a 

psychiatric category is determined depending on the 

severity of the illness, diagnosis, and mental status. 

It is the responsibility of the CASF mental health 

team to regularly reassess the patient to ensure that 

the assigned psychiatric category is appropriate. The 

CASF staff should alert the flight surgeon if a category 

requires changing or if other modifications are needed 

regarding medications, need for restraints, appropriateness for flight, and need for a medical or nonmedical 

attendant. Almost all mental health patients require 

either a medical or nonmedical attendant prior to entering the aeromedical evacuation system. Nonmedical attendants are usually a member of the patient’s 

military unit and are required to be the same gender 

and of higher military rank. Nonmedical attendants are 

assigned to accompany stable and cooperative mental 

health patients during the aeromedical evacuation. 

Medical attendants can include mental health technicians, mental health nurses, or other medical personnel 

who accompany more severe mental health patients 

during aeromedical evacuation. CASF mental health 

personnel ensure the patient’s attendant is briefed and 

educated on the responsibilities prior to the aeromedical evacuation flight. Furthermore, psychiatric patients 

are often asked to complete a behavioral contract form 

agreeing to comply with aeromedical evacuation system standards.

Contingency Aeromedical Staging Facilities

To provide medical support for operational missions, CASFs are positioned in key locations to facili-
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The Aeromedical Evacuation

tate the aeromedical evacuation of patients. For OIF, 

a CASF was initially established in Baghdad adjacent 

to the Baghdad International Airport. The CASF was 

moved from this location because Baghdad International Airport was converted back to commercial use. 

The 332nd CASF was established at Joint Base Balad, 

which became the primary air hub in the region for 

all US operations. At Balad, about 25% of patients 

are direct transfers from one of several CSHs located 

throughout the area of responsibility. The largest 

proportion of the patients at the Balad CASF is first 

transferred to the Air Force Theater Hospital at Balad, 

where the patients are screened and treated prior to 

transfer to the CASF. A small number of stable patients not requiring medical screening are transferred 

directly to the CASF. Aeromedical evacuations from 

Balad depart for Germany several times per week. 

The frequency of flights depends on the number of 

medical patients requiring transport; more frequent 

flights are arranged when necessary. Critical care air 

transport flights are mobilized for the most seriously 

injured or ill patients who require urgent aeromedical evacuation after initial patient stabilization. The 

critical care air transport team consists of a physician, 

a nurse, and a cardiopulmonary technician, which 

allows ventilated patients to be evacuated. Burn 

patients are often evacuated on these critical care 

transport missions. 

The CASF at Kuwait has a significantly smaller 

mission than the Balad CASF. Patients with less severe injuries or ones who can be adequately treated in 

Kuwaiti hospitals are evacuated to the Kuwait CASF. 

Many of these patients are ones who are expected to 

be able to return to duty in the deployed setting after 

their medical care.

Currently, there is no CASF to support the transport 

of medical patients at Bagram Air Base in Afghanistan. Patients requiring aeromedical evacuation from 

Afghanistan are transferred to Bagram using rotary 

or fixed-wing aircraft. Patients are then transported 

to the CASF at Ramstein Air Base, Germany, on C-17 

aircraft. 

Patients evacuated from the combat zone in Iraq 

and Afghanistan are received at Landstuhl. Once there, 

patients are reassessed and may undergo additional 

surgery or medical treatments prior to aeromedical 

evacuation to CONUS. 

The Ramstein Air Base Contingency Aeromedical 

Staging Facility

The 435th CASF at Ramstein Air Base, Germany, is 

staffed by a contingency of 96 medical personnel. This 

includes two flight surgeons, 18 registered nurses, and 

76 medical technicians and administrative support 

staff. The medical staff is responsible for receiving 

patients aeromedically evacuated from all OIF and 

OEF locations. The ambulatory patients are housed 

in the CASF, which has a 60-bed capacity. Ambulatory patients are transported to CONUS on the next 

available flight. The more critically injured patients 

are transferred via ambulance bus from Ramstein Air 

Base to Landstuhl Army Regional Medical Center. 

Once patients are treated and stabilized at Landstuhl, 

a small proportion of them are returned to duty at 

their deployed location. Most patients, however, are 

medically evacuated to CONUS after treatment at 

Landstuhl. 

