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Zingg SW, Elterman J, Proctor M, Salvator A, Cheney M, Hare J, Davis WT, Rosenberry N, Brown DJ, Earnest R, Robinson FE, Pritts TA, Strilka R. Descriptive Analysis of Intratheater Critical Care Air Transport Team Patient Movements During Troop Drawdown: Afghanistan (2017-2019). Mil Med 2023; 188:3086-3094. [PMID: 35446424 DOI: 10.1093/milmed/usac097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/15/2022] [Accepted: 04/17/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The majority of critical care air transport (CCAT) flights are regulated, meaning that a theater-validating flight surgeon has confirmed that the patient is medically cleared for flight and that evacuation is appropriate. If the conditions on the ground do not allow for this process, the flight is unregulated. Published data are limited regarding CCAT unregulated missions to include the period of troop drawdown at the end of the Afghanistan conflict. The objective of our study was to characterize the unregulated missions within Afghanistan during troop drawdown and compare them to regulated missions during the same timeframe. STUDY DESIGN We performed a retrospective review of all CCAT medical records of patients transported via CCAT within Afghanistan between January 2017 and December 2019. We abstracted data from the records, including mission characteristics, patient demographics, injury descriptors, preflight military treatment facility procedures, CCAT procedures, in-flight CCAT treatments, in-flight events, and equipment issues. Following descriptive and comparative analysis, a Cochran-Armitage test was performed to evaluate the statistical significance of the trend in categorical data over time. Multivariable regression was used to assess the association between vasopressors and preflight massive transfusions, preflight surgical procedures, injury patterns, and age. RESULTS We reviewed 147 records of patients transported via CCAT: 68 patients were transported in a regulated fashion and 79 on an unregulated flight. The number of patients evacuated increased year-over-year (n = 22 in 2017, n = 57 in 2018, and n = 68 in 2019, P < .001), and the percentage of missions that were unregulated grew geometrically (14%, n = 3 in 2017; 37%, n = 21 in 2018; and 81%, n = 55 in 2019, P < .001). During the time studied, CCAT teams were being used more to decompress forward surgical teams (FST) and, therefore, they were transporting patients just hours following initial damage control surgery in an unregulated fashion. In 2 instances, CCAT decompressed an FST following a mass casualty, during which aeromedical evacuation (AE) crews assisted with patient care. For the regulated missions, the treatments that were statistically more common were intravenous fluids, propofol, norepinephrine, any vasopressors, and bicarbonate. During unregulated missions, the statistically more common treatments were ketamine, fentanyl, and 3% saline. Additional analysis of the mechanically ventilated patient subgroup revealed that vasopressors were used twice as often on regulated (38%) vs. unregulated (13%) flights. Multivariable regression analysis demonstrated that traumatic brain injury (TBI) was the only significant predictor of in-flight vasopressor use (odds ratio = 3.53, confidence interval [1.22, 10.22], P = .02). CONCLUSION During the troop drawdown in Afghanistan, the number of unregulated missions increased geometrically because the medical footprint was decreasing. During unregulated missions, CCAT providers used ketamine more frequently, consistent with Tactical Combat Casualty Care guidelines. In addition, TBI was the only predictor of vasopressor use and may reflect an attempt to adhere to unmonitored TBI clinical guidelines. Interoperability between CCAT and AE teams is critical to meet mass casualty needs in unregulated mission environments and highlights a need for joint training. It remains imperative to evaluate changes in mission requirements to inform en route combat casualty care training.
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Affiliation(s)
- S Whitney Zingg
- Department of Surgery, University of Cincinnati, Cincinnati, OH 45219, USA
| | | | - Melissa Proctor
- University of Cincinnati Center for Sustainment of Trauma and Readiness Skills, Cincinnati, OH 45219, USA
| | - Ann Salvator
- Air Force Research Laboratory Airman Biosciences Division, Wright-Patterson Air Force Base, Dayton, OH 45433, USA
| | - Mark Cheney
- University of Cincinnati Center for Sustainment of Trauma and Readiness Skills, Cincinnati, OH 45219, USA
- Department of Anesthesiology, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Jonathan Hare
- University of Cincinnati Center for Sustainment of Trauma and Readiness Skills, Cincinnati, OH 45219, USA
| | - William T Davis
- United States Air Force En route Care Research Center/59th MDW/Science and Technology, JBSA-Fort Sam Houston, TX 78234, USA
| | - Nathan Rosenberry
- University of Cincinnati Center for Sustainment of Trauma and Readiness Skills, Cincinnati, OH 45219, USA
| | - Daniel J Brown
- University of Cincinnati Center for Sustainment of Trauma and Readiness Skills, Cincinnati, OH 45219, USA
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Ryan Earnest
- Department of Surgery, University of Cincinnati, Cincinnati, OH 45219, USA
- University of Cincinnati Center for Sustainment of Trauma and Readiness Skills, Cincinnati, OH 45219, USA
| | - F Eric Robinson
- Naval Medical Research Unit Dayton, Wright-Patterson AFB, OH 454335, USA
| | - Timothy A Pritts
- Department of Surgery, University of Cincinnati, Cincinnati, OH 45219, USA
| | - Richard Strilka
- Department of Surgery, University of Cincinnati, Cincinnati, OH 45219, USA
- University of Cincinnati Center for Sustainment of Trauma and Readiness Skills, Cincinnati, OH 45219, USA
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Veldman A, Diefenbach M, Taymans L, Vadera B, Lelo J, Rouaud Y. Please get me out of here: The difficult decision making in fit-to-fly assessments for international fixed-wing air ambulance operations. Travel Med Infect Dis 2023; 54:102613. [PMID: 37331494 DOI: 10.1016/j.tmaid.2023.102613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/18/2023] [Accepted: 06/15/2023] [Indexed: 06/20/2023]
Abstract
INTRODUCTION With international travel for leisure and business almost back to pre-pandemic levels, demand for repatriation due to illness and injury abroad is increasing [1,2]. In any repatriation, there is considerable pressure on all involved to organize a rapid transport back home. Delay in such action may be perceived by the patient, relatives, and the public as an attempt by the underwriter to hold off on an expensive air ambulance mission [3-5]. METHODS Review of the available literature and analysis of assistance and air ambulance Companies' infrastructure and processes to identify risk and benefit of executing or delaying aeromedical transport for international travellers. KEY FINDINGS While patients of almost any severity can be safely transported over great distances in modern air ambulance aircraft, immediate transport is not always in the patient's best interest. Each call for assistance requires a complex and dynamic risk-benefit analysis with multiple stakeholders involved to achieve an optimized outcome. Opportunities for risk mitigation within the assistance team include active case management with clearly assigned ownership, as well as medical and logistical experience with knowledge on local treatment opportunities and limitations. On the air ambulance side, modern equipment, experience, standards and procedures as well as accreditation can reduce risk. CONCLUSIONS Each patient evaluation remains a highly individual risk-benefit assessment. Optimal outcomes require a clear understanding of responsibilities, flawless communication and significant expertise among the key decision-makers. Negative outcomes are mostly associated with insufficient information, communication, inadequate experience or a lack of ownership/assigned responsibility.
