Prepared for the United States Department of Defense April 2011
Highlights of the Report Robert W.Koch, RN, DNSc, Wayne J. Pitts, PhD, Marian Levy, PhD,
Daniel Kirkpatrick, RN, MSN., Tera M. Tongumpun, and Amanda L. Yacko
• The University of Memphis,
Loewenberg School of Nursing
Civilian Aeromedical Evacuation Sustainment Training:
and the School of Public Health, A Survey of Professionals Regarding Curriculum
in partnership with Wright State Content, Format, and Implementation
University, are working to de-
velop a curriculum for Civilian
Aeromedical Evacuation Sus- Introduction completing the survey than females
tainment Training (CAEST). The University of Memphis, (47.8%). There were far more white
Loewenberg School of Nursing and the respondents (88.1%) than blacks
• In January 2011, 673 profession- School of Public Health, in partnership (9.0%), Native Americans (1.2%),
als were invited to complete a with Wright State University, through Asians (0.5%), or others (1.2%).
web-based survey designed to a grant funded by the United States Despite the convenience sampling
measure opinions about the con- Department of Defense are working to strategy, the researchers were able to
tent, format and implementation create a program for civilian medical reach a wide-variety of respondents
of the proposed CAEST curricu- and emergency personnel who may according to the distribution of or-
lum. interact with military personnel in ganizational types. Approximately
emergency disaster situations. In Janu- one-third of respondents came from
• Almost half (49.0%) of respon- ary 2011, the Midsouth Survey Re- non-profit organizations (32.1%)
dents had personally responded search Center at the University of followed by local government em-
to some sort of disaster. Memphis launched a web-based survey ployees (28.3%), for profit organiza-
designed to measure attitudes and tions (17.5%), state government
• Respondents felt most well- opinions to inform civilian practitio- (9.0%), federal government (3.9%),
prepared to respond to medical ners engaged in disaster recovery ac- and military (2.8%). The remaining
and emergency triage situations, tivities to help them become more ef- 6.3% included individuals who
natural disasters, and mass casu- fective when working with military marked some other employer type
alty events. personnel during aeromedical evacua- (i.e., self-employed, retired, city gov-
tion. The major goals of the survey ernment, academics). See Chart 1.
• Respondents believe they are were to learn what information and Nurses (35.2%) were the most repre-
least well prepared for chemical, data are collected and what informa- sented profession in this sample of
hazardous materials, radiologi- tion and data are needed to support respondents followed by emergency
cal, and biological threats. recovery activities. The survey also medical technicians (32.8%), and
gathered information on needs, gaps, firefighters (10.7%).
• Military and civilian relations challenges and opportunities related to The convenience sample yielded
will be complicated by commu- training - especially in situations in- a group of respondents with signifi-
nication barriers, role confusion, volving civilian and military collabora- cant professional experience working
and chain of command ambigu- tion during disaster events. with disasters. Almost half (49.0%)
ity. (continued on page 3)
• Respondents favor active, hands-
on, simulation-based training A total of 673 respondents com-
activities. pleted the survey. Respondents
ranged between 21 and 74 years of
• The most common barriers to age with a mean age of 42 years old
participating in training are the (SD =11.0). The population was
cost to participate and available split fairly even according to gender
time. with slightly more males (52.2%)
All research protocols were reviewed and approved by the Institutional Re-
view Boards of the University of Memphis and Wright State University prior to
launching the survey. The potential risks of the research protocols were consid-
ered especially low because the questionnaire does not include any sensitive
questions and because respondents voluntarily and anonymously completed the
web-based survey. The respondents are all working professionals and the
bounds of survey were clearly within their everyday work responsibilities.
The survey was conducted using Qualtrics software, an online data collection
tool widely used by academic and business professionals around the world.
Qualtrics offers superb on-screen graphics capabilities, a wide-range of question
design features, and useful reporting tools. After the data collection period was
completed, the records were exported to SPSS for analysis.
This research used a convenience sampling strategy to recruit potential re-
spondents. The principal investigators received e-mail contacts for a variety of
professional contacts and the survey was distributed via electronic invitations to Training Priorities
a variety of hospitals, list serves, military contacts, and individuals who had pre- A list of possible training topics
viously attended trainings or meetings. The letter of introduction also invited related to military and civilian
potential respondents to share the survey link with other relevant professionals at aeromedical evacuation training
their discretion. were provided and respondents
All respondents were offered a $25 gift card incentive in return for their par- were asked to check them if they
ticipation in the study. The gift card registration was facilitated through an thought additional training was
anonymous link to a second survey where respondents could provide their name needed in these areas. The list be-
and mailing address. Personal information cannot be matched to survey data. low rank orders the selections with
Over 450 respondents claimed the incentive. the most needed at the top.