Those patients who require CONUS evacuation are 

transported to the Ramstein CASF. Patients are then 

sent to receiving hospitals within CONUS for further 

treatment and disposition. In most cases, patients from 

Landstuhl are first transported to the Andrews Air 

Force Base ASF and then to Walter Reed Army Medical Center. However, patients are also sent to a variety 

of military hospitals around CONUS, depending on 

the medical needs of the patient and the availability 

of medical care resources.

Between March 2003 and March 2007 approximately 

62,000 patients were seen at the Ramstein CASF as 

part of OIF and OEF. About 40,000 of these patients 

arrived at Landstuhl from OIF/OIF, and about 22,000 

of them were transported to CONUS. Differences in 

the inbound and outbound patient numbers reflect 

that slightly less than half of the patients who arrived 

were transported back to theater or to other locations 

through nonmedical transportation methods. Overall, 

battle-injured patients have accounted for about 21% 

of the total number of patients transported. 

The Andrews Air Force Base Aeromedical Staging 

Flight

The ASF at Andrews Air Force Base plays a critical 

role in the aeromedical evacuation process of patients 

during both war and peace. Andrews’ ASF is the first 

stop into the United States for all patients from the 

European theater, OIF, and OEF. The Andrews ASF 

is operated by 31 permanent party members and 33 

augmentees. In addition, the ASF has one marine and 

three soldiers permanently assigned to the unit to assist with the transition of marines and soldiers. The Air 

Force Family Liaison Officer program is also used to 

meet patient needs. To perform their mission, the ASF 

is equipped with six “ambuses” (medium-size buses 

equipped to carry litters), three ambulances, one box 

truck, one step van, and two patient-loading systems. 

On average, each month the ASF assists about 800 
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Combat and Operational Behavioral Health

inbound and outbound patients. 

In Germany, the Joint Patient Movement Requirement Center coordinates with the GPMRC to establish 

CONUS destinations for patients who are grouped 

into mission loads based upon the bed availability at 

Landstuhl and patient care movement requirements. 

Aeromedical evacuation missions are launched three 

times per week from Germany, with other missions 

added as needed depending upon Landstuhl’s capacity or patient acuity. 

The mission operations component of the Andrews 

ASF receives information regarding the mission and 

its patient load. The PMR information obtained via 

TRAC2ES’ Web-based electronic record describes 

clinical information, equipment, staffing, and other 

operational information on every patient. This information is available to Walter Reed, Bethesda, and the 

Andrews ASF at the same time through TRAC2ES. 

The TRAC2ES system is also used in the area of 

responsibility and is the key communication link to 

the Theater Patient Movement Requirements Center 

in Qatar.

A typical mission load is 25 to 30 patients with a 

variety of diagnoses, medical conditions, and levels of 

acuity. These may include critical care, amputations, 

head injuries, psychiatric conditions, cardiac complications, diabetes, and eye injuries. An example of a 

mission package is as follows: “Mission K-6 includes 

12 litters, 17 ambulatory, 4 medical/nonmedical personnel arriving at 1600 hours at Andrews AFB [Air 

Force Base] on Julian date 214.” The mission load is 

further broken down to reveal which patients will be 

transported to Walter Reed or Bethesda, and which 

will need to remain overnight at Andrews prior to 

transport to another medical facility.

During the 24-hour period prior to a plane’s arrival 

at Andrews, much preparatory work is accomplished. 

Rooms are readied, meals are ordered, clinical information is reviewed, the flight line crews are alerted, 

and leaders are notified of mission and other pertinent 

clinical and administrative information.

Three hours before the plane’s arrival, the ASF 

flight line nurse arrives to review the latest information received from Germany on the patients’ conditions after the plane departed. A typical report might 

contain information such as the number of patients 

added or cancelled and reason for cancellation; number of critical care air transport (CCAT) cases; if blood 

was transfused en route; the need for an ambulance 

on arrival; patients with conditions requiring special 

room accommodations or care; family member traveling with a patient; amputee needs for wound wash 

or operating room visit for dressing change; and if a 

psychiatric patient is to be admitted at Walter Reed. In 

summary, to be properly prepared for the arrival of a 

mission, all staff members involved in each aspect of 

Andrews ASF review the latest available information 

regarding vital clinical and administrative information 

before the aeromedical evacuation mission arrives.