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Affiliation(s)
- Alex Veldman
- UNICAIR, Idstein, Germany; Hudson Institute of Medical Research, Monash University, Melbourne, Australia.
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3
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King B, Cancio LC, Jeng JC. Military Burn Care and Burn Disasters. Surg Clin North Am 2023; 103:529-538. [PMID: 37149388 DOI: 10.1016/j.suc.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Mass-casualty incidents can occur because of natural disasters; industrial accidents; or intentional attacks against civilian, police, or in case of combat, military forces. Depending on scale and type of incident, burn casualties often with a variety of concomitant injuries can be anticipated. The treatment of life-threatening traumatic injuries should take precedent but the stabilization, triage, and follow-on care of these patients will require local, state, and often regional coordination and support.
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Affiliation(s)
- Booker King
- North Carolina Jaycee Burn Center, University of North Carolina Chapel Hill, Burnett Womack Building, Campus Box 7206, Chapel Hill, NC 27599-7206, USA
| | - Leopoldo C Cancio
- U.S. Army Burn Center, U.S. Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234-6315, USA
| | - James C Jeng
- University of California Irvine, 3800 West Chapman Avenue, Suite 6200, Orange, CA 92868, USA.
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Leclerc T, Sjöberg F, Jennes S, Martinez-Mendez JR, van der Vlies CH, Battistutta A, Lozano-Basanta JA, Moiemen N, Almeland SK. European Burns Association guidelines for the management of burn mass casualty incidents within a European response plan. Burns 2023; 49:275-303. [PMID: 36702682 DOI: 10.1016/j.burns.2022.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 12/19/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND A European response plan to burn mass casualty incidents has been jointly developed by the European Commission and the European Burn Association. Upon request for assistance by an affected country, the plan outlines a mechanism for coordinated international assistance, aiming to alleviate the burden of care in the affected country and to offer adequate specialized care to all patients who can benefit from it. To that aim, Burn Assessment Teams are deployed to assess and triage patients. Their transportation priority recommendations are used to distribute outnumbering burn casualties to foreign burn centers. Following an appropriate medical evacuation, these casualties receive specialized care in those facilities. METHODS The European Burns Association's disaster committee developed medical-organizational guidelines to support this European plan. The experts identified fields of interest, defined questions to be addressed, performed relevant literature searches, and added their expertise in burn disaster preparedness and response. Due to the lack of high-level evidence in the available literature, recommendations and specially designed implementation tools were provided from expert opinion. The European Burns Association officially endorsed the draft recommendations in 2019, and the final full text was approved by the EBA executive committee in 2022. RECOMMENDATIONS The resulting 46 recommendations address four fields. Field 1 underlines the need for national preparedness plans and the necessary core items within such plans, including coordination and integration with an international response. Field 2 describes Burn Assessment Teams' roles, composition, training requirements, and reporting goals. Field 3 addresses the goals of specialized in-hospital triage, appropriate severity criteria, and their effects on priorities and triage. Finally, field 4 covers medical evacuations, including their timing and organization, the composition of evacuation teams and their assets, preparation, and the principles of en route care.
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Affiliation(s)
- Thomas Leclerc
- Percy Military Teaching Hospital, Clamart, France; Val-de-Grâce Military Medical Academy, Paris, France
| | | | - Serge Jennes
- Charleroi Burn Wound Center, Skin-burn-reconstruction Pole, Grand Hôpital de Charleroi, Charleroi, Belgium
| | | | - Cornelis H van der Vlies
- Department of Trauma and Burn Surgery, Maasstad Hospital, Rotterdam, the Netherlands; Trauma Research Unit Department of Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Anna Battistutta
- Directorate-General for European Civil Protection and Humanitarian Aid Operations (DG-ECHO), European Commission, Brussels, Belgium
| | - J Alfonso Lozano-Basanta
- Emergency Response Coordination Center, Directorate-General for European Civil Protection and Humanitarian Aid Operations (DG-ECHO), European Commission, Brussels, Belgium
| | - Naiem Moiemen
- University Hospitals Birmingham Foundation Trust, Birmingham, UK; University of Birmingham, College of Medical and Dental Sciences, Birmingham, UK
| | - Stian Kreken Almeland
- Norwegian National Burn Center, Department of Plastic, Hand, and Reconstructive Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Norway; Norwegian Directorate of Health, Department of Preparedness and Emergency Medical Services, Oslo, Norway.
