Project PEGASUS (Perfused En-route General and Acute Surgical Utility Simulation): In-flight damage control surgery during fixed-wing transport-Observations from the West Virginia National Guard Ridge Healer Exercises.

Abstract

Prolonged evacuation intervals, infrastructure disruption, and contested environments increasingly prevent timely access to surgical care for casualties with ongoing hemorrhage or contamination. Prior operational reports, including the Joint Medical Augmentation Unit experience, have shown that emergency life- and limb-saving surgical intervention can occur in flight when required. The present article addresses a different problem: how to train teams for intentional fixed-wing transport of a casualty whose operative needs may begin, continue, or recur during evacuation. This observational descriptive report summarizes 5 single-flight C-130 simulation iterations conducted during the West Virginia National Guard Ridge Healer exercises from 2024 to the present. Each iteration included up to 1 hour of in-flight scenarios with 1 surgical casualty and at least 2 critical care casualties using perfused wearable cut suits on live role players. Common operative tasks included splenectomy, small bowel resection, vascular ligation, and temporary abdominal closure. After-action reviews led by Ridge Healer staff informed the identification of recurrent themes through repeated faculty observation, participant discussion, and iterative curriculum refinement. Across the 5 iterations, several recurrent adaptations improved procedural flow and team safety. These included loading the most unstable surgical casualty first and positioning that patient forward in the aircraft, using voice-activated communication systems, employing standing operative posture on stanchion-mounted litters, favoring staplers and clips over hand-sewn techniques, rehearsing rapid turbulence bailout procedures, and standardizing temporary abdominal closure and handoff documentation methods. Participant feedback consistently emphasized loadout streamlining as the highest-yield operational adjustment, and teams reported subsequent changes to loadouts and team composition, including greater reliance on hemostatic clips, bowel staplers, and cross-trained personnel rather than a dedicated assistant role. Simulation-based training for in-flight damage control surgery during fixed-wing transport is feasible and yields practical lessons in ergonomics, communication, staffing, and procedural simplification. These observations should be interpreted as descriptive lessons learned from repeated exercise iterations rather than as proof of clinical efficacy or claims that in-flight surgery itself is unprecedented.