The mean time to complete the survey on-line was 1 hour and 14 minutes.
The outliers at the upper end were trimmed which made the mean far more rea- 1. Communication
sonable at 19 minutes. 2. Chain of command during a
3. Logistics of working with mili-
Type of Employing Organization 4. Responder Safety
5. Expectations of the military
6. Patient tracking
Other Federal (non- 7. Patient stabilization and needs
6% m ilitary) 8. Standards of care
Military 4% State 9. Military protocol and acro-
3% 9% nyms
10. Logistics of working with mili-
Private (for 11. Data bases
Local 12. Other (i.e., expectations of ci-
28% vilians, mutual respect, triage,
dealing with uninjured patients
with preexisting health condi-
tions including pregnancy,
public and environmental
Non-profit health issues)
of those who completed the survey aster training was also prominently
had personally responded to some mentioned. More than two hundred
sort of disaster. Not surprising, the other training programs were men-
most common type of disaster ex- tioned by the respondents. In a later
periences were weather related (i.e., question in the survey, 77.8% of re-
tornadoes, hurricanes, floods, ice spondents report that they have re-
storms) but there were several re- ceived NIMS training and 62.7% say
spondents with hazardous materials they have received FEMA training
spills, and there were a variety of through the National Domestic Prepar-
transportation related disasters. Of edness Consortium. A total of 38.0% needed additional training.
these with disaster experience, most have received Community Emergency Almost one-fifth of respondents felt
had more than ten years of service Response Training (CERT). that they needed more training in all
(69.5%). Only 10.2% had three Respondents felt most well- areas of disaster response. This was
years of experience or less. Thus, prepared to respond to medical and the most common response when
even though the sample was non- emergency triage situations, natural asked in what area the respondent
random, the survey reached a popu- disasters, and mass casualty events. It felt more training was needed. The
lation of people that have significant is no coincidence that these are also second most common answer was
disaster related experience. areas with which respondents report related to military involved disaster
When asked to specify the types having the most experience. When responses with 17.1% mentioning
of disaster training they had received asked what type of situations they felt the need for more training in work-
in an open-ended question there were least trained for, chemical, hazardous ing with the military. Communica-
a broad range of types mentioned. materials, radiological, and biological tion issues, chain of command, and
Training provided by the Federal threats were mentioned most often. coordinating multiagency opera-
Emergency Management Agency Respondents also mentioned a lack of tions were also prominently men-
(FEMA) was the most common with earthquake training. Some two hun- tioned. When asked what they per-
National Incident Management Sys- dred other training weaknesses were ceived to be the greatest training
tem (NIMS) and Incident Command also mentioned. needs among other organizations,
System (ICS) specifically mentioned Less than one-third of respondents the leading overall response was
the most often. Hazardous materials (29.3%) had ever interacted with mili- related to communications. Spe-
(HAZMAT) and hospital-based dis- tary personnel during a disaster opera- cific training on strategies for im-
tion. This finding is not altogether un- proving collaboration with military
expected since the military is usually personnel was also identified.
only involved in the more severe disas- The next question asked respon-
ter situations. Given that fact, having dents to consider how military and
almost a third who had interacted with civilian medical personnel interact
the military during a disaster operation during a disaster event. Next, re-
make the results of this survey more spondents were asked what they
informative. thought the most important training
There was considerable ambiva- needs that should be addressed to
lence about working with military per- improve this working relationship
sonnel. While 28.1% felt they were were. Again, issues of communica-
well-trained to work with military per- tion were the most common prob-
sonnel, most did not feel so confident. lem and concerns about the use of
Over one-third said they did not feel common terminology was raised
well-trained (36.8%) to work with the several times. Other leading issues
military during a disaster response, and included: understanding the chain of
another third were unsure (35.1%) as command and awareness of capa-
to whether they were well-trained for a bilities, protocols, authority, and
disaster response partnership or not. responsibility of military and civil-
Despite this apparent lack of clarity, ian responders. There were con-
nearly all respondents (87.4%) felt they cerns raised about the different roles
and functions within the same or- their personal preference. The op-
ganizations. Another frequently tions were: 1) Training as a group
raised concern was interoperability over a concentrated period (8 hours);
and compatibility of equipment. 2) Training as a group in 1-2 hour
sessions spread out over time; and 3)
Training Format Self-paced individual training - on
One of the goals of this research your own, as you have time. Re-
was to obtain feedback from profes- spondents were given the option of
sionals about preferred learning for- writing in any other training option.