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Ferrada P, Cannon JW, Kozar RA, Bulger EM, Sugrue M, Napolitano LM, Tisherman SA, Coopersmith CM, Efron PA, Dries DJ, Dunn TB, Kaplan LJ. Surgical Science and the Evolution of Critical Care Medicine. Crit Care Med 2023; 51:182-211. [PMID: 36661448 DOI: 10.1097/ccm.0000000000005708] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.
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Affiliation(s)
- Paula Ferrada
- Division of Trauma and Acute Care Surgery, Department of Surgery, Inova Fairfax Hospital, Falls Church, VA
| | - Jeremy W Cannon
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rosemary A Kozar
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Eileen M Bulger
- Division of Trauma, Burn and Critical Care Surgery, Department of Surgery, University of Washington at Seattle, Harborview, Seattle, WA
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, County of Donegal, Ireland
| | - Lena M Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Samuel A Tisherman
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Craig M Coopersmith
- Division of General Surgery, Department of Surgery, Emory University, Emory Critical Care Center, Atlanta, GA
| | - Phil A Efron
- Department of Surgery, Division of Critical Care, University of Florida, Gainesville, FL
| | - David J Dries
- Department of Surgery, University of Minnesota, Regions Healthcare, St. Paul, MN
| | - Ty B Dunn
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Section of Surgical Critical Care, Surgical Services, Philadelphia, PA
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Post J, Maeckelburg MC, Jagel V, Sammito S. Changes in vital signs, ventilation mode, and catecholamine use during intensive care aeromedical evacuation flights. Front Public Health 2023; 11:1100832. [PMID: 36923050 PMCID: PMC10008855 DOI: 10.3389/fpubh.2023.1100832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/09/2023] [Indexed: 03/01/2023] Open
Abstract
Introduction Especially after (natural) disasters, local health systems are also destroyed or their ability to work is massively restricted. The transport of injured patients is therefore often necessary for further care. Numerous nations keep fixed-wing aircraft with intensive-care capabilities available for secondary transport, but little data on the transport is available to date. Methods An analysis of all flights with the German Air Force's intensive care fixed-wing-aircraft carried out in the context of humanitarian aid missions since 2002 with a focus on intubated patients was done. Results A total of 38 patients were transported. Two patients had to be intubated on or during transport. There were significant changes in the necessary positive end-expiratory pressure (PEEP) and the fraction of inspired oxygen. Circulatory parameters did not change. Discussion Overall, there are no clinically relevant deteriorations due to secondary transport with corresponding air transfers. Due to the hypobaric hypoxic conditions on board of all aircrafts, intubation in clinically borderline patients should be performed electively on the ground before flight.
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Affiliation(s)
- Janina Post
- Department Experimental Aerospace Medicine Research, German Air Force Centre of Aerospace Medicine, Cologne, Germany
| | - Marc Christoph Maeckelburg
- Department Experimental Aerospace Medicine Research, German Air Force Centre of Aerospace Medicine, Cologne, Germany
| | - Vitali Jagel
- Department Experimental Aerospace Medicine Research, German Air Force Centre of Aerospace Medicine, Cologne, Germany
| | - Stefan Sammito
- Department Experimental Aerospace Medicine Research, German Air Force Centre of Aerospace Medicine, Cologne, Germany.,Department of Occupational Medicine, Faculty of Medicine, Otto von Guericke University of Magdeburg, Magdeburg, Germany
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Abstract
OBJECTIVES To assess recent advances in interfacility critical care transport. DATA SOURCES PubMed English language publications plus chapters and professional organization publications. STUDY SELECTION Manuscripts including practice manuals and standard (1990-2021) focused on interfacility transport of critically ill patients. DATA EXTRACTION Review of society guidelines, legislative requirements, objective measures of outcomes, and transport practice standards occurred in work groups assessing definitions and foundations of interfacility transport, transport team composition, and transport specific considerations. Qualitative analysis was performed to characterize current science regarding interfacility transport. DATA SYNTHESIS The Task Force conducted an integrative review of 496 manuscripts combined with 120 from the authors' collections including nonpeer reviewed publications. After title and abstract screening, 40 underwent full-text review, of which 21 remained for qualitative synthesis. CONCLUSIONS Since 2004, there have been numerous advances in critical care interfacility transport. Clinical deterioration may be mitigated by appropriate patient selection, pretransport optimization, and transport by a well-resourced team and vehicle. There remains a dearth of high-quality controlled studies, but notable advances in monitoring, en route management, transport modality (air vs ground), as well as team composition and training serve as foundations for future inquiry. Guidance from professional organizations remains uncoupled from enforceable regulations, impeding standardization of transport program quality assessment and verification.
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Aeromedical Transportation of the Critically Ill Cardiac Patient: Pre-flight Planning and Preparation. Curr Probl Cardiol 2022:101246. [DOI: 10.1016/j.cpcardiol.2022.101246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 11/17/2022]
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Nowadly CD, Foley KE, Davis ML, Hebert EJ, Corey GA. Development of a Critical Care Air Transport Team "Go Bag": Slimming Down ICU Capability to Augment Pararescue or Civilian Contract Medical Evacuation Personnel. Mil Med 2021; 188:usab466. [PMID: 34755847 DOI: 10.1093/milmed/usab466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/26/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Critical Care Air Transport Team (CCATT) is a three-person United States Air Force (USAF) medical asset, typically providing intercontinental medical evacuation on large military aircraft. The CCATT equipment Allowance Standard (AS) weighs approximately 272 kg (600 lbs). In austere locations, CCATT teams may augment contract medical evacuation (CME) personnel or Pararescue (PJ) in small aircraft with limited space for medical equipment. It was unknown what deployed PJ and CME carry within their packouts. We sought to design a packout or "Go Bag," weighing less than 22.7 kg (50 lbs) and sourced from the CCATT AS, that a CCATT member could use to complement CME or PJ equipment to provide a higher level of care while limiting redundancy. MATERIALS AND METHODS Equipment lists were obtained from a CME and PJs from two separate USAF squadrons. The equipment lists were combined to provide a reference for development of a CCATT Go Bag. Three members of a deployed CCATT team independently generated a list of necessary equipment from the CCATT AS. The list was peer reviewed by a separate, deployed CCATT team. RESULTS A Go Bag was developed with the supplies and equipment necessary for video laryngoscopy, ventilation, invasive pressure monitoring, basic laboratory capability, chest tube placement, ultrasound, and advanced pharmacologic interventions. The Go Bag weighed 18.3 kg (40.4 lbs). A separate respiratory bag weighing 1.1 kg (2.4 lbs) was attached directly to a ventilator. Intravenous pumps and cardiac monitoring equipment were notable ICU equipment excluded from the Go Bag. CONCLUSION Major components of the CCATT AS can be reduced into a Go Bag and accompanying Ventilator Accessory Bag. This may benefit CCATT teams required to augment PJs or CME in small aircraft during prolonged field care scenarios.
