The U.S. Army Burn Flight Team has transported patients twice from Singapore back to the U.S. Army Institute of Surgical Research at Joint Base San Antonio – Fort Sam Houston, Texas, and both flights resulted in record-breaking missions.
The Burn Flight Team is a five-person team that flies burned military personnel from anywhere in the world back to the USAISR Burn Center, which is the only burn center servicing the Department of Defense. A team consists of a burn surgeon, a critical care registered nurse, a licensed vocational nurse, a respiratory therapist and a forward operations noncommissioned officer. Four teams rotate call, so that two teams are always ready to deploy.
The team’s first mission to Singapore, on Feb. 22, 2013, was the longest nonstop flight in the team’s history. Because of the patient’s critical status, the Air Force critical care transport team operating the C-17 Globemaster III refueled inflight, allowing the Burn Flight Team to get the patient to the burn center as soon as possible.
“They have a hook up in the front, and then a little fueling plane flies ahead and lets out a little cable, and they have to connect them,” said Sgt. Matthew Anselmo, NCO in charge of the burn team. He is a respiratory therapist who worked as the rear operations NCO for that particular mission.
The team flew for 19 hours straight over 9,850 miles to bring the patient home. As the Burn Flight Team is not part of the plane’s crew, they are not afforded crew rest. But the team members said they didn’t mind the exhaustion. Getting their fellow service member back home safely was the only thought in their minds.
The second and only other time the flight team transported a patient from Singapore was Nov. 9, 2015. This flight also resulted in a record-breaking mission, but for a different reason. It was the first time the team used a kidney dialysis machine to provide continuous renal replacement therapy inflight.
The patient, a Marine who had suffered severe electrical and thermal burns, was experiencing kidney failure, and would not have survived the flight without the procedure, said Staff Sgt. Daniel Zimmerman, the NCOIC of the team at that time and the respiratory therapist on the flight.
Continuous renal replacement therapy, or CRRT, is similar to regular dialysis in that it removes blood, filters it and then replaces it back in the body. It is different, however, in that it is a slow, continuous process. Because CRRT pulls blood at a slower rate, it does not disrupt the patient’s hemodynamics.
“Without CRRT, that patient would have had to stay at that remote hospital, being treated in another country,” said Staff Sgt. David Shelley, a licensed vocational nurse and assistant NCOIC of the flight team. “So the medical director decided we needed to do what it takes, get this service member to the best place in the military to treat burns, and we made it happen.”
“We are always ready,” Zimmerman said. “I was the NCOIC at the time and the only respiratory therapist on the team, so I was basically on call for two years straight. When you get that call, it’s exciting.”
And this time, the team members knew the flight would require them to use equipment they had never before taken on a flight. The team now considers CRRT part of its capabilities and has dedicated transport equipment, but on that flight, the team used equipment from the intensive care unit.
“Everything went as planned in so much as we had never done the CRRT before,” Zimmerman said. “We weren’t sure what complications we were going to run into, but it was overall a pretty uneventful flight, and that is definitely a success.
“Every successful mission comes with a very rewarding feeling,” he said. “To go pick up a critically injured service member who really needs attention that they can only get in the ISR in our unit, to be able to get them back here safely and see them get better — it is a very rewarding feeling.”
Noncommissioned officers play a crucial role on the U.S. Army Burn Flight Team, which is prepared to fly any time, anywhere to transport burned military personnel to the U.S. Army Institute of Surgical Research Burn Center at Joint Base San Antonio – Fort Sam Houston, Texas.
During the height of the War on Terror, the flight team would routinely meet injured service members at Landstuhl Regional Medical Center in Germany. Since the drawdown of the war, however, flight team members will tell you that the frequency of calls has slowed significantly and that every mission is unique.
Since the 1950s, the team has successfully transported service members suffering from both combat- and noncombat-related burns back to the United States from far-off locations including Honduras, El Salvador, Argentina, Norway, Japan, Korea, Guam, Vietnam and Singapore.
