War zone transfers present difficulties in preparing patients for medical air evacuation. We have limited neurosurgery capabilities at the 10th Combat Support Hospital in Baghdad, and the only neurosurgeons in our war zone theater are in Balad, Iraq. Therefore, the most common type of patient requiring transfer is a patient with a head injury. The process starts with confirmation of neurological injury with a head or spinal CT scan. The neurosurgeons are then contacted and we have the radiology department transfer the images electronically to the physicians in Balad. The ED physician, the surgeon on call, and the neurosurgeon in Balad collaborate before the decision is made to transfer the patient. Once the decision is made to transfer the patient, coordination starts between the patient administration, the nursing supervisor, and radiology. We call the nursing supervisor to gather any equipment needed for the transfer, radiology starts to copy all CT scans to a CD, and the ED team starts "packaging" the patient. There are many ways to package patients for rotor wing transport, the following steps are our ED standard at the 10th CSH. The steps are implemented to ensure consistency in packaging for all patients (see Figures 5 and 6).

Figure 5. SMEED mounted on stretcher of a patient with a head injury packaged and prepared for urgent transfer by helicopter.

Figure 6. Preparing to load a brain-injured patient onto a Blackhawk helicopter.

1. Place a litter and rickshaw in the patient's room.

2. Place a pad on the litter followed by an open blanket.

3. Remove all air from IV bags and drip chambers.

4. Apply pressure bags to all IV bags.

5. If the patient has severe head trauma, ensure that an arterial line is in place for transport.

6. If the patient requires mechanical ventilation, apply a CO₂ detector to the endotracheal tube.

7. Place the patient onto the litter.

8. Tape the tubing of at least one of the IVs to the shoulder, next to patient's head for easy in-flight access.

9. Place bag-valve-mask (BVM) next to patient's head.

10. Place Kevlar O₂ tank between patient's legs, attach to the ventilator and BVM.

11. Transfer the Special Medical Emergency Evacuation Device (SMEED) onto the foot end of the litter.

12. Transfer cables over to the fully charged equipment on the SMEED.

13. Last, switch the oxygen to the tank on the litter.

14. Wrap the patient with the blanket, making sure all remaining cables are tucked in, and leaving the selected IV port available for access on the shoulder. Another option is to place the patient into a body bag with an opening at the face for added warmth; however, this makes the unstable patient less accessible.

15. Make sure all paperwork is copied (send originals with the patient), copy any CTs onto disk, and gather all x-rays.

16. Gather all needed medications for transport (standard list is epinephrine, lidocaine, neosynephrine, 23% saline, atropine, vecuronium, propofol, midazolam, and an analgesic).

17. Call report to Balad ED.

18. Put on all protective gear (Kevlar vests, helmet, weapon).