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Affiliation(s)
- Craig D Nowadly
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Kyle E Foley
- Department of Emergency Medicine, Keesler Air Force Base, Biloxi, MS 39534, USA
| | - Maxwell L Davis
- Department of Emergency Medicine, Keesler Air Force Base, Biloxi, MS 39534, USA
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Kırbaş Ö. Air transport of patients with critical cardiac conditions requiring intensive care. Anatol J Cardiol 2021; 25:31-33. [PMID: 34464299 DOI: 10.5152/anatoljcardiol.2021.s112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
It is extremely important that patients with severe heart disease who need an intensive care unit can be quickly transferred to advanced centers. Air transport is the fastest and safest way for doing this in these patients, and its importance has been recognized in recent years. In this review, we examined the details of air transport of patients with critical cardiac conditions.
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Affiliation(s)
- Özgür Kırbaş
- Department of Cardiology, Faculty of Medicine, Lokman Hekim University; Ankara-Turkey
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11
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Ponsin P, Swiech A, Poyat C, Alves F, Jacques AE, Franchin M, Raynaud L, Boutonnet M. Strategic air medical evacuation of critically ill patients involving an intensive care physician: A retrospective analysis of 16 years of mission data. Injury 2021; 52:1176-1182. [PMID: 33082029 DOI: 10.1016/j.injury.2020.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/18/2020] [Accepted: 10/01/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Strategic medical evacuation (MEDEVAC) allows airborne repatriation of soldiers injured or sick on missions to their national territory. The aim of this study was to describe the epidemiology of strategic MEDEVAC performed by intensive care physicians (ICP) and to analyze the role of the ICP in the management of critical care situations in flight. METHODS All soldiers who had high or medium dependency conditions and who benefited from a strategic MEDEVAC with an ICP on board between 1 January 2001 and 30 November 2017 were included in this epidemiological retrospective study. RESULTS A total of 452 soldiers were repatriated; the causes of repatriation were either trauma (n = 245; 54%) or medical pathologies (n = 207; 46%). Two hundred and seventy-six (61%) evacuations were performed within 48 h. The median annual number of strategic MEDEVAC with an ICP was 26 [20-32]. One hundred and fifty-five (34%) patients were mechanically ventilated and 103 (23%) received catecholamines. The median SAPS II score was 13 [8-24]. One hundred and seventy-eight adverse events were identified, of which 123 (69%) related to a worsening of the patient's clinical condition and 30 (20%) related to a technical problem. Forty-seven (20%) patients who initially appeared stable worsened during the flight. No deaths occurred on board, however, and no flights had to be diverted due to an uncontrolled care situation. CONCLUSION The results suggested that the presence of an ICP ensured a continued high-level care for patients with serious trauma and medical injuries, due to the medical and aeronautical expertise that resulted from the theoretical and practical training of the personnel on board. Based on these results, lessons regarding future MEDEVAC flights could be learned in order to continue to improve patient outcome.
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Affiliation(s)
- Pauline Ponsin
- Burn Treatment Center, Percy Military Teaching Hospital, Clamart, France.
| | - Astrée Swiech
- Department of Anesthesiology and Intensive care, Percy Military Teaching Hospital, Clamart, France
| | - Chrystelle Poyat
- Department of Anesthesiology and Intensive care, Percy Military Teaching Hospital, Clamart, France.
| | - François Alves
- Department of Anesthesiology and Intensive Care, Sud Francilien Teaching Hospital, Corbeil-Essonnes, France
| | | | - Marylin Franchin
- 2ème Centre Medical des Armées, 12ème Antenne Médicale, French Army Medical Service, Villacoublay, France.
| | - Laurent Raynaud
- Department of Anesthesiology and Intensive care, Bégin Military Teaching Hospital, Saint-Mandé, France.
| | - Mathieu Boutonnet
- Department of Anesthesiology and Intensive care, Percy Military Teaching Hospital, Clamart, France
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Abstract
OBJECTIVES Modern critical care amasses unprecedented amounts of clinical data-so called "big data"-on a minute-by-minute basis. Innovative processing of these data has the potential to revolutionize clinical prognostics and decision support in the care of the critically ill but also forces clinicians to depend on new and complex tools of which they may have limited understanding and over which they have little control. This concise review aims to provide bedside clinicians with ways to think about common methods being used to extract information from clinical big datasets and to judge the quality and utility of that information. DATA SOURCES We searched the free-access search engines PubMed and Google Scholar using the MeSH terms "big data", "prediction", and "intensive care" with iterations of a range of additional potentially associated factors, along with published bibliographies, to find papers suggesting illustration of key points in the structuring and analysis of clinical "big data," with special focus on outcomes prediction and major clinical concerns in critical care. STUDY SELECTION Three reviewers independently screened preliminary citation lists. DATA EXTRACTION Summary data were tabulated for review. DATA SYNTHESIS To date, most relevant big data research has focused on development of and attempts to validate patient outcome scoring systems and has yet to fully make use of the potential for automation and novel uses of continuous data streams such as those available from clinical care monitoring devices. CONCLUSIONS Realizing the potential for big data to improve critical care patient outcomes will require unprecedented team building across disparate competencies. It will also require clinicians to develop statistical awareness and thinking as yet another critical judgment skill they bring to their patients' bedsides and to the array of evidence presented to them about their patients over the course of care.