“As soon as we get notice of the mission, the team pulls together,” said Staff Sgt. David Shelley, a licensed vocational nurse and assistant NCO in charge of the flight team. “We want to get there as fast as possible and make sure we have the ability to take care of that service member. There is just that drive to make sure everybody comes home safely and gets the best care possible.”
Roles of the NCO team members
The flight team is composed of active duty Soldiers and DA civilians who work daily in the Burn Intensive Care Unit at the U.S. Army burn center, which is the only burn center servicing the Department of Defense.
A team consists of one burn surgeon and one critical care registered nurse, both officers, and one 68C licensed vocational nurse, one 68V respiratory therapist and a forward operations NCO. A rear operations NCO also assists the team from Fort Sam Houston. Four teams – about 20 personnel – rotate call, so that two teams are on call and deployable at all times.
Both the vocational nurse and respiratory therapist positions are filled by NCOs. The vocational nurse provides wound care to the patient during the flight and works closely with the surgeon and other nurses, while the respiratory therapist manages the ventilator and everything related to the patient’s airway and lungs.
“The nurses and doctors are all concentrated on wound care and the other aspects of the patient’s health, and we (the respiratory therapists) are pretty much on our own there,” said Sgt. Matthew Anselmo, a respiratory therapist and NCOIC of the flight team. “We manage our ventilators. If the pressure changes, we change the ventilators as we see we need to. We are the only ones who can manage the ventilators as we do. Nurses and doctors are trained on basic ventilator management, but [respiratory therapists] are really needed in this situation because of the specialized equipment and circumstances.”
The forward operations NCO, usually either a vocational nurse or a respiratory therapist, is responsible for getting the team from point A to point B and makes sure all of the equipment traveling with them gets there and back. The rear operations NCO stays behind in San Antonio to act as liaison between the flight team and the Institute of Surgical Research leadership during the mission. The rear operations NCO is also responsible for providing the team with logistical support during the flight and arranging transportation from the airport for the team and the patient once they return. The forward and rear operations NCOs work together to make sure the team has everything it needs and to ensure the logistics of the mission run as smoothly as possible.
“The forward operations NCO is really coordinating the entire movement, and they are responsible for accountability and really every aspect of the team’s movement from when we leave here in San Antonio to wherever we arrive, getting to and from the hospital and getting back,” said Staff Sgt. Daniel Zimmerman, a respiratory therapist. “The forward ops and rear ops are constantly dealing with all levels of command. Some of our missions are very high visibility; sometimes they go all the way to the Secretary of Defense for approval. Communication is key to our missions, and the operations folks have to handle all of that.”
The team’s NCOs are offered frequent opportunities to use their leadership skills in unique ways, Zimmerman said. The NCOIC in particular is responsible for training and teambuilding exercises for a team of mostly officers, and all of the NCOs are involved in setting up that training to make sure the team stays current on certifications and is familiar with the different types of equipment they may need to use.
“The NCOIC is responsible for the training and the readiness of this team that is mostly officers,” Zimmerman said. “It can definitely be challenging to have influence over people you really don’t have authority over. So it is definitely about tact and mutual respect, team building, gaining the confidence of everyone. Everyone on the team is very professional. It normally runs pretty smoothly, but it can be intimidating.”
Bringing them home
Team members have regular jobs providing daily care to patients at the hospital. But once they get that text message notifying them of a mission, they have two hours to be ready to fly. The forward and rear operations NCOs quickly get to work arranging transportation, because their goal is to have the team in the air within six to eight hours.
The five-member team travels to the patient’s location on a commercial flight, bringing with them eight large cases of specialized equipment, each weighing about 70 pounds. The forward and rear operations NCOs coordinate with the Air Force through the Theater Patient Movement Requirements Center to arrange the team’s travel back on the nearest C-17 Globemaster III, which is operated by an Air Force critical care air transport team.