mats and styles of training. There The second option was the most
was clear consensus regarding the ties that require trainees to be in- popular. That is, respondents
utility of hands-on exercises and volved actors. Multi-methods strate- slightly favored 1-2 hour sessions
over 90% of respondents favored this gies are also strongly favored. Simu- spread out over time with 83.4%
approach to training. Listening and lation exercises (mock disaster sce- ranking this choice as either first or
participating in discussions and narios) are seen as the most effective second. Concentrated, all-day train-
watching films, seeing pictures and training method and are strongly fa- ings were slightly less favored with
diagrams were equally popular vored by most respondents. Group 79.5% choosing this option as either
strategies with the vast majority find- discussion and classroom training their first or second choice. Self-
ing these somewhat effective or very methods are also seen as effective paced training was the least favored
effective. The least popular format strategies for training. Methods em- option. A number of training alter-
for training was taking notes or read- phasizing self-paced training such as natives were recommended. Many
ing. It is worth noting that only assigned readings, online courses and respondents favored didactic meth-
36.1% thought video games and workbook exercises appear to be less ods that were coupled with interac-
computer simulations would be a favored. Computer based simulation tive sessions, especially hands-on
very effective learning format. methods fall somewhere in between. motor skills and lab experiences.
Nearly all respondents favored a Another question that appears later in One person wrote, “learn one, do
combination of more than one format the survey asks if respondents believe one, teach one,” suggesting that
for training. that aeromedical evacuation training trainees should perhaps learn first in
In addition to format, the survey should include human simulation the classroom, practice their new
also included questions about train- training. Essentially all of the respon- skills, and then teach someone else.
ing methods. Table 1 show percent- dents believe that training needs to be Some favored augmenting lectures
ages for perceived effectiveness for active and that participants should be with multimedia options including
the various methods proposed. able to engage in physical activity, on-line work, podcasts, and videos.
Qualitative comments in several sec- scenario-based training. See Table 1. The survey also included ques-
tions of the survey emphasize a Respondents were asked to order tions regarding which method of re-
strong preference for applied activi- three training options according to tention would be most effective.
Most respondents favor having bian-
Table 1: Perceived effectiveness of Training Methods
Not Somewhat Very
Proposed Training Method Effective Effective Effective
Scenario Simulation Exercises 1.9 15.7 82.4
Group Discussions 3.0 40.3 56.7
Classroom Settings 1.5 46.4 52.1
Computer Simulation Games 10.9 48.0 41.1
Workbooks/Training Manuals 16.1 61.7 22.2
Online Courses 18.6 63.7 17.7
Text-based Reading 26.8 61.4 11.8
nual refresher course designed to keep
Table 2: Barriers to Training
information up to date. On-line tutorials
were a distant second choice and was Barriers Making Training Inconvenient
only slightly preferred over receiving a %
printed reference text containing up- Costs - too expensive 71.0
dated information. Throughout the sur- Ineffective, boring training methods 62.2
vey, respondents consistently favor face
-to-face training methods over self-
Amount of time needed 49.7
paced training methods. Video gaming Travel to training locations 47.8
formats designed to review and update Redundancy of information 25.7
training information was the least fa-
vored option. Although not accounted Other 4.9
for directly in the survey results, it may
be that some respondents are less famil- issue affecting training participation is
iar with more recent video gaming the amount of time required to partici- self-paced methods are not fa-
simulation technology. These findings pate in training. The first and third vored. Respondents want to see
could evolve as these choices become factors are possibly related since train- more lively and energetic ses-
more widespread. ing time is essentially downtime for sions with significant opportuni-
Next, respondents were asked to that employee. Ordinarily an extra ties to practice their new skills.
identify the main factors that make any person has to be brought in to replace Some of the other barriers men-
type of training inconvenient for them. the individual who is out for training. tioned include: too few options
The most common barrier to participat- The second issue of ineffective and for attendance, the inconsistency
ing in training are the costs to partici- boring methods should be considered of training content, poorly
pate. There also seemed to be signifi- carefully as future training strategies planned simulation exercises,
cant concern about ineffective and bor- develop. Respondents are weary of and too much required reading.
ing training methods. The third leading ineffective and boring trainings and See Table 2.