Prior to the plane’s landing, transport vehicles from 

Walter Reed Army Medical Center and the National 

Naval Medcial Center (Bethesda, Md) are positioned to 

move designated patients to their respective facilities 

based upon TRAC2ES information and any updates 

and changes from GPMRC. Sometimes patient destinations are changed while the plane is in the air due 

to changes in patient condition, medical capability 

changes, and other administrative reasons. All of this 

is done in the best interest of patient care.

Two hours before the plane’s arrival, all flight line 

personnel report to duty. This usually includes about 

10 personnel from the ASF, Walter Reed, and Bethesda; 

the Army and Marine liaisons; and volunteers. During the first hour, refresher training is conducted on 

the litter carry, and mission planning is performed to 

identify vehicles, drivers, spotters, and other necessary 

personnel. During the second hour, a mission brief is 

given on the latest clinical picture and an ASF flight 

surgeon is present to clarify any clinical questions. 

At the flight line landing zone, the ground crew 

coordinator interacts with the medical crew director 

and loadmasters to arrange the vehicles in the best 

manner to expedite the offload and transport of patients from the plane to the waiting motor vehicles. 

Priority is given to the CCAT patients. Usually, the 

Walter Reed and Bethesda buses are loaded prior to 

the Andrews bus, because they have a 40- to 50-minute 

travel time to their respective hospitals. During this 

transition period, a flight surgeon or other physician 

completes an assessment of every patient onboard. 

The flight surgeon can evaluate, stabilize, and arrange 

transportation for the patient to the emergency room 

at Andrews if needed. 

Once the patients arrive at their designated medical facilities, additional personnel process them based 

on their ward destinations. After treatment at Walter 

Reed or Bethesda, many patients are transferred to 

other hospitals depending on the specific needs of the 

patient. Patients are often transferred to hospitals or 

clinics near their home military station or near their 

hometown once they have become medically stable. 

The time frame for these transfers varies widely. The 

aeromedical evacuation process varies somewhat for 

special patient categories such as burn patients. Brooke 

Army Medical Center at Fort Sam Houston in San Antonio, Texas, is the Department of Defense Burn Center. 

Burn patients are transferred to Brooke as soon as they 

are stable enough for aeromedical evacuation. Some 
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The Aeromedical Evacuation

patients are flown directly to the burn unit from the 

area of responsibility or from Landstuhl.

Patients remaining at Andrews Air Force Base are 

housed in the ASF, which has 32 beds and an expansion capability to 45. The next morning, missions are 

launched to transport patients to their various CONUS 

destinations. Ultimate destinations are determined by 

clinical needs and facilities’ capabilities.

AEROMEDICAL EVACUATION OF PATIENTS IN SUPPORT OF OPERATION ENDURING FREEDOM 

AND OPERATION IRAQI FREEDOM

As of January 2009, there had been over 65,000 

hostile and nonhostile US military casualities in Iraq, 

including over 4,000 fatalities and almost 30,000 

wounded in action.25 About 70% of the wounded 

were treated in theater and returned to duty without 

the need for evacuation for additional medical care. 

However, about 45,000 US military personnel required 

aeromedical evacuation out of Iraq, including about 

9,000 wounded, 9,000 with nonhostile injuries, and 

26,000 with other medical conditions. 

Significantly fewer aeromedical evacuations have 

been required for patients deployed to Afghanistan 

in support of OEF.26 As of January 2009, over 9,000 

US military personnel were evacuated, including 

about 1,400 wounded, 2,000 with nonhostile injuries, 

and 5,500 with other medical conditions requiring 

care outside the area of responsibility. There were 

over 600 US fatalities in OEF during this same time 

period.

