Even in exercises with simulated entities and weapons effects systems, the real world often intrudes. Tragically, on the morning of May 21, 2014, the commanding officer of the 2nd Regiment, Royal Canadian Horse Artillery (RCHA) was killed and four members of 2 RCHA were injured when their light armored vehicle rolled during a training scenario on Exercise Maple Resolve in Wainwright, Alberta. Two of the injured soldiers were airlifted by military helicopter to civilian medical facilities in Edmonton, while two others were treated by Canadian Armed Forces (CAF) medical personnel at the garrison.
More recently, in 2021, a soldier was medically evacuated from the Wainwright training area to an Edmonton hospital after a CH-147F Chinook experienced a hard landing during the same annual exercise. The airlift was conducted in a UH-60 Black Hawk helicopter by air medevac personnel from the Wisconsin Army National Guard who were participating in the exercise.
Casualty evacuation is a regular feature of Ex Maple Resolve, the Canadian Army’s largest annual confirmation training event. Scripted scenarios will feature individual injuries and even mass casualties to which army medical technicians and Canadian Forces Health Services (CFHS) personnel will respond, transporting the wounded by ground or, with the support of Royal Canadian Air Force (RCAF) tactical aviation, by air to actual and simulated field hospitals for treatment.
Sometimes, however, reality interrupts the virtual. A “no duff” incident will pause the exercise and require the immediate extraction of an injured participant to a local hospital.
In past iterations of Maple Resolve, those U.S. National Guard Black Hawks or a contracted civilian air ambulance service, such as Calgary-based STARS, might have provided the evacuation. For Maple Resolve 2023 and a lead-up live fire exercise called Reflexe Rapide, the RCAF and the CFHS opted to develop an internally delivered forward air medical evacuation capability.
“1 Canadian Air Division wanted a solution that is similar to civilian air ambulance, that would have the medical vetting piece at activation and at the point of injury,” explained Major Andrew McLaren, a Reservist with 1 Canadian Field Hospital’s Ottawa Detachment. “So, treating and moving a patient with critical injuries to a civilian centre and being able to land on a roof top, right away, that is not a [CH-147F] Chinook.”
To support the United Nations peacekeeping mission in Mali, the CAF built and validated a forward medical evacuation capability known as the Canadian Medical Emergency Response Team (CMERT) and deployed it for 13 months in August 2018.
Though designed as a scalable response for medevac in conflict zones, its primary configuration consists of 13 personnel, including a medical component of a flight surgeon or trauma doctor, critical care nursing officer, and two aeromedical technicians. The team also includes a force protection detail of four infantry soldiers able to provide medical assistance on the ground and in the aircraft, as well as a Chinook air crew of a pilot, co-pilot, two door gunners, and a loadmaster. Often, the medical ship is escorted by one or more CH-146 Griffon helicopters.
The requirement for Maple Resolve was a nimbler and less personnel-intensive footprint.
McLaren, an intensive care unit trauma doctor and part-time paramedic in Nanaimo, British Columbia, who also works with Blackcomb Helicopters’ medevac services as a mountain doctor at Blackcomb-Whistler, was tasked to advise and help stand up the medical component of a patient evacuation capability in the considerably smaller cabin of a Griffon. Were there effective cabin configurations to access both patients and medical equipment, with a medical team of just a doctor and medic, while incorporating a novel blood supply chain?
Though the initial goal was a capability for a permissive environment, such as the Wainwright training area, it was also understood he would be demonstrating a capability that could be “amplified and propagated into a non-permissive environment” such as Latvia, where the CAF is in the process of scaling a Canadian-led multinational battle group to a full-strength brigade and considering the deployment of tactical aviation.
“There is a lot of interest in this,” McLaren noted.
Whatever the strategic decisions about possible future deployments, Ex Maple Resolve “showed what is possible” with an advanced medical package in a small footprint that can be “integrated with a local health care system” or military care such as a Role 2 field hospital, he said.
“We can move a ventilated patient, a patient that is fully anesthetized, or have ongoing damage control resuscitation [DCR] that includes blood product,” McLaren said. “That is a unique part about this, and people are thinking about how we could apply it in a different, non-permissive environment. There are a lot of eyes-on as to what can we take from this to create a true capability.”
McLaren was a part of the initial CMERT rotation deployed to Mali in 2018 as a medical specialist and drew heavily on how that capability was developed.
“We have pulled what we needed from CMERT, including a lot of the equipment,” he said.