“You fly there, you have all of this adrenaline, excitement, nervousness, going through the steps A, B, C of what you need to look out for on this particular patient,” Shelley said. “We get an outlook of what the patient’s picture is, so we always have that in the back of our minds. It’s important to try to calm yourself down and get the rest you can get, because there will be no sleep on that long flight back.”
As soon as the patient is ready, they begin the journey home.
“I think the biggest feeling we have once we leave ground is of being … alone,” Anselmo said. “You know, once you are in the air, it’s your team. That’s all you’ve got. There is no one else who can help, especially when you are over the ocean.”
Because of that, the team is prepared for anything and everything to go wrong. Elevation affects patients’ blood pressure levels and airway pressures, and any movement brings some sort of risk. The team monitors all of those things as well as the patient’s hydration and temperature, which are key to the healing process.
As soon as they land, they are met by the rear operations NCO and other team members who were not on the mission to help load the patient into the ambulance and then get the equipment back to the hospital, break it down, clean it, restock and make sure everything is ready to go again.
Getting into this line of work
Shelley initially came into the Army as a 68W combat medic. Anselmo began as a 19K M1 armor crewman. Both of them, like many of their fellow NCOs, changed their MOSs and were eventually assigned to the Institute of Surgical Research.
“As soon as I found out I was coming here, one of my main goals was to get on the flight team,” Anselmo said.
A year of experience in the Burn Intensive Care Unit is required for vocational nurses and respiratory therapists to be considered for the flight team. Both Shelley and Anselmo said it takes a lot of work to ensure you have the needed capabilities.
“For example, we use different ventilators up here that really no conventional ICU would use, so it takes a lot of training,” Anselmo said. “It just works with pressure – it doesn’t give you any numbers, so you really have to know what you are doing with it before you take it in the air.”
All of the extra work is worth it, Shelley said, because working closely with a small group like this is an opportunity unlike any other.
“To have such an impact around the world for fellow service members is amazing,” Shelley said. “That’s why I got into the medical field – to help other service members, and it’s been great to be there in their critical time of need and to provide such a high level of care at the top of my scope of practice.
“I hope other NCOs learn that the Army has this type of capability,” he said. “Respiratory therapists and vocational nurses – or even medics looking to become one of those MOSs, if this is the route that they want to go, they should work hard to hone their skills in a critical-care sense. It’s an amazing chance to grow as a leader and as a clinical expert. They will have to work hard, but the opportunity is here.”
The U.S. Army Institute of Surgical Research Burn Center at Fort Sam Houston, Texas, is the military’s only burn facility, as well as that for the civilian population in the San Antonio area. For the burn victims who become patients for life – coming back years later for follow-up treatments or surgeries — NCOs are a vital part of the team that provides individualized care for each of them.
NCOs who are licensed vocational nurses, nutritionists, interns, and physical, occupational and respiratory therapists work together to help each patient reach their highest level of functioning, often returning Soldiers to the jobs they were trained to do.Depending on the severity of a burn and the overall health of a patient, some burn victims may remain in the hospital for more than a year. Others may only require a few days. As a general rule of thumb for those with partial- to full-thickness burns, a day of hospitalization will be required for every 1 percent of the body that is burned, said Steven Galvan, the public affairs officer for the U.S. Army Institute of Surgical Research.When a patient first arrives, he or she is evaluated by a therapist and often starts therapy from day one. Therapists work closely with patients seven days a week until they are able to function on their own and transition to outpatient status.
Staff Sgt. Mike Calaway, the NCO in charge of Outpatient Burn Rehabilitation, said one of the keys to patients’ progress is a seamless transition from their life as an inpatient to the routine of living at home and making frequent visits to the center for therapy.
“They do so much on the inpatient side, and we know exactly where they are in their recovery when they come to us. So we don’t let them skip a beat,” Calaway said. “I’ve seen some amazing progress. We have a patient right now who is recovering from nerve damage; his nerves are waking back up. His progress is amazing. This is really aggressive therapy. Just keeping on top of it as they move from the inpatient side to the outpatient side, that’s the big thing.”