Other Training Programs for Civilian Responders and Military Personnel
Thirty-six respondents (7.4%) said they were aware of some structured disaster related training to help civilian re-
sponders work with military personnel. They identified the following training programs:
• Basic Disaster Life Support and Advanced Disaster Life Support – see www.ndlsf.org
• Centers for Disease Control, Environmental Health Training in Emergency Response (EHTER) – See
• Military Emergency Management Specialist (MEMS). This is provided through the State Guard Association
of the United States (SGAUS). http://www.sgaus.org/training/mems.html
• Metropoltian Medical Response System (MMRS) Especially useful for patient tracking. See http://
• National Disaster Life Support Classes (CDLS, BDLS, ADLS, NDLS-Decon) are approved through the
• Prehospital Trauma Life Support, Counter Terrorism and Narcotics Operations Management (CONTOMS )
– See http://www.acep.org/
• Tennessee, Indiana, Kentucky, Illinois, and Missouri – Military Assistance, Safety, Traffic (TIKI-MAST) –
• World Health Organization (Violence & Injury Prevention Program and Essential Surgery Program), USAID/
OFDA (PEER & HOPE courses), Especially for emergencies & disasters that meet the criteria of the new
International Health Regulations. See violence_injury_prevention/services/traumacare/traumaguidelines/en/
The survey respondents have identified a number of also less desirable Videos are fine as supplemental
challenges and opportunities for those who are develop- training tools.
ing the curriculum Civilian Aeromedical Evacuation There were numerous helpful comments and rec-
Sustainment Training. First, there is widespread agree- ommendations that should be carefully considered
ment that additional training is needed. This is sup- during the curriculum design process. The appendix
ported by the respondents’ self-reflection on their train- section on the next two pages includes paraphrased
ing needs and their perceptions of others’ training needs. suggestions from the qualitative data collected. Each
Most people feel most comfortable with their levels of one of those included poses questions and unique
training for more common disaster scenarios (i.e., observations from these professionals.
weather related, mass casualty traffic events) and least Extra expenses and the amount of time required to
comfortable with terrorism related events, earthquakes, attend trainings are pressing concerns. Many respon-
and biological threats. dents favor allowing training to be included as part of
The most common concerns in dealing with civilian their continuing education requirements. Some re-
medical personnel and military transport and evacuation spondents are also interested in developing more
activities are communication and chain of command. grant resources to help support training efforts. An-
How can the differences in goals, roles, and expectations other challenge for curriculum designers will be in-
be bridged? How will differences in jargon, equipment, formation retention and ensuring that training reflects
and standard operating procedures affect patient care? the most recent threat information.
There are many unanswered questions and there is con- Several promising training programs already ex-
siderable anxiety amongst civilian and military profes- ist. A sampling of these are included in the report
sionals. and should be systematically reviewed. Several re-
Respondents in this convenience sample favor hands spondents mentioned there are often conflicts be-
-on mock event training, and mixed presentation formats tween the various training materials. Every effort
are preferred. Self-paced training, especially workbook should be made to ensure best practices are being
formats and other strategies that require significant followed.
amounts of reading were criticized. On-line options are
For more information about the Midsouth Survey Research
Center or about this survey, contact:
Wayne J. Pitts, Ph.D.
Director, Midsouth Survey Research Center
School of Urban Affairs and Public Policy
University of Memphis
Appendix A: Recommendations for Training Content
• Military medics are great when treating 18-30 year old, fit soldiers
Is there anything else that you that are injured - pediatric patients and older adults with co-morbidity
concerns are another matter.
think we should consider regard-
• We all need to be trained in the same Incident Command System.
ing the content of any proposed
• Utilize an “All-Hazards” approach.
training curriculum? • Because the possibility of chemical and biological weapons of
mass destruction are a real threat, all participating should be well
trained in dealing with this type of attack.
• Both the civilian and military personnel should receive this standard national training and be licensed the same.
• We need to understand the care, food and shelter of those who are not ill or injured and the evacuation of them.
• Civilians must be trained on the medical equipment and techniques used by the military.
• Cohesive planning and logistics are needed for all groups involved.
• Utilize common datasets, standards, and terminology.
• Communication of orders (Who gives the orders and what are their practical qualifications? Do they really have the
experience to be giving the orders?)
• Content needs to cover more than the 'standard' things we get as part of alphabet
soup (ITLS, PALS, ACLS, BLS, etc).
• Training should include issues of dealing with nonmilitary personnel at nonmilitary
• Dealing with psychological trauma is important—sometimes the emotional aspects
• Describe proper patient movement and give examples of military litters.
• Describe what a Flight Surgeon does in an Air Evacuation capacity.
• Plan for different resources and staffing levels at night and on the weekends.
• During an emergency, first responders must make rapid decisions to protect their community’s safety as well as
their own. Should they evacuate the area? How many blocks should they evacuate? Should they don protective
• It is imperative to understand equipment hand receipt procedures and chain-of-custody procedures.