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Cannon J, Pamplin J, Zonies D, Mason P, Sine C, Cancio L, McNeill J, Colombo C, Osborn E, Ricca R, Allan P, DellaVolpe J, Chung K, Stockinger Z. Acute Respiratory Failure. Mil Med 2019; 183:123-129. [PMID: 30189088 DOI: 10.1093/milmed/usy151] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Indexed: 11/12/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a condition affecting critically ill patients, characterized by pulmonary inflammation and defects in oxygenation due to either direct or indirect injury to the lungs. These guidelines will define the diagnosis and management of ARDS, particularly among combat casualties and patients in the deployed environment. The cornerstone of management of ARDS involves maintaining adequate oxygenation while avoiding further pulmonary injury through lung-protective ventilation. Additional strategies for advanced respiratory failure, such as prone positioning, neuromuscular blockade, and extracorporeal membrane oxygenation will be reviewed here as well. Particularly important to the care of the patient with ARDS in the deployed environment is a familiarity with the challenges and indications for transport/aeromedical evacuation.
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Affiliation(s)
- Jeremy Cannon
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Jeremy Pamplin
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - David Zonies
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Phillip Mason
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Christy Sine
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Leopoldo Cancio
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Jeffrey McNeill
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Christopher Colombo
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Erik Osborn
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Robert Ricca
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Patrick Allan
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Jeff DellaVolpe
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Kevin Chung
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Zsolt Stockinger
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
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Paul Pelletier N, Fisher A. Infusion Pump in UH60L/M Flight in Afghanistan: Why Failures Occur. Air Med J 2017; 36:248-257. [PMID: 28886786 DOI: 10.1016/j.amj.2017.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 04/04/2017] [Accepted: 04/15/2017] [Indexed: 11/18/2022]
Abstract
The ALARIS MSIII Infusion Pump (CareFusion, San Diego, CA) uses 3 separate alarms designed to prevent air emboli: "check air sensor," "air in lower tubing," and "air in line." It is assumed that ambient pressure changes cause air emboli that lead to pump failure although evidence to support this is limited. In this small study, the MSIII proved to be highly resilient and able to maintain function even after large repetitive emboli. Although unproven, it is more likely that these alarms are usually caused by loosening of the intravenous tubing within the pump's collar. This disjointing of the tubing and the ultrasonic sensor can be perceived as an air embolus leading to severe consequences. If the user attempts the clear air function, the pump will not resume function. Problems such as this may have been related to at least 1 reported patient death. More research is needed to determine the cause of these alarms and determine the exact cause. Patient safety can potentially be improved at all levels including manufacturer modifications and operator training. It seems reasonable that the manufacturer should design a mode ("transport mode") that allows the pump to function even with air emboli.
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Affiliation(s)
| | - Andrew Fisher
- MAJ, 7249th Medical Support Unit, United States Army Reserve, Houston, TX; Texas A&M College of Medicine, Bryan, TX
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Boutonnet M, Pasquier P, Raynaud L, Vitiello L, Bancarel J, Coste S, de Saint Maurice GP, Ausset S. Ten Years of En Route Critical Care Training. Air Med J 2017; 36:62-66. [PMID: 28336015 DOI: 10.1016/j.amj.2016.12.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 11/10/2016] [Accepted: 12/24/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The French Military Health Service (FMHS) has developed a training program for medical evacuation (MEDEVAC) of critical care patients on fixed wing aircraft. METHODS We conducted a 10-year retrospective analysis (2006-2015) of the data from the FMHS Academy. The number of trainees was listed according to the different courses and medical specialties. The number of MEDEVACs recorded during the period was described. RESULTS Since 2006, the FMHS has developed training courses designed for MEDEVAC of critical care patients. Forty-five collective strategic MEDEVAC courses were delivered to 91 intensivists, 130 anesthetic nurses, 79 flight surgeons, 55 flight nurses, and 89 nurses. Five sessions of tactical MEDEVAC courses were performed for 14 flight surgeons, 6 flight nurses, and 17 other nurses. Ten sessions of individual strategic MEDEVAC courses were delivered to 17 intensivists, 10 flight surgeons, 21 flight nurses, and 7 other nurses. Between 2006 and 2015, 818 (± 68) individual strategic MEDEVACs were performed per year. Thirty-three (± 19) concerned critical care patients. Five missions of collective strategic MEDEVAC were performed for 56 patients. CONCLUSION The FMHS has developed specific courses for the MEDEVAC of critical care patients, allowing the training of numerous MEDEVAC teams.
