en route critical care · evacuation, patient transport and critical care teams from any nation...
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The Quadruple Aim: Working Together, Achieving Success
2011 Military Health System Conference
EVOLVING, IMPROVING & ADVANCING CAPABILITES
En Route Critical Care
26 Jan 2011Colonel Beverly Johnson
2011 Military Health System Conference
The Quadruple Aim: Working Together, Achieving Success
Headquarters Air Mobility Command Surgeon’s Office
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Report Documentation Page Form ApprovedOMB No. 0704-0188
Public reporting burden for the collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering andmaintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, ArlingtonVA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to a penalty for failing to comply with a collection of information if itdoes not display a currently valid OMB control number.
1. REPORT DATE 26 JAN 2011 2. REPORT TYPE
3. DATES COVERED 00-00-2011 to 00-00-2011
4. TITLE AND SUBTITLE En Route Critical Care: Evolving, Improving & Advancing Capabilities
5a. CONTRACT NUMBER
5b. GRANT NUMBER
5c. PROGRAM ELEMENT NUMBER
6. AUTHOR(S) 5d. PROJECT NUMBER
5e. TASK NUMBER
5f. WORK UNIT NUMBER
7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) Headquarters Air Mobility Command Surgeon?s Office,Scott AFB,IL,62225
8. PERFORMING ORGANIZATIONREPORT NUMBER
9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSOR/MONITOR’S ACRONYM(S)
11. SPONSOR/MONITOR’S REPORT NUMBER(S)
12. DISTRIBUTION/AVAILABILITY STATEMENT Approved for public release; distribution unlimited
13. SUPPLEMENTARY NOTES presented at the 2011 Military Health System Conference, January 24-27, National Harbor, Maryland
14. ABSTRACT
15. SUBJECT TERMS
16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF ABSTRACT Same as
Report (SAR)
18. NUMBEROF PAGES
45
19a. NAME OFRESPONSIBLE PERSON
a. REPORT unclassified
b. ABSTRACT unclassified
c. THIS PAGE unclassified
Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39-18
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2011 MHS Conference
En Route Critical Care
Evolution of Critical Care Air Transport– Taking Aeromedical Evacuation to Higher Levels
Improving Care Across the Continuum– System within a System
Advancing Capabilities– Closing Gaps in the Continuum– Building Partnerships– Research, Training and Technology
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2011 MHS Conference
EVOLUTION OF ENROUTECRITICAL CARE
3
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2011 MHS Conference
Point of Injury Battalion Aid Station
In the Beginning…Patient Evacuation World War II
4
Field Hospital
Allied rear areasMax 90 days
then unit or home
Ship
General HospitalRail
Time to CONUS:
<90 days via Ship & Ground
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2011 MHS Conference
AE System Organized‒ Despite resistance – proven‒ High Volume System for
Patient Movement Airlift
‒ Initially denied use of aircraft‒ Sporadic use of airlift
Medical Care in the Air‒ Formal Flight Training‒ Flight Surgeons at Airheads‒ Nurses & Med Techs Inflight
Enter Air Evacuation
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2011 MHS Conference
World War II
6
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2011 MHS Conference
Korean Conflict
7
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2011 MHS Conference
Vietnam
8
-
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2011 MHS Conference
Dedicated Airlift
■ C-9 Nightingale■ Integrated Patient Support
■ Oxygen■ Suction■ Electrical■ Special Care Area■ Ramp■ Medical Supplies■ Cooking Facilities
■ Limited Range■ Peacetime and Contingency■ Utilized for 30+ years
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2011 MHS Conference
Battalion Aid Station“Level 1”
In TheaterHospital“Level 3”
Definitive Care“Level 4”
Historical Perspective
CASUALTY EVAC- Evac Policy -
1 Day
TACTICAL EVAC
- Evac Policy -7 Days
STRATEGIC EVAC- Evac Policy -
15 Days
Field Hospital“Level 2”
Continuous En-Route Care:Stable Patient
10
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2011 MHS Conference
Critical Care Air Transport Begins
1988 Gen PK Carlton II presents idea
