The Canadian Forces (CF) has announced in its July newsletter that the CF now has an improved capability for aeromedical evacuation (AE). For the first time, eight flight surgeon candidates spent a week at CF Base Trenton learning about the CF aeromedical evacuation system and how it works, the equipment and aircraft used, and how to deal with medical problems that might occur in the air while transporting sick or injured patients. The Afghanistan mission has resulted in many seriously injured or ill personnel who require care on the long flights to Canada from Landstuhl Regional Medical Centre in Germany. School of Operational Medicine (SOM) head Major Rick Grodecki commented: “With the changing mission, we at SOM felt CF flight surgeons ought to be trained in real aircraft, with real AE crewmembers and with the actual AE medical equipment they would be tasked to use if called to augment an AE flight. We wanted our candidates to experience the stresses and pressures of doing medicine in an environment they may not be used to.” Staff from 426 Squadron AE Training Flight and the new CF AE Flight served as instructors. The ground training culminated in a real flight in a CC-150 Polaris long-range transport aircraft with simulated patients. Each candidate had to deal with multiple medical and equipment challenges during his or her time at bat. Candidates were ‘solo’ as physicians, but worked with a typical AE team comprising one or two nurses and a medical technician. They were monitored by one instructor while a specialist physician acted as scenario advisor. CF physicians may find providing care in the air presents some unique challenges. The pressure inside an aircraft cabin is lower than that at sea level; it’s equivalent to being at an altitude of between 1.8 and 2.4 km above sea level. This creates two potential problems for patients. As pressure falls, gas expands, and any gas trapped in a patient’s abdomen from surgery will expand, causing pressure on the internal organs that, in turn, could result in dangerous changes in blood pressure and significant discomfort. Also, the partial pressure of oxygen in the cabin air is lower, so oxygen delivery to a patient who already requires extra oxygen on the ground may become an issue. Captain Terry McCormack, a candidate from 23 CF Health Services Clinic Winnipeg, said: “The expanded AE training was a phenomenal opportunity for the candidates on our flight surgeon course. The hands-on training, in particular the training flight with patient scenarios, demonstrated to us the very unique challenges of delivering medical care on a CF aircraft. Some of these challenges included anticipating the effects of flight on a patient’s condition, patient assessment and treatment with numerous stressors on both the patient and the care provider … and problem-solving in the event of an in-flight deterioration of the patient’s condition.” The other challenge the candidates had to meet was simply working in an aircraft cabin. The beds are low to the floor; the noise level interferes with a physician’s ability to hear things such as heart and breath sounds; and back-up from a trauma team is not going to come because patient and doctor are at 10.6 km above the Atlantic Ocean. Major Tim Sveinbjornsen, a CF anaesthesiologist and clinical instructor for the AE training, explained: “We drove the point home when we had one of the simulated patients collapse in cardiac arrest in the corridor by the toilets. The flight surgeons were admirably up to the challenge of resuscitating their patient in a space no bigger than a shoe closet. It was a great demonstration of crew resource management principles, ingenuity and physical agility.” The AE training gave the candidates the opportunity to ask questions and gain valuable knowledge from instructors from all disciplines with previous AE experience, and allowed them to familiarise themselves with the AE environment, equipment and procedures. Capt McCormack commented: “All the candidates agree that gaining this experience in training prior to an actual AE flight was very valuable and has made us better prepared to care for sick and injured patients on AE flights in the future.” Overall, the experience was reported to have been a great success and the week-long module will be incorporated into subsequent operational flight surgeon courses.