Calaway noted the quality and professionalism of the burn center’s highly trained staff. The burn center is the third Army medical center in which Calaway has worked, and he said the work environment is truly unique, with therapists in different specialties working closely as a team to treat each patient.In many hospitals, the two departments complement each other but operate separately. Physical therapists usually focus on helping patients regain mobility, while occupational therapists work with patients to perform basic tasks independently. But at the burn center, Calaway said, occupational and physical therapists work hand-in-hand to provide co-treatment every single day. One knows the other’s job, and physical therapy technicians will often work directly under an occupational therapist, or vice versa.“There is a lot of care and training that goes into the team that I work with here,” Calaway said. “For me, that’s what sets us apart from any other medical facility: the professionalism and the care provided by the techs all the way up to the doctors.
“You don’t see that at other places — nurses, physical therapists, occupational therapists, surgeons, nutritionists — every single part of the team working together every single day. They know each other very well, each knows the patient very well, and everybody contributes to the treatment and care of each patient.”
Sgt. 1st Class Hugo Roman, the NCOIC for burn occupational therapy, and Sgt. 1st Class Russell Gilmore, the NCOIC for burn physical therapy, said their departments and others within the burn unit work as closely as possible to provide patients with the best care.
“We have all the parts working together here to provide the most complete care,” Gilmore said. “We have our own operating room, our own respiratory therapists, our own doctors and nurses — everything specifically for the burn patients. Dieticians, operating room staff, nursing staff, research, you name it.”
In addition to the team of health care providers at the hospital, the burn center has a flight team prepared to fly at a moment’s notice to Afghanistan, Singapore, Germany or anywhere else in the world where there is a burned or critically injured Soldier and transport him or her to the burn center in San Antonio.
The five-member team, usually composed of a burn surgeon, nurses, a therapist and a supporting NCO, leaves San Antonio on a commercial flight. The team then coordinates with units caring for the patient at their destination, often synchronizing efforts with Marine Corps, Air Force and Navy personnel to provide a seamless transition onto the aircraft that transports them back to San Antonio. The flight team provides constant care in-flight, and lands on a helipad on the roof of the burn center, where a team meets them to bring the patient directly into the intensive care unit or the operating room.Though it typically takes from 3 to 4 days from the time of injury to a patient’s arrival at the burn center, the team recently completed a mission within 39 hours, Galvan said. No matter how long the trip takes, however, the team travels with all of the equipment it would use in the intensive care unit, allowing the team to provide nonstop care.“There are so many roles of an NCO on the flight team, and all are vital to mission success,” said Staff Sgt. Seth Holland, NCOIC of the burn flight team.
As NCOIC, Holland counsels team members on the expectations placed on them. He conducts training, enforces standards, and maintains logistics and equipment, in addition to stepping in as the operations NCO as needed.
“Various specialties work together to care for these patients as we bring them back from theater to the ISR burn center for care. NCOs are a crucial part of that,” said Dr. David Baer, director of research at the burn center. “They do the classic NCO job of being the operations NCO — making sure all the equipment is ready to go and maintained, and all the supplies are ready to go — because those teams, when the phone rings, they have about six hours before they need to be wheels-up on a plane heading out to meet the patient. So being ready to go and having the training ready to go is a key part of what the NCOs do. But NCOs are also crucial health care providers on the flight team.”
As members of the flight team, NCOs work as licensed vocational nurses, in charge of continuous evaluation and monitoring of the patient before, during, and after the flight and transportation. The LVN is also responsible for wound care, maintaining the patient’s blood pressure, and pre-combat checks and inspections of all flight equipment. Another key position on the team filled by an NCO is that of the respiratory therapist, the team member in charge of evaluating the patient’s airways, ventilation and oxygen levels throughout changes in altitude, all while in flight and prepped in a foreign country with limited resources.
Cutting-edge therapy and technology
The burn center utilizes the latest research to specialize all treatments and equipment to the unique needs of burn patients, and employees participate in extra training to ensure they are experts in their field.