1994 Pilot Unit Stood Up 1995 First 6 months
– Teams managed 20+ critical patients
– Combat missions/trans-Atlantic missions
– Supported non-combatant evacuation from Liberia
– Supported Khobar Towers bombing victims
11
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2011 MHS Conference
NICU Teams
More than War-time Capability
12
Presidential Support - BangladeshCivilian Air Crash Guam
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2011 MHS Conference
MacKay Trophy 2000
13
-
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2011 MHS Conference
Proof Of Concept
14
USS Cole Oct 2000
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2011 MHS Conference
Enroute Critical Care Saved Lives
15
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2011 MHS Conference
Continue to Save Lives
Any Patient
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2011 MHS Conference
IMPROVING CARE ACROSS THE CONTINUUM
17
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2011 MHS Conference
Transformation
AE is no longer transporting stable patients between two MTFs
Care in air equal or higher than that on ground Care that is started on the ground will continue
until final destination Patient Driven Special Teams
– Critical Care Air Transport– Neonatal Intensive Care– Burn Team – Acute Lung Team
18
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2011 MHS Conference
OCONUS Medical Center/ASF
INTRA-THEATER INTER-THEATER
Theater Hospital/CASF,
CSH
EMEDS/MASF, FST
Tactical AE Strategic AE
AE Crews& CCATT
AE Crews& CCATT
CONTINUOUS EN ROUTE CARE:AE System
TACTICAL MEDEVAC/AE
TACTICAL/STRATEGIC AE
19
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2011 MHS Conference
OCONUS Medical Center/ASF
INTRA-THEATER INTER-THEATER
DefinitiveCare
Theater Hospital/CASF, CSH
EMEDS/MASF, FST Theater
Hospital CareForward
ResuscitativeCare
68W, PA, FS, PJ, 4N, RN, SOFME/SOCCET, CCATT
Battalion Aid Station
SABC/TCCC
US Medical Center
Tactical AE Strategic AE
AE Crews& CCATT
AE Crews& CCATT
CONTINUOUS EN ROUTE CARE:System of Systems
CASEVAC/MEDEVAC1 Hour
TACTICAL MEDEVAC/AE1-24 Hours
TACTICAL/STRATEGIC AE24-72 Hours
20
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2011 MHS Conference 21
Ability to Move “Stabilizing” Patients
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2011 MHS Conference
Without It…System Failure
22
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2011 MHS Conference
ADVANCING CAPABILITIES
23
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2011 MHS Conference
Wounded TCCC, SABC
BASATLS/ACLS
En Route Critical CareTransport Gap
Lvl-II/Forward Surgical Teams
Damage Control
Surgery/Resuscitation
Lvl-III/CSH, EMEDS, EMF
Theater Hospitals
Definitive Care
GOAL: Maintain Equal or
Greater Level of CareDuring Intra/Inter-Theater
Patient Movements
Continuous Increase in Level of Care Provided
Leve
l of C
are
INTRA-THEATER CRITICAL CARE TRANSPORT GAP
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2011 MHS Conference
BACKGROUND Current Lvl-II to Lvl-III Patient Movement
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2011 MHS Conference
CONCERN Lowest Ever “Died Of Wounds Rate” Largely
the Result of Integrated En Route Care “System of Systems”
GAP: Ad Hoc Intra-Theater Movement of ICU-Level Patients Utilizing Assets Not Specifically Organized/Trained/Equipped for Critical Care Patient Movements
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2011 MHS Conference
TACTICAL CRITICAL CARE EVACUATION TEAM (TCCET)
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2011 MHS Conference
TCCET Personnel/TrainingAFSCs/Experience Medical
TrainingOperational
Req’t/Training
Nurse
• 46M3 CRNA• SUBS: 46N3E Critical Care*
46N3J Emergency Room*
* Experience: Active ICU/Critical Care or ER(US Level 1-2 Trauma Center)
• BLS/ACLS• ATLS/PALS• TNCC or ATCN• CCATT/CSTARS-C• Joint En Route Care Course (JECC)
• Operational support physical
• Combat Skills Training (CST)
• SERE 100, HRC
• RW ops familiarization incl. night ops (low light & blackout conditions, NVG use, etc.)…JECC
Provider
• 44E3A Emergency Dept Physician*• SUBS:45A3 Anesthesiologist*44M3 Internal*48R Residency Trained Flight
Surgeon*
* Experience: Active ICU/ER/Critical Care
• BLS/ACLS• ATLS/PALS• CCATT/CSTARS-C• JECC
