with “V” shape to disperse the energy caused in the explosion (third generation), with a stronger cabin and higher axes (fourth generation)19. In February, 2007 a Spanish armored ambulance (BMR 600) suffered an IED attack causing the driver’s death, severe injuries to the nurse (blunt abdominal trauma and posterior laparotomy) and a minor traumatism to military physician20. Seven months later, there was an accident of this vehicle ambulance that caused 3 wounded men (costal trauma, traumatic brain injury and hand trauma)21. These reasons moved forward the buy of fourth generation vehicles (RG-31 Nyala) to increase crew and patient protection18. Throughout the decade, a large number of not armored and armored ambulances have been employed inside and outside of the military bases (Figure 2)6, 22-27. Although each vehicle has some strength and weaknesses, the authors think that RG-31 armored ambulance provides high tactical and medical qualities regarding BMR 600 to treat the casualty, showing a safer ambulance. Figure 2: Left (Spanish Army ambulances in Afghanistan external/internal vision vision-) Iveco, TOM, VAMTAC, BMR600, Lince, RG-31. Right (Spanish Air Force ambulances in Afghanistan - external/internal vision vision) Mercedes Sprinter, Nissan Patrol, VAMTAC, Mercedes, Iveco truck for mass casualties.
paramedic. Nevertheless, the helicopter (AS-332 Super Puma initially employed by Army and later by Air force) has significant similarity with the US helicopter than with the British. This team is activated by “9 lines” message and has capability to evacuate 2 critical casualties and 5 minor casualties. During ten years of uninterrupted medical evacuation missions, 2 MEDEVAC helicopters got lost on night missions and impacts of light weapons were suffered on at least 5 occasions26, 33-37. In a retrospective study describing casualties attended in the Spanish Role 2 (Herat) between 2005 and 2008, it shows that 176 casualties (74%) were evacuated by Spanish helicopter, with IEDs being the main injury agent38. In a later study conducted between 2011 and 2013, that analyzes 108 casualties evacuated by Spanish team and 353 by US crews. 75,6% of the medical evacuations were daytime, 29,4% were classified as Alpha, 38,2% as Bravo, 29% as Charlie and 1,3% were died of wounds. The main reason for evacuation was the IED attack39. In whole, during eight years since Spanish aeromedical crews were deployed in Herat, it has flown 5910 hours, with almost 1900 missions and evacuating 1030 patients of diverse considerations and nationalities (Figure 3)40-41. Figure 3: Left: Spanish Army Helicopter Cougar ambulance version. Right: Spanish Air Force Helicopter Super Puma ambulance version. Image a-d: Evolution of the internal devices configuration.
TACTICAL AND FOWARD MEDICAL AEROEVACUATION (MEDEVAC)
Several studies have demonstrated that early use of medical helicopter along with adequate medical crews can improve casualty’s survival in the area of operations28-29. There have been described several types of medical care given in the helicopter. The US model (PEDRO) is based on paramedics on board in helicopter UH-60 BlackHawk, while British version (MERT) employs a physician, a nurse and two paramedics in a CH-47 Chinook30-32.
In addition to the evacuations performed by rotary wing, the Spanish Air Force had deployed fixed-wing aircrafts (C-130 Hercules and C-295 Nurtanio) to perform evacuations in the area of operations. González42 analyses 33 tactical evacuations from January, 2002 to October, 2015. The most used aircraft was the C-130 Hercules (30 missions), in 28 times the missions had their origin in Manas (Kirziguistan), 3 from Dusambe and 2 from Kuwait. 57% were surgical or traumatic casualties, being the lesional agent predominantly accident, sports activity and less frequent combat.
Spanish model of aeromedical evacuation looks more like the British MERT for the human component, since it is composed by a flight surgeon, a flight nurse and a
MEDICAL TREATMENT FACILITIES
Afghan terrain and climate h