Like CMERT, the Griffon-based enhanced forward air medical evacuation falls in the dynamic middle on the spectrum of pre-hospital care — shifting when needed between a system where rotors stay hot as patients are loaded and only minimal care is provided at the point of injury and in flight, to a stay-and-play scenario. This is similar to when a civilian air ambulance might land on a highway, shut down the rotors, and provide advanced level care before loading and transporting a patient to the “right hospital, not necessarily the closest hospital,” he explained.
Forward air medevac requires judgement and high stakes medical decision-making at an advanced level, in a mobile setting that directly connects a trauma doctor and a medic pushed far-forward to the point of injury. “That is rare in the military and Canadian civilian prehospital care system, generally,” he observed.
To ensure best access to patients, McLaren configured the CH-146 cabin to cross-load stretchers, rather than laying them nose to tail as might have previously been standard practice in a similar sized helicopter. That allows the medical team — the doctor on the left and medic in the middle or right — to sit on forward facing seats, with the patient at their feet.
“Cross-loading and putting the patient in front of the attendant allows us 360-degree ‘walk around’ — you can reach all sides of the patient and get to all injuries,” he said. “If trouble is in the left chest, I can still squeeze in there and deal with that.”
Most of the medical equipment, including ultrasound, suction, a blood warmer, an oxygen tank, two monitors, as well as airway and chest decompression tools and other supplies, are in easy-access Velcro pouches attached to netting hanging directly behind the cockpit and in front of the stretcher. Behind and to the left of the doctor are a ventilator, extra stretcher and an extra oxygen tank.
The configuration, which required extensive certification to ensure air worthiness, allows “me to deal with the whole patient and have all of the equipment visible and grabbable, so I’m not reaching around in bags,” said McLaren, who worked for a period with London Air Ambulance in the United Kingdom, as a trauma doctor in the back of an MD 902.
Working with Canadian Blood Services, McLaren transported whole blood in a Credo Cube for the exercise, a rarity in Canadian civilian trauma response. Hospitals fractionate whole blood into red cells, plasma, platelets and clotting factors so a single donation can help multiple patients. It takes significant time even in a trauma hospital to reconstitute multiple cooled and frozen blood products required for trauma resuscitation.
“Whole blood has not been used for many decades in Canada, in hospitals or ambulance,” he said. “But with whole blood, I can take that half liter bag, hang it up, run it through the warmer, and it is going into the patient within minutes” — critical for soldiers with severe wounds.
As with CMERT, where the Army’s four-soldier force protection detail has been trained to assist with medical care once the Chinook is airborne, the Griffon’s flight engineer (FE) can also support the doctor and medic in extreme situations.
“We have done some simulations right at the most extreme end of the medical care,” McLaren said. “If someone went into cardiac arrest, we can pull the FE forward to do CPR or hold something. They would have a role at the most extreme end of the spectrum, but not routinely, I hope.”
Throughout Maple Resolve, McLaren, two CMERT-trained medics, two forward aeromedevac (FAE)-trained medics, two support medics, and the Griffon aircrew conducted static and dynamic training almost every day. They trained in the hangar and on the helicopter, building best practices and establishing communications protocols, especially for managing fuel when duration on the ground and the correct hospital destination were often unknowns.
They also trialed cabin configurations that would allow for multiple patients and additional medical technicians that could be “injected” into an incident to provide additional ground support while the Griffon, with McLaren and one medic, transported one to two patients to hospital.
How a CH-146 would be configured in a non-permissive environment where both door gunners are required and doors are open is part of an ongoing discussion, he said. “I imagine as guns are added, as doors come off, the amount and kind of medical care you can provide contracts.”
Fortunately, the nascent capability was never required during the five weeks of Reflexe Rapide and Maple Resolve, despite multiple near-misses. There were injuries to participants, and on occasion, rotor blades began to whirl. But the final call to respond was never issued, a fact McLaren attributed in part to a thorough medical vetting process.
“Maybe that is one of the most valuable things,” he suggested. “If an incident automatically triggers a helicopter and 90 percent of those patients don’t require it, it’s all risk and resources burning. I’ll hypothesize that we have gone to the point of injury less because of the medical vetting — you have three experienced trauma doctors involved in real time, [assessing the injuries and the response]. We want to reserve and maintain our availability for the people who are going to benefit from it the most.”
As a deployable forward air medical evacuation capability, “this is the developmental stage of it,” McLaren said. “It’s not a fully hatched baby. There are some gaps in physician and med tech training and availability, to enable a standard and reproducible trauma team response to the point of injury.”
But if such a capability were required by the brigade in Latvia, there is a well rehearsed template to draw from.