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2011 MHS Conference
MEDICAL EQUIPMENT
Lightweight, Modular, Grab-n-Go Medical Supplies Approaching ICU Level Care – Rotary Wing or Fixed-Wing– Tight, Austere Environs – AFSOC & CCATT
Equipment Personal Protective
Ensemble – (PPE) To Accompany
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2011 MHS Conference
TCCET SUMMARY
Current Ad Hoc Solutions Result in Non-Standard Level of Care
Intra-Theater Movement of ICU-Level Patients– Presents Option for Care Gap in Non-AE Missions
Lvl-II to Lvl-III– Must be Driven by Clinical Requirements
TCCET Developed to Fill Care Gaps and Augment CCATT
6 AF Personnel (2 Teams) & Equipment being prepared for summer deployment
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2011 MHS Conference
Pain Management
Epidural Management
Regional Blocks
Narcotic Administration
Acupuncture Feasibility Study Jan 11
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2011 MHS Conference
Expanding Global En Route Care
32
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2011 MHS Conference
AE InterFly:Advancing Interoperability
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2011 MHS Conference
Air and Space Interoperablity Council
Mission: Working together to advance global AE response
Focus areas– Medical Equipment– Clinical Capabilities– Command and Control– Doctrine
Goals: – Publish Guidance on each nations capabilities– Exercises that demonstrate AE/Critical Care
34
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2011 MHS Conference 35
Building International Partnerships-
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2011 MHS Conference
Civilian Partnerships
ECMO Pediatric/Neonatology Consortium
58 y/o Male unresponsive to care Needed Adult ECMO
– USA ECMO MD– USAF Neonatologist– Civilian Perfusionist– Civilian ECMO RN
Transported to Iowa36
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2011 MHS Conference
International AE En Route Medical Care Conference
20-21 July 2011Joint Base McChord, WA
Target Audience: Aeromedicalevacuation, patient transport and
critical care teams from any nation
This multinational consortium will allow nations to share advances
in patient transport to include clinical management of patients,
clinical and aircrew training platforms and new technology used to support patient care.
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2011 MHS Conference
Aircraft Modernization
38
-An aircraft's ability to support rapidly developing medical
capabilities is vital to continued advancement in En Route Care
HIGH
WWII
LOW C-47
1940 1950 1970 1980 1990 2000 2010
Medical capabilities (crew skills, training, equipment, special teams)
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2011 MHS Conference
Aircraft Modernization
39
-An aircraft's ability to support rapidly developing medical
capabilities is vital to continued advancement in En Route Care
HIGH
DS/DS
C-17
WWII
LOW C-47
1940 1950 2010
Medical capabilities (crew skills, training, equipment, special teams)
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2011 MHS Conference
Clinical + Aircraft = Capabilities10
40
-An aircraft's ability to support rapidly developing medical
capabilities is vital to continued advancement in En Route Care
HIGH OIF/OEF
DS/DS
WWII
1940 1950
Medical capabilities (crew skills, training, equipment, special teams)
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2011 MHS Conference
Aircraft Design and Acquisition
41
-
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2011 MHS Conference
Clinical and Aircraft Capabilities
Mission Loading Configuration Systems Communication (Future)
Patient Environmental Therapeutic oxygen Electrical Tele-Health (Future)
42
AE Support Requirements
Incorporate AE support requirements into aircraft design
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2011 MHS Conference 43
Research, Training and Technology-------------
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2011 MHS Conference
En Route Care
The Future is Now……
44
Video Link to AF Recruiting Video
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2011 MHS Conference
Questions
45
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