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Affiliation(s)
- Mathieu Boutonnet
- Department of Anesthesiology and Intensive Care, Percy Military Teaching Hospital, Clamart, France.
| | - Pierre Pasquier
- Department of Anesthesiology and Intensive Care, Percy Military Teaching Hospital, Clamart, France; 14th Airborne Forward Surgical Team, Percy Military Teaching Hospital, Clamart, France
| | - Laurent Raynaud
- Department of Anesthesiology and Intensive Care, Bégin Military Teaching Hospital, Saint-Mandé, France
| | | | - Jérôme Bancarel
- Operational Headquarters of the French Military Health Service, Paris, France
| | | | | | - Sylvain Ausset
- Department of Anesthesiology and Intensive Care, Percy Military Teaching Hospital, Clamart, France
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Bradley M, Nealeigh M, Oh JS, Rothberg P, Elster EA, Rich NM. Combat casualty care and lessons learned from the past 100 years of war. Curr Probl Surg 2017; 54:315-351. [PMID: 28595716 DOI: 10.1067/j.cpsurg.2017.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 02/06/2017] [Indexed: 12/25/2022]
Affiliation(s)
- Matthew Bradley
- Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD.
| | - Matthew Nealeigh
- Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - John S Oh
- Division of Global Surgery, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Philip Rothberg
- Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Norman M Rich
- Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD; Division of Global Surgery, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
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17
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Nye NS, de la Motte SJ. Rationale for Embedded Musculoskeletal Care in Air Force Training and Operational Units. J Athl Train 2016; 51:846-848. [PMID: 27685161 DOI: 10.4085/1062-6050.51.5.10] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Nathaniel S Nye
- 559th Trainee Health Squadron, Joint Base San Antonio-Lackland, TX
| | - Sarah J de la Motte
- Injury Prevention Research Laboratory, Consortium for Health and Military Performance, Uniformed Services University, Bethesda, MD
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Alfes CM, Steiner S, Rutherford-Hemming T. Challenges and Resources for New Critical Care Transport Crewmembers: A Descriptive Exploratory Study. Air Med J 2016; 35:212-215. [PMID: 27393756 DOI: 10.1016/j.amj.2016.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 04/07/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE The purpose of this study was to identify the challenges new crewmembers experience in the critical care transport (CCT) environment and to determine the most valuable resources when acclimating to the transport environment. To date, no study has focused on the unique challenges nor the resources most effective in CCT training. METHODS This descriptive exploratory study was conducted with a convenience survey sent to the 3 largest professional CCT organizations: the Association of Air Medical Services, the Air and Surface Transport Nurses Association, and the Association of Critical Care Transport. RESULTS The study survey responses revealed that more education and training are needed. Novice crewmembers identified areas in safety, communication, environment, and crew resource management as particularly challenging. Responses also validate the need for more simulation training, especially for CCT of low-volume/high-risk patient populations. CONCLUSION Results of this survey provide valuable insight for improving training effectiveness of health care professionals transitioning to the CCT environment. More information regarding best practice on the frequency and timing of CCT simulation training should be collected, particularly for simulations completed in the transport environment.
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Affiliation(s)
- Celeste M Alfes
- Learning Resource Skills and Simulation Center, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH.
| | - Stephanie Steiner
- Dorothy Ebersbach Academic Center for Flight Nursing, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH
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Medication Administration in Critical Care Transport of Adult Patients with Hypoxemic Respiratory Failure. Prehosp Disaster Med 2015; 30:431-5. [PMID: 26178583 DOI: 10.1017/s1049023x1500494x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Critical care transport (CCT) teams must manage a wide array of medications before and during transport. Appreciating the medications required for transport impacts formulary development as well as staff education and training. Problem As there are few data describing the patterns of medication administration, this study quantifies medication administrations and patterns in a series of adult CCTs. METHODS This was a retrospective review of medication administration during CCTs of patients with severe hypoxemic respiratory failure from October 2009 through December 2012 from referring hospitals to three tertiary care hospitals. RESULTS Two hundred thirty-nine charts were identified for review. Medications were administered by the CCT team to 98.7% of these patients, with only three patients not receiving any medications from the team. Fifty-nine medications were administered in total with 996 instances of administration. Fifteen drugs were each administered to only one patient. The mean number of medications per patient was 4.2 (SD=1.8) with a mean of 1.9 (SD=1.1) drug infusions per patient. CONCLUSIONS These results demonstrate that, even within a relatively homogeneous population of patients transferred with hypoxemic respiratory failure, a wide range of medications were administered. The CCT teams frequently initiated, titrated, and discontinued continuous infusions, in addition to providing numerous doses of bolused medications.
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A Prospective Observational Study of Abdominal Injury Management in Contemporary Military Operations. Ann Surg 2015; 261:765-73. [DOI: 10.1097/sla.0000000000000657] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fleming ME, Bharmal H, Valerio I. Regenerative medicine applications in combat casualty care. Regen Med 2015; 9:179-90. [PMID: 24750059 DOI: 10.2217/rme.13.96] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The purpose of this report is to describe regenerative medicine applications in the management of complex injuries sustained by service members injured in support of the wars in Afghanistan and Iraq. Improvements in body armor, resuscitative techniques and faster transport have translated into increased patient survivability and more complex wounds. Combat-related blast injuries have resulted in multiple extremity injuries, significant tissue loss and amputations. Due to the limited availability and morbidity associated with autologous tissue donor sites, the introduction of regenerative medicine has been critical in managing war extremity injuries with composite massive tissue loss. Through case reports and clinical images, this report reviews the application of regenerative medicine modalities employed to manage combat-related injuries. It illustrates that the novel use of hybrid reconstructions combining traditional and regenerative medicine approaches are an effective tool in managing wounds. Lessons learned can be adapted to civilian care.
