Exercise Operation Dionysus: 446 AES creates exercise to hone capabilities Published June 1, 2023 By 2nd Lt Heather Cozad Staley JOINT BASE LEWIS-MCCHORD, Wash. -- Flight nurses triage patients, moving up and down the stretchers lined up four rows deep, an anxious crowd pressing in. Then, as the ground crew work behind the scenes to launch the mission, medical technicians and loadmasters configure the C-17 Globemaster III aircraft for aeromedical evacuation. A man hollers in distress, grasping his injured side and appearing to slide in and out of shock. Amid the noise from the aircraft's engines, the flight nurse checked for signs of shock and comforted him. The medical crew checked the equipment that monitored patients on the stacked gurneys. The team worked intently to care for an aircraft full of passengers weaving past equipment, focused on their part of the mission. The back door closed. The mission was ready to launch and transport the simulated patients to the next level of care. This mass casualty exercise was the culminating event of Operation Dionysus, which occurred May 9-12, 2023, at Naval Air Station Sigonella, Italy. Air Force Reserve units gathered in the shadow of Mt. Etna to participate in the full-scale, joint and allied mobility exercise that tested the capabilities along all levels of medical care. The 446th Aeromedical Evacuation Squadron (AES), Joint Base-Lewis McChord designed and implemented Operation Dionysus. Other participants included the 439 AES, Westover Air Reserve Base; 315 AES, Joint Base Charleston; United States Navy Medicine Readiness and Training Corps and the Navy Sicily Maritime Command Chief Medical Office. A grassroots training exercise The 446 AES asked a question to itself: “Are we ready if we get the order to push the whole squadron out the door?” The only way to find gaps is to exercise the full capabilities. To do this, they decided to push the limits to the breakpoint to see where to improve. The result was a homegrown exercise. To meet objectives, the exercise needed to occur somewhere unfamiliar, required medical infrastructure, an airfield, and people willing to try something new. The 446 AES usually heads west to train, but this time they headed east. After visiting a few bases, Naval Air Station Sigonella fit the criteria exactly. "The Naval Hospital Sigonella leadership and Emergency Management team met with us. Our idea aligned exactly with their training objectives - to do a joint force, mass casualty exercise with full-patient care," said Capt. Katie Catino, a flight nurse with the 446th AES and member of the team that planned the exercise. As weekly video planning meetings progressed, exercise Operation Dionysus was born. The exercise grew in scope. The whole became more significant than the sum of the parts said Brett Wallace, assigned to the Navy Medicine Headquarters. Wallace, who had been in the business of scripting multi-agency, multi-national exercises for nearly 20 years, observed and evaluated the exercise. "This was not directed from the top down; two commands with their own training requirements asked, "How can we train together?" said Wallace. "This is the largest, most-complex grassroots exercise I have ever observed." Ready Now! Exercise Operation Dionysus called for no wasted time. Teams rotated through currency training during the flight to and from NAS Sigonella. Once the aircraft landed, the teams hit the ground running. Navy Hospital Sigonella hosted tours and clinicals at the Emergency Department and Multi-Service Department. Aeromedical teams and hospital corpsmen completed egress and aircraft patient configuration training on the flight line. There were opportunities for all AES career fields to train to full unit type code deployment capability. The 446th Operations Support Squadron intelligence analysts presented external intelligence training. In a few short days, it was time for the culminating event to test career proficiency, readiness, and resiliency. More than 40 costumed role players gathered in the shadow of the C-17 Globemaster aircraft with realistic moulage, injury report cards, and a readiness to stretch their acting skills. While on the aircraft’s ramp, Master Sgt. Darwin Najera, a clinical management flight chief assigned to the 439 AES, listened with a clipboard in hand and directed the medical team from his headset. The chaotic atmosphere will benefit everybody's life by building confidence, said Najera, who participated in the Observe Control/Coach Train (OCT) role. On the civilian side, Najera brings ten years of experience as a firefighter and emergency medical technician (EMT). The flight nurses triaged and implemented additional measures on the simulated patients before they were carried onto the aircraft. Part of the training is adapting and keeping the patients and everyone safe, said Catino. "It can be a life and death decision," Catino said. Experienced reservists Reserve Citizen Airmen bring a wide range of experience from the Air Force and from their civilian occupations. In the aeromedical evacuation squadrons, decades of experience is represented through work as nurses and medical staff in emergency departments, critical care, post care, radiology, pediatrics, and more with diverse populations in a variety of settings. "It was amazing seeing the experience shine through mentoring and coaching during the exercise," stated Col. Carolyn Concia, the commander of the 446 AES and commanding officer of the exercise. "Passing down knowledge is critical in an exercise." Coaching and mentoring flowed between new and seasoned medical technicians and flight nurses. For example, a dry suction water seal chest drain was a piece of equipment used during a torso injury scenario with a simulated patient taken to the Naval Hospital Sigonella. Rarely used in this facility, the new 446 AES member slotted to be a flight nurse advised the hospital trauma team on the use of this specialized piece of equipment-expertise gained from his civilian experience. Team players Exercise Operation Dionysus brought together the Air Force Reserve, Navy, and Italian national medical systems. The Navy witnessed how the Air Force provides ground and inflight medical care. Navy hospital corpsmen learned how to configure the aircraft into a mobile hospital, and some received inflight medical care for their simulated injuries as role players. "In the beginning, it was very eye-opening to see what the Air Force does in the air," said Capt. Jean Fisak, the commanding officer of the US Navy Medicine Readiness and Training Command Sigonella. Fisak flew on the aircraft during the evacuation and observed the aeromedical crews caring for the mass casualty role players in flight and as they prepared to land and hand off the patients. From the vantage of the aircraft ramp, members of the Italian military had the opportunity to observe this hand off to the Navy corpsmen and the local Italian national medical teams. Those loaded into ambulances were transported to Naval Hospital Sigonella and to a local Sicilian hospital accompanied by flight nurses, medical technicians, or corpsmen. Working with our allies, in exercises like Operation Dionysus, strengthens U.S. partnership. "The most important thing is that we speak the same language," stated Captain Filippo La Rosa assigned to the Navy Sicily Maritime Command Chief Medical Office. The unique opportunity to work with allied partners and build bridges is valuable to our training and readiness, said Concia. Muscle memory Through wild madness and festivities, exercise Operation Dionysus taught many lessons. Even though it was stressful and challenging, AES ran missions larger than they had ever before, said Maj. Donna Olson, a flight nurse assigned to the 446 AES. "The aeromedical evacuation team was given a patient load that didn't fit," said Olson, who was instrumental in the planning and execution of the exercise. "They had to creatively problem solve while considering multiple regulations and develop a safe solution to complete the mission." The aeromedical teams came together and operated with large patient loads. At the end of the day, they met the mission objectives – a successful mission launch. "If this were a real-world scenario and we needed air capabilities, I would ask the Air Force to please come, help us care for our patients," said Fisak. Exercise Operation Dionysus built muscle memory and confidence to tack on the next challenge. Participants were pushed to operate in unfamiliar environments, move pass communication barriers, draw from other experiences, and prove their readiness and agility. "People don't just rise to the occasion; they rise to the highest level of their education," said Darwin. "Everybody who came out here will never, ever forget this experience."