“I’ve learned a lot while working here; it’s a very different physical therapy than most,” said Sgt. Scott Stapleman, a physical therapy technician. “We do a lot of things here that you just don’t do in regular physical therapy. Because of the physiological changes from burns, we use tilts to increase vascular flow, lung capacity and things of that nature … a lot of compression on extremities that you don’t do in normal rehab. I love working here. It would be a great opportunity for someone to come here after getting a start in regular physical therapy. The experience of working with burn patients will aid them wherever they go in the future.”Roman explained that a lot of what they do focuses on edema control – controlling the swelling caused by fluid retention – and preventing scar formation.“Scars prevent range of motion, so we try to prevent them from forming — whether it is scars that prevent the patient’s use of their fingers, mouth or ventilation,” Roman said.
When scar tissue forms, the skin becomes less elastic and cannot extend as much as uninjured skin. Therapists at the burn center use splints and slings designed by the research team specifically for burn patients to keep their bodies in positions that will elongate their joints while they are healing. These methods, combined with compression and gentle stretching, help patients retain their range of motion.
“Whether you are a Soldier, a spouse or a mechanic, the less you can move a joint, the less you will be able to do the activities you need to do,” Gilmore said.To control swelling for patients with fresh burns, therapists use wraps to put a certain amount of pressure where it is needed the most. Once a scar has matured, technicians create custom compression garments for a patient’s arms, legs, chest or other areas to be worn like a shirt, sleeve or glove. The garment provides protection from ultraviolet radiation and even pressure to the area to prevent swelling and further scar growth.If a patient is burned on his or her face, therapists use custom-made silicone masks held in place with a hockey mask-like harness to apply the needed pressure.
“Compression is key in recovery,” Roman said. “For facial burns, material is applied to the burn victim’s face using the compression mask. And that’s going to influence whether the patient retains many of their facial features or not. Because of edema and other changes a patient goes through, they may go through several masks. Using the old equipment, it would take 8 to 10 hours to create a mask. With the equipment we have now, it takes us 30 to 45 minutes. We take a scan of the patient’s face and manipulate the scan, make a mold of the face with a milling machine, then apply the thermoplastic material to create the mask.”
For patients who are unconscious or bed-bound for lengthy periods of time, therapists use mechanized chairs or frames that can lift a patient from a flat position into a sitting or standing position. Even if the patient is still unconscious, sitting and standing are beneficial because gravity helps push fluids throughout the body. The frames also have an attached table, and the therapists encourage patients who are able to use their arms and hands and to engage in activities.“We always try to disassociate the patient with their pain,” Gilmore said. “They may be horrifically burned; it’s very, very painful. Sometimes, if we ask them to do something, and that pain is their area of concentration, they are not going to be able to fully do what we want them to do. So if we can get them thinking about something else, the pain is still there, but they are not thinking about it, so it becomes more bearable.“I remember we were trying to get a patient up to standing for an hour, but we couldn’t do more than 10 or 15 minutes before he was just in too much pain. We found out that he liked to play chess. I like to play chess, so we brought the standing frame in there, I started playing chess with him, and hours would fly by. Within a couple of days, he was walking again. The pain was still there the whole time, but I got him concentrating on the game, and he was able to cope.”
As patients continue to heal, the therapists begin to help them walk again. The hallway between the burn unit and the rest of the building, featuring windows from floor to ceiling, is referred to as the “rehab hallway,” because it has a rail system installed along the ceiling to which a patient can be attached with a harness. Patients gain confidence using the system as they try walking for the first time, knowing it will catch them if they fall or lose consciousness.
“Within a day or two, they are usually running up and down that hallway,” Gilmore said. “They get over their fear. It gets them out of their room; they get all that sunshine and see the world a little bit.
“We try to get them out doing exercises near someone else who is going through what they are going through,” Gilmore said. “Maybe that person is a little further along in their treatment, so the patient can see the progress they can make. It provides a light at the end of the tunnel. It helps a lot for them to have others going through the same thing to talk to and ask questions.”