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Affiliation(s)
- Mark E Fleming
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889, USA
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King MA, Niven AS, Beninati W, Fang R, Einav S, Rubinson L, Kissoon N, Devereaux AV, Christian MD, Grissom CK. Evacuation of the ICU: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2015; 146:e44S-60S. [PMID: 25144509 DOI: 10.1378/chest.14-0735] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Despite the high risk for patient harm during unanticipated ICU evacuations, critical care providers receive little to no training on how to perform safe and effective ICU evacuations. We reviewed the pertinent published literature and offer suggestions for the critical care provider regarding ICU evacuation. The suggestions in this article are important for all who are involved in pandemics or disasters with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. METHODS The Evacuation and Mobilization topic panel used the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop seven key questions for which specific literature searches were conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. RESULTS Based on current best evidence, we provide 13 suggestions outlining a systematic approach to prepare for and execute an effective ICU evacuation during a disaster. Interhospital and intrahospital collaboration and functional ICU communication are critical for success. Pre-event planning and preparation are required for a no-notice evacuation. A Critical Care Team Leader must be designated within the Hospital Incident Command System. A three-stage ICU Evacuation Timeline, including (1) no immediate threat, (2) evacuation threat, and (3) evacuation implementation, should be used. Detailed suggestions on ICU evacuation, including regional planning, evacuation drills, patient transport preparation and equipment, patient prioritization and distribution for evacuation, patient information and tracking, and federal and international evacuation assistance systems, are also provided. CONCLUSIONS Successful ICU evacuation during a disaster requires active preparation, participation, communication, and leadership by critical care providers. Critical care providers have a professional obligation to become better educated, prepared, and engaged with the processes of ICU evacuation to provide a safe continuum of critical care during a disaster.
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Gilhooly J, Siu A, Beare M, Ecklund JM. Acute management of military-related injury. HANDBOOK OF CLINICAL NEUROLOGY 2015; 127:379-93. [PMID: 25702229 DOI: 10.1016/b978-0-444-52892-6.00024-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Since the dawn of armed conflict head trauma has remained one of the most challenging afflictions for surgeons and medical personnel to treat. Interventions for head trauma from antiquity through the American Civil War were met with dismal outcomes. In the 20th century, despite greater lethality of weapons, progressive advances in management led to improved outcomes for head injured patients. A triage system consisting of appropriate levels of care from the front lines, through combat support hospitals to reconstructive and rehabilitative hospitals, has also contributed to the improved outcomes of head injured patients. This chapter examines the progressive improvement in management strategies during major conflicts, the mechanisms causing head trauma during conflict, and the current medical and surgical therapies recommended in the care of head-injured patients during armed conflict.
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Affiliation(s)
- Jonathan Gilhooly
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Alan Siu
- Department of Neurosurgery, George Washington University, Washington, DC, USA
| | - Marianne Beare
- Department of Neurosciences, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - James M Ecklund
- Department of Neurosciences, Inova Fairfax Medical Campus, Falls Church, VA, USA.
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Raynovich W, Hums J, Stuhlmiller DF, Bramble JD, Kasha T, Galt K. Critical care transportation by paramedics: a cross-sectional survey. Air Med J 2014; 32:280-8. [PMID: 24001916 DOI: 10.1016/j.amj.2013.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 05/27/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The purpose of this study was to gather data from paramedics practicing in the critical care transport setting to guide development of the education, training, and clinical practices for certification as a critical care paramedic. METHODS A paper survey of 1991 randomly selected nationally registered (NREMT) paramedics was conducted. Nine paramedics with residences in small US Pacific Island territories were not included in the survey. RESULTS We received 610 responses (30.6%). Respondents that stated that they provided critical care transport services reported using pediatric skills and equipment the most and intracranial pressure monitoring the least. Paramedics served as the primary provider for pediatric patients (72.5%), 12-lead electrocardiogram (66.3%), intravenous infusion pump (76.7%), mechanical ventilator (66.9%), central line management (63.1%), and chest tube management (63.3%). Paramedics served in a team member capacity most often with neonatal isolette (71.8%), intra-aortic balloon pump (79.2%), and ICP monitoring (64.9%). The majority provided ground critical care transport (249) compared to 44 rotor-wing and 6 fixed-wing. Sixteen respondents reported serving as primary providers on combinations of ground, rotor-, and fixed-wing services. CONCLUSIONS Paramedics reported being the primary provider on the critical care transport team and performing skills while using equipment and administering medications that exceeded their education and training as paramedic and, at times, without the benefit of any additional education or training. National appreciation of this reality should spur development of standardized education, licensing or certification, and continuing education to prepare paramedics for their role as critical care medical providers.
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Affiliation(s)
- William Raynovich
- Emergency Medical Services Medical Education Program, Creighton University, Omaha, NE, USA.
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Abstract
OBJECTIVES Inappropriate distribution of casualties in mass-casualty incidents (MCIs) may overwhelm hospitals. This study aimed to review the consequences of evacuating casualties from a bus accident to a single peripheral hospital and lessons learned regarding policy of casualty evacuation. METHODS Medical records of all casualties relating to evacuation times, injury severity, diagnoses, treatments, resources utilized and outcomes were independently reviewed by two senior trauma surgeons. In addition, four senior trauma surgeons reviewed impact of treatment provided on patient outcomes. They reviewed the times for the primary and secondary evacuation, injury severity, diagnoses, surgical treatments, resources utilized, and the final outcomes of the patients at the point of discharge from the tertiary care hospital. RESULTS Thirty-one survivors were transferred to the closest local hospital; four died en route to hospital or within 30 minutes of arrival. Twenty-seven casualties were evacuated by air from the local hospital within 2.5 to 6.15 hours to Level I and II hospitals. Undertriage of 15% and overtriage of seven percent were noted. Four casualties did not receive treatment that might have improved their condition at the local hospital. CONCLUSIONS In MCIs occurring in remote areas, policy makers should consider revising the current evacuation plan so that only immediate unstable casualties should be transferred to the closest primary hospital. On site Advanced Life Support (ALS) should be administered to non-severe casualties until they can be evacuated directly to tertiary care hospitals. First responders must be trained to provide ALS to non-severe casualties until evacuation resources are available.