Recent publications have underscored the potential mental health impact of the military operations 

in Iraq and Afghanistan on personnel.27–29 Since 2003, 

all personnel returning from deployment complete a 

Post-Deployment Health Assessment.30 A review of 

303,905 of these health assessments showed that over 

19% of soldiers and marines who returned from OIF 

met risk criteria for a mental health concern. However, 

only 18.4% of these “at risk” soldiers were referred for 

mental health treatment. In addition, posttraumatic 

stress disorder symptoms are associated with lower 

general health ratings, more primary care visits, and 

missed workdays among military personnel during 

the year following deployment.31

Several recent journal articles have evaluated the 

aeromedical evacuation of psychiatric patients from 

OIF/OEF.32–35 Turner and colleagues35 evaluated 116 

British military personnel who were evacuated between January 2003 and October 2003 to the United 

Kingdom for admission at a military inpatient psychiatric facility. The majority of the psychiatric patients 

(69%) were noncombatants, and 21% were Reserve 

personnel. A large percentage (37%) had a previous 

mental health history. 

Harman and colleagues32 completed a descriptive 

analysis of 11,183 US military patients who were aeromedically evacuated from Iraq between January 2003 

and December 2003. Of those patients evacuated, the 

most common patient categories were orthopaedic surgery (21.5%) and general surgery (13.3%). Psychiatric 

patients were the third most common patient category, 

comprising 6.9% of all evacuees. 

Two articles reviewed US military patients evacuated from both OIF and OEF. Stetz and associates34

evaluated 5,671 OEF/OIF patients evacuated from 

March 2003 to September 2003. Out of all patients 

aeromedically evacuated, 386 (6.8%) were psychiatric 

patients. Seventy-three patients (19%) were diagnosed 

with psychotic disorders, 242 (63%) were nonpsychotic 

disorders, and 60 (15%) had either DSM-IV (Diagnostic 

and Statistical Manual, 4th revision) V-codes or a deferred diagnosis. About l3% of patients had suicidal 

ideations or self-injurious behaviors. 

Rundell33 conducted the most comprehensive review of psychiatric patients evacuated from OIF/OEF. 

He included data from 1,264 US military psychiatric 

patients who were evacuated to Landstuhl Army 

Medical Center in Germany between November 4, 

2001 and July 30, 2004. The psychiatric patients were 

about 10% of the total population of 12,480 patients 

evacuated to Landstuhl. A retrospective review of the 

psychiatric clinical records was conducted to characterize the demographic composition, clinical diagnoses, 

and clinical dispositions given to the patients. A psychiatrist or clinical psychologist evaluated all patients 

according to a single, standardized clinical process. 

The results indicated that women were twice as 

likely to be psychiatric patients compared to the 

percentage of female medical patients (19% vs 10%). 

Psychiatric patients were more likely to be younger, 

enlisted, Reserve or National Guard members, and 

African-American or Hispanic. The majority of psychiatric patients were Army personnel (86%), which 

most likely reflects the higher proportion of deployed 

Army personnel during that time. About half of the 

psychiatric patients (49%) were evacuated during the 

first 3 months of their deployment. Another third of 

the patients (33%) were evacuated during the second 

3 months of deployment. 

The most frequent psychiatric diagnostic categories 

were adjustment disorders (34%), mood disorders 

(22%), personality disorders (16%), and anxiety disorders (15%). Of the patients diagnosed with anxiety 
204

Combat and Operational Behavioral Health

disorders, 36% were diagnosed with acute stress 

disorder and 29% with posttraumatic stress disorder. 

About 6% were diagnosed with a psychotic disorder, 

4% with bipolar disorder, and 5% with a substance 

abuse disorder.

After psychiatric hospitalization at Landstuhl, most 

patients (81%) were sent back to their home stations 

for outpatient mental health treatment, and 14% were 

transferred to other inpatient psychiatric settings. 

Only about 5% of these patients were returned to 

duty in a deployed location after successful treatment at Landstuhl. The long-term disposition of the 

psychiatric patients evacuated from OEF/OIF is not 

known. However, previous research has shown that 

about two thirds of active duty military members who 

are hospitalized for a mental health condition are discharged from active duty within 2 years of the initial 

hospitalization.30,36

BEHAVIORAL HEALTH CONSULTATION FOR MEDICAL PATIENTS

The primary mission of mental health staff members 

involved in the aeromedical evacuation process is the 

screening and preparation for evacuation of psychiatric 

patients. However, psychiatric patients are usually less 

than 10% of all patients evacuated, and it is known that 

a much larger percentage of patients have had some 

type of combat or other trauma exposure.34

Military personnel who sustain combat-related 

physical injuries are at increased risk for developing combat-related stress disorders. A recent study37

