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The soldier on the military cargo plane struggles to breathe. He developed pneumonia while serving in Afghanistan and needs medicine now, but the pump to deliver it won't work properly. "I can't believe I'm still messing around with this pump," the nurse says, speaking on a headset because the three-person crew is surrounded by the constant roar of jet engines even as she struggles with the thin air at 30,000 feet. But those engines aren't real. The "plane" is a simulation center deep inside the University of Cincinnati Medical Center, the pump failure orchestrated from a control room next door. The patient is a mannequin. The whole thing, in fact, is a training exercise, with those in the control room recording every word and reaction. "There are communication issues for sure," said Air Force Maj. Daniel Cox after the training exercise is done. "(The doctor) has got to be more vocal." "The cadre," 17 Air Force trainers housed here at the University of Cincinnati, is charged with developing a new generation of war doctors, nurses and respiratory therapists. The university is one of three training sites for Air Force doctors, including those in the National Guard and Reserves, about to be deployed to Afghanistan or other active theater. The other training sites are in Baltimore and St. Louis. Once deployed, the doctors, nurses and respiratory therapists will treat injured service members being flown to other sites in theater or to an American military hospital in Germany. Most have backgrounds in critical care, but they often haven't seen the range of injuries common in America's 21st century wars: blast injuries, amputations, multi-trauma head injuries. "It can be a difficult transition," said Lt. Col. Elena Schlenker, deputy director of the training program, called C-Stars, or Center for Sustainment of Trauma and Readiness SkillsThere are all kinds of rules for pilots. How often can they fly? How far can they fly? But there are no rules for the people in the back of the aircraft. Richard Branson, University of Cincinnati surgery professor. Even for doctors and nurses active in the military, the stress, confined space and oxygen-deprived conditions in transport planes can be overwhelming, said University of Cincinnati surgery professor Richard Branson. The experiments hone in on how altitude affects not only the patients, but the caregivers and their equipment as well. "There are all kinds of rules for pilots," he said. "How often can they fly? How far can they fly? But there are no rules for the people in the back of the aircraft."

Military medicine big focus

The training is part of the University of Cincinnati's Institute of Military Medicine. Air Force training has become a staple there, including a slew of recent contracts that total more than $1 million. Those are extensions of $24 million in contracts signed in 2010, all dealing with air medical evacuation. University of Cincinnati has a database of more than 5,000 missions flown during the wars in Iraq and Afghanistan and plans to examine treatments and complications. C-Stars is only one part of the Institute of Military Medicine, with the Air Force paying most of the $4 million-plus the institute collects in research money. Surgery professor Timothy Pritts, for example, is researching the effects of freezing red blood cells for long transport trips, as well as investigating how to resuscitate patients before transporting them. Another study involves saline solutions, trying to find the lowest level that can keep an injured soldier alive through the transport.

High altitude affects how treatment works

That all has practical implications -- which become even more complicated at high altitudes and under the stress of wartime transport, Branson said. "This environment also causes gases in a closed space to expand, which can cause the cuff of an endotracheal tube to expand in a patient's airway," he said. "That puts the patients at risk of reduced blood flow and tissue damage." That's just what the simulator exercise is trying to prevent. There are 13 two-week sessions per year, each with about 15 students. They do four sessions in the simulation center at the University of Cincinnati, and there also are twice-monthly training flights out of Cincinnati Municipal Lunken Airport. As the group in the control room creates problems for the team, they deal with them one by one. "What we teach is not just maintaining," said Cox, one of the trainers. "We're functioning as an ICU. We expect you to be doing ongoing management so the patient arrives in better condition than when you picked them up."

Article By: Cliff Peale, The Cincinnati Enquirer

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