• Everyone has to understand how significant and important dysentery is in a shelter.
• One of the worst things I have seen at disaster scenes is the overabundance of people. That usually leads to
some type of freelancing and then you have the problem of accountability.
• What are the expectations related to communication with family members of responders?
• FEMA IC classes (the 100/200/300/400) preach the importance of plain language and no jargon/codes. The mili-
tary is still very reliant on this and it should be addressed.
• Fire and rescue need to work/train side by side for training.
• Fire is a paramilitary structured organization, yet the military does not recognize our ICS system. Bridging this gap
would be beneficial.
• First responders need to understand that all credible threats, even if they test negative, need to be sent to a labo-
ratory for confirmation to avoid false negatives.
• Are there any financial resources or grants available to obtain additional training?
• Great focus should be placed on symbiotic relationships between civilian health care professionals and military
• HIPPA is always an issue, but it helps to know what was done, what worked and what didn't.
• How are we covered for malpractice in disaster settings?
• How can we forecast the needs of the next 48 hrs not just the current crisis?
• How can we use all agencies involved and their resources to their full extent? There is no need to call for 100 and
actually on use 25 of them.
• How will Public Health be protected during the first response and clean up of the site?
• I feel a curriculum should include a variety of exercise involving a multi agency response.
• Identify treatment options that require electricity or other electronic resources.
• If not injured, we have to know their BIG problems that will become problems without meds.
• If we are working a natural disaster, what do we do with the children who are not hurt, but
who may have lost parents?
• Include a copy of the paperwork that a Flight Surgeon would use to move a patient.
• Include the Global Patient Movement Resource Center (GPMRC) requirements for move-
ment including a list of approved and unapproved devices for flying.
• Training should emphasize infection prevention in temporary conditions.
• Interface with bioenvironmental/HAZMAT teams and decontamination is a critical component.
• Training should involve all hospital staff - not just emergency dept staff.
• Knowing the other's method of care would broaden my own knowledge base with the cross training.
• Landing and loading procedures are important. Lock down procedures should be covered.
• Most state plans do not include anything under ESF regarding the pediatric patient. We cover pets, but not kids.
• Needs to cover the 'fringe' items that those courses won't cover such as management of a tent hospital, care for pedi-
atric patients, mental health needs secondary to a disaster, recognition of disaster related 'emergent' conditions
• Patient tracking is super important.
• It is important to consider principles and practice of public health surveillance in complex emergencies (where civil
strife is present or possible).
• Review the procedures for casualties. What are the nurse specific duties in mass casualty situations?
• Include issues of prolonged care in disaster area alternative care sites.
• What are the responsibilities of the Treatment Group Supervisor? When should there be an actual treatment area vs.
just using the area where the patients are as the treatment area?
• What would the role be for quasi-military agencies, (e.g., local agencies)?
• Search and rescue response on how to locate victims in a disaster should be included.
• Standards for manufacturers to assure that instruments detect analytes at the level required to assess potential human
impact should be considered.
• The simple things like contaminated water are important. We can't use that water to clean a wound. For elderly people
with ulcerated feet in a shelter, this isn't the time or the place to unwrap those. This isn't the emergency.
• The training (and maintaining it) will save lives that maybe lost due only to poor training efforts. We work on the earth
quake fault line, and we do not have any earth quake drills of any kind. Furniture is not stabilized through out the hos-
pital—these issue need to be addressed.
• The training should be conducted with civilian and military personnel together to know what is expected of both
• There should be disaster scenarios in various locations, even in high-rise buildings.
• Too many times, we all focus on the large scale incident when many communities struggle with handling the simple,
small scale incident. And in many cases, this is exactly where large scale disasters occur, in smaller communities.
• Train the responders to use options not requiring electricity or other electronic resources.
• Training needs to be simple enough that it can be remembered because it will not be used frequently.
• Cover issues related to validation under variable field conditions (vs. pristine, highly-controlled laboratory conditions).
• What I learned on 9/11 is that the FDA regulates blood donations. NO one who hasn't been through that 2 week train-
ing can do anything to help with blood donors. There is no point in nurses or physicians going to help at these local
blood donation centers. Clarify this point in the curriculum.
• Without training, sample material may be depleted resulting in loss of criminal evidence and the ability to conduct ap-
propriate laboratory testing.
• Consider issues where WMD considerations/terrorism may be involved, or where martial law could be imposed.
• I would like to see trainings at different times of the day and some a night; very seldom are there drills at night.
• Write out a training curriculum that is as brief as possible and covers everything in easy-to-read and understandable
English. Any responder should be able to pick it up, read it, and know the basics of what to do in each situation.