evaluated the relationship between combat-related 

physical injuries and posttraumatic stress disorder 

in 60 combat-injured soldiers. A matched group of 

40 soldiers who took part in the same combat situations but were not injured was used as a comparison 

group. The study found that 16.7% of the combatinjured soldiers met diagnostic criteria for posttraumatic stress disorder as compared to 2.5% in the 

noninjured comparison group. Another recent study 

found that a large percentage of combat-injured 

personnel have a delayed onset of combat stress 

symptoms.38 Almost 80% of combat-injured patients 

who initially screened negative for posttraumatic 

stress disorder or depression at the 1-month point 

after the injury were later found to screen positive 

at the 7-month point. These results suggest that brief 

contact of combat-injured personnel by mental health 

staff during the aeromedical evacuation process may 

be warranted. This may be important even if combat 

stress symptoms are not present at the time of the 

aeromedical evacuation. 

Many locations across the aeromedical evacuation continuum have implemented programs using 

a behavioral health consultation model to provide 

for brief contact and screening of all medical patients 

by mental health staff members. Various versions of 

behavioral health consultation programs are currently 

being used at the Air Force theater hospital and CASF 

at Balad,39 at Landstuhl, and at Walter Reed Army 

Medical Center.40

Brief contact with at-risk medical patients has 

allowed mental health providers to expand their 

role and be actively involved with all patients being 

evacuated for medical or nonpsychiatric reasons. This 

approach has been used successfully in primary care 

settings where many patients have significant behavioral health risk factors or are at risk for comorbid 

psychiatric conditions.41–45 A similar model was used 

with approximately 700 military personnel who were 

deployed to work at the Armed Forces Mortuary at 

Dover Air Force Base, Delaware, to process the human 

remains from the 189 individuals killed in the terrorist 

attacks at the Pentagon.46

The behavioral health consultation model involves 

brief individual consultation with all medical patients. 

The goals are to assess for trauma or combat stress 

exposure, normalize combat stress symptoms, initiate 

positive contact with mental health staff, and describe 

symptoms that might emerge in the future that would 

indicate that follow-up with a mental health provider 

might be helpful.39 It is helpful to provide patients 

with a description of the normal course of traumarelated symptoms and how some symptoms can have 

a delayed onset. 

SUMMARY

The US military aeromedical evacuation system is 

one of the primary contributors to the significantly 

improved survival rate in patients injured in support 

of OIF/OEF. Its ability to transport a patient from point 

of injury to specialized hospital trauma care is currently unsurpassed. The professionals who maintain 

this system continue to make strides to improve safety, 

comfort, and speed. Military mental health professionals play an important role in the aeromedical evacuation of medical and mental health patients from a war 

zone. Mental health professionals are actively involved 

in all aspects of the aeromedical evacuation system, 

including screening of psychiatric patients, making 

recommendations of psychiatric patient category, 
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The Aeromedical Evacuation

preparing patients and attendants for the aeromedical evacuation flight, and providing organizational 

consultation to aeromedical evacuation medical staff. 

Nonpsychiatric medical personnel often have little or 

no experience in working with severe psychiatric cases. 

The placement of mental health professionals as part 

of the aeromedical evacuation system is a significant 

relief to medical staff. 

The Department of Defense patient movement and 

aeromedical evacuation system involves a complex 

interaction between patients, healthcare providers, patient movement administrators, aircraft, and computer 

tracking systems. In this chapter, an overview of the 

entire aeromedical evacuation process was provided 

with as much accuracy as possible. However, as with 

many complex systems, changes in the aeromedical 

evacuation process occur on a regular basis depending on local conditions, operational requirements, and 

changing priorities. Therefore, it is likely that some of 

the specific details contained in this chapter may have 

changed since the time that the chapter was written. 

Nevertheless, it is hoped that this chapter will serve 

as a general guide for the military aeromedical evacuation system and a helpful tool for military personnel 

involved in the aeromedical evacuation of patients in 

both deployed and nondeployed locations.

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