Roman said he is always astonished at the rate of patients’ progress once they are able to venture out of their rooms and mingle with other patients and family who could not visit them in their rooms. This reintegration goes a long way to helping patients get back into society, whether as a civilian or back into the military.
To prepare patients for their life outside of the hospital, therapists use an “activities of daily living” room – a small but fully functional apartment that mimics a household where they will eventually need to function independently. They use the room to work with patients on basic needs such as meal preparation, hygiene, transfer from the showers, getting dressed, washing dishes and doing laundry.
“Working with patients here helps us to determine when a patient is ready for discharge and what modifications will be needed at their home before they move,” Roman said.
New research: the future of patient care
In the past few decades, researchers have made leaps and bounds, Gilmore said. The burn victim survival rate is much higher than it used to be, but there are still many unknowns when it comes to scar formation and other aspects of patient recovery. To address this, the burn center has its own research department, which publishes studies through the American Burn Association.
“If we keep their arms elevated for a longer period of time instead of just a few hours a day, will their progress be faster? With the new techniques and technology being developed through our research, patients’ rehabilitation has become much more effective,” Gilmore said.
NCOs who are technicians as well as NCOs who are health care providers in the burn center play key roles as part of the research team.
“Working with clinicians is crucial to research to make sure the things we develop are going to be useful in that clinical environment,” Baer said. “So the NCOs are very useful in helping us understand the best ways to treat patients and ways we can improve patient care.”
Roman said a great part about the burn center having its own research team is that not only are NCOs involved in the research – which doesn’t happen very often – but they are also able to apply the findings right away, whether it be new methods in the operating room or the use of virtual reality instead of drugs for pain management.
One advantage patients at the burn center now have is that of replacement skin. The main treatment used for burn patients continues to be skin transplants from their own bodies, but because donor sites are painful and there is often not enough skin to cover large burns, research efforts have been focused on developing synthetic options that require little or no skin from the patient.
Burn victims at the ISR burn center may now participate in the clinical trial for ReCell, a spray-on skin made from a small biopsy of the patients’ skin. The biopsy is used to create a substance containing keratinocytes, regenerative cells that promote the growth of new skin cells.
“We surgically remove any skin that is burned, and then the sprayed skin sort of ‘seeds the lawn’ and helps with the growth of new skin. Those cells actually grow in place and create new skin. It is amazing,” Baer said. “Not only can those who get treated here at the burn center enroll in an experimental protocol like this, but everyone across the country can benefit from that. We know it will make the care for Soldiers better, in addition to the care for civilians who are burned in accidents and such.”
Another method now in clinical trials is the use of skin sheets. A small sample of skin is taken from the patient and sent off to a company that puts it in a culture and grows it into sheets. The sheets of skin are sent back to the burn center and applied to the patient’s burns.
“It’s good to have more than one option for treatment,” Baer said. “The use of spray-on skin is limited by the depth of the burn, but we can use it immediately. You don’t need to send the cells off to another company to grow them for a few weeks and send it back. So it’s faster. The other kind takes longer, but it has a better outcome for full thickness, third-degree burns.”
An experimental line of research in an earlier phase involves the use of adult stem cells harvested from fat that would normally be discarded in surgery to create “off-the-shelf skin.” The spray-on skin will hopefully not require any skin from the patient, and will be ready to use on any type of burn, whenever a patient needs it.
“The research is very significant. It is what makes us unique,” Roman said. “We can apply this immediately, whereas other burn centers in the U.S. do not have that luxury. They may learn from our published studies and apply it in their own clinic, but we have that advantage right away.”
NCOs work in every aspect of the burn center to make the facility the best in the country. From conducting research to changing the dressings of a Soldier’s burn, they are the ones getting things done, who observe and share in each patient’s victories — great or small. Whether a patient’s goal is to walk again, live on their own, get back to their family life or even to their job in the military, NCOs help them get there.
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