Cooked Therapeutic In-flight Meals (CTIM)

By Brigadier General Harold F. Funsch, USAF, MC
Lt Colonel Filomena R. Manor, USAF, BSC

First published in Medical Service Digest, December 1969,
Reprinted in 50 Years of Air Force Dietetics 1949 - 1999

One of the more difficult problems of military patients medicine over the years has been to provide airborne aeromedical evacuation patients with therapeutic meals that taste as good—and are as easy to prepare and serve—as regular in-flight menus. Military Airlift Command has introduced the Cooked Therapeutic In-flight Meat (CTIM) system to provide reliable, tasty, and easy to handle dinners which satisfy a variety of nutritional needs for aeromedical evacuation patients. Those patients traveling on the C-9,"Nightingale," are served attractive hot meals which feature chicken and steak entrees, fresh potatoes and vegetables, and suitable accessory food items.

C-9A Nightingale "flying hospital wards"

As casualties returning from Vietnam are known for their husky appetites, the newly devised meals are not only therapeutically correct for each patient but are also designed to satisfy gourmet tastes. Four standard menus include sautéed chicken breasts in white wine or tomato marinara sauce, broiled tenderloin or sirloin steak, and marinated steak in wine sauce. All food items are precut into bite-size pieces, as some patients are unable to cut their food. Flight nurses can thus devote more time to nursing care.

The CT1M system was developed to meet increasingly complex food support needs for the Air Force aeromedical evacuation system. The arrival of the first C-9 on 10 August 1968—the first plane designed specifically for aeromedical evacuation of patients— dramatized the need for coordinated efforts to provide accurate therapeutic meals to increasing numbers of patients. It was learned that existing procedures were not adequate to meet the compression of time experienced in the 550 mph jet planes.

To gather information about aeromedical evacuation food service operations, a questionnaire was sent from the Office of the Surgeon General to all Air Force medical activities worldwide in September 1996. It was found that most Air Force bases supplied box lunches for regular in-flight meals. Some overseas bases used precooked frozen dinners. For therapeutic diets, food items were "subtracted" from the regular frozen meals. There were no uniform or acceptable hot therapeutic meals in the aeromedical evacuation system, except for foil pack meals used on C-141 flights from Wiesbaden Air Base, Germany. Most therapeutic meals were "brown bag" lunches, and left much to be desired.

Since no system for providing therapeutic meals had been developed, the quality varied with the interest, ingenuity, and skill of the originating facility. A lack of coordination between servicing kitchens means a patient could receive the same menu on consecutive flight segments as his plane flew through the aeromedical evacuation system.
It was determined that a universal plan and standard procedures were needed to support the C-9 mission. Four basic in-flight menus, each with the many variations needed for commonly prescribed therapeutic diets, were standardized. Supportive recipes, preparation and serving instructions, checklists, menu plans, and ordering guides were also developed. 

In September 1968, the MAC Command Surgeon introduced the Cooked Therapeutic In-flight Meal System—a concept which placed the primary responsibility for preparing therapeutic in-flight meals on major hospitals with Casualty Staging Units (now called Aeromedical Staging Flights).The Commanders of the USAF Medical Center Scott, USAF Regional Hospital Maxwell, Malcolm Grow USAF Medical Center, Wilford Hall USAF Medical Center, and David Grant USAF Medical Center were requested to support the CTIM system. In addition, a workshop for the chief dietitians of these hospitals was held at Scott to discuss and demonstrate implementation of the CTIM system. Subsequently, medical food service personnel of Andrews, Travis, Maxwell, Kelly (Wilford Hall), and Scott Air Force Bases were briefed on the new system. As part of the plan, in-flight kitchens continued to provide precooked frozen flight meals for patients on regular diets. On 3 October 1968, the CTIM was first used on a domestic aeromedical evacuation flight.

The inland bases each offer a different menu; the east and west coast bases serve the same menu. For sodium-restricted diets, for example, David Grant and Malcolm Grow Medical Centers serve Menu 3— sautéed chicken in wine sauce. The USAF Medical Center, Scott Air Force Base, serves Menu 4—marinated steak in wine sauce. Maxwell and Wilford Hall provide chicken breast in tomato marinara and broiled tenderloin or sirloin steak respectively. Diet orders are received by the medical food service activities in advance of each flight through each base's Aeromedical Evacuation Control Center. The most frequently prescribed therapeutic meals are sodium restricted, soft, bland, caloric restricted, dental liquid, fat restricted, diabetic, child junior, and controlled fat-cholesterol.

Servicing kitchens prepare each CTIM by partially cooking the main meal and packaging in a three-compartment aluminum tray. The meals are then stored in the refrigerator of the plane's galley. When the regular precooked frozen meals are heated, the CTIMs are also placed in the plane's forced air convection oven. Cooking times and temperatures for both types of meals are the same: 25 minutes at -t25 degrees F. After cooking, the CTIMs are served with accessory foods selected to meet therapeutic diet requirements. These include canned pears and applesauce, chopped lettuce, apricot or peach nectar, apple and pineapple juice, milk and crackers.

During the standardization studies at USAF Medical Center Scott, it was determined that meat cooked with gravy or liquid was the most satisfactory. Boiling, roasting, and slow roasting produced inferior products. Chicken breasts, when lightly sautéed just to sear the outside, and steak, just browned lightly for color, were the most tender and flavorful. Turkey and roast beef were found to be too tough for regular use. In addition to the chicken and steak main dishes, acceptable hot food items were mashed, baked, and small new potatoes; rice, green beans, peas, and cooked carrots.

Acceptability and ease of serving are major considerations. The patients' morale, as well as nutritional needs, is also of prime importance. Implementation of the CTIM system for the C-9 has demonstrated all these requirements can be met successfully-even at 30,000 feet.

A zoned CTIM meal system has also been established in support of the C-l4ls in the Pacific. On 1 April 1969, USAF Hospital Elmendorf initiated CTIM service. On 1 June 1969, CTIM service support from the medical food service activities at Tachikawa became a reality. The Cooked Therapeutic In-flight Meal System has become firmly established routine for aeromedical evacuation.

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