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Extracorporeal organ support following trauma: the dawn of a new era in combat casualty critical care. J Trauma Acute Care Surg 2013; 75:S120-8; discussion S128-9. [PMID: 23883896 DOI: 10.1097/ta.0b013e318299d0cb] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Massalou D, Fournier M, Salucki B, Baqué P. Small bowel obstruction secondary to transport aircraft: coincidence or reality? Clin Res Hepatol Gastroenterol 2013; 37:434-6. [PMID: 23806628 DOI: 10.1016/j.clinre.2013.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 04/23/2013] [Accepted: 05/14/2013] [Indexed: 02/04/2023]
Abstract
Small bowel obstructions (SBO) are a leading cause of admission to general surgery, posing the problem of the aetiology and treatment based on the diagnosis. More than 300 patients were admitted for SBO in 2011 in our institution. In our clinical practice, we have had to care for patients with SBO immediately after air travel, all of whom had an antecedent of abdominal surgery by laparotomy. The finding of episodes of acute SBO immediately following a commercial flight has never been reported in the literature. We report the cases of four patients for whom we offer several pathophysiological hypotheses, and we publish the first dietary rules for people with a history of intraperitoneal surgery to adopt during a flight.
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Affiliation(s)
- D Massalou
- Acute care surgery unit, St Roch Hospital, University Hospital of Nice, University of Nice Sophia-Antipolis, Nice, France.
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Marchigiani R, Gordy S, Cipolla J, Adams RC, Evans DC, Stehly C, Galwankar S, Russell S, Marco AP, Kman N, Bhoi S, Stawicki SPA, Papadimos TJ. Wind disasters: A comprehensive review of current management strategies. Int J Crit Illn Inj Sci 2013; 3:130-42. [PMID: 23961458 PMCID: PMC3743338 DOI: 10.4103/2229-5151.114273] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Wind disasters are responsible for tremendous physical destruction, injury, loss of life and economic damage. In this review, we discuss disaster preparedness and effective medical response to wind disasters. The epidemiology of disease and injury patterns observed in the early and late phases of wind disasters are reviewed. The authors highlight the importance of advance planning and adequate preparation as well as prompt and well-organized response to potential damage involving healthcare infrastructure and the associated consequences to the medical response system. Ways to minimize both the extent of infrastructure damage and its effects on the healthcare system are discussed, focusing on lessons learned from recent major wind disasters around the globe. Finally, aspects of healthcare delivery in disaster zones are reviewed.
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Affiliation(s)
- Raffaele Marchigiani
- Department of Surgery, Temple St Luke's Medical School, Bethlehem, Pennsylvania, United States of America
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Lairet J, King J, Vojta L, Beninati W. Short-term outcomes of US Air Force Critical Care Air Transport Team (CCATT) patients evacuated from a combat setting. PREHOSP EMERG CARE 2013; 17:486-90. [PMID: 23865806 DOI: 10.3109/10903127.2013.811564] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE The purpose of this study is to describe the short-term outcomes (during air transport) of patients managed by the United States Air Force Critical Care Air Transport Teams (CCATT). METHODS This is a retrospective chart review of patients who were transported by CCATT between March 1, 2007 and June 30, 2008. A standardized abstraction form was used. Patients were classified as medical or trauma. Care given inflight was documented, including mechanical ventilation, vasoactive medication administration, and administration of blood products. Short-term events (during air transport) included death, oxyhemoglobin desaturation, hypotension, decline in neurological status, development of anuria or oliguria, and dislodgement of endotracheal and chest tubes. RESULTS A total of 656 patient moves met inclusion criteria, of which 425 (64.8%) were trauma and 231 (35.2%) were medical. Mechanical ventilation was required by 318 (49%), 68 (10%) received vasoactive medications, and 43 (7%) required blood products during the flight. There were a total of 75 events documented on 65 patient transports (10%). Of these, 19 were oxyhemoglobin desaturation, 29 were hypotension, 3 were decline in neurological status, and 23 were due to anuria or oliguria. We did not encounter any deaths or loss of airway or chest tubes during transport. CONCLUSION CCATTs are a successful platform in transporting critically injured/ill patients with minimal short-term complications.
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Affiliation(s)
- Julio Lairet
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA 30308, USA.
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The incidence of fever in US Critical Care Air Transport Team combat trauma patients evacuated from the theater between March 2009 and March 2010. J Emerg Nurs 2013; 39:e101-6. [PMID: 23684131 DOI: 10.1016/j.jen.2013.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 01/31/2013] [Accepted: 02/03/2013] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Most critically ill injured patients are transported out of the theater by Critical Care Air Transport Teams (CCATTs). Fever after trauma is correlated with surgical complications and infection. The purposes of this study are to identify the incidence of elevated temperature in patients managed in the CCATT environment and to describe the complications reported and the treatments used in these patients. METHODS We performed a retrospective review of available records of trauma patients from the combat theater between March 1, 2009, and March 31, 2010, who were transported by the US Air Force CCATT and had an incidence of hyperthermia. We then divided the cohort into 2 groups, patients transported with an elevation in temperature greater than 100.4°F and patients with no documented elevation in temperature. We used a standardized, secure electronic data collection form to abstract the outcomes. Descriptive data collected included injury type, temperature, use of a mechanical ventilator, cooling treatment modalities, antipyretics, intravenous fluid administration, and use of blood products. We also evaluated the incidence of complications during the transport in patients who had a recorded elevation in temperature greater than 100.4°F. RESULTS A total of 248 trauma patients met the inclusion criteria, and 101 trauma patients (40%) had fever. The mean age was 28 years, and 98% of patients were men. The mechanism of injury was an explosion in 156 patients (63%), blunt injury in 11 (4%), and penetrating injury in 45 (18%), whereas other trauma-related injuries accounted for 36 patients (15%). Of the patients, 209 (84%) had battle-related injuries and 39 (16%) had non-battle-related injuries. Traumatic brain injury was found in 24 patients (24%) with an incidence of elevated temperature. The mean temperature was 101.6°F (range, 100.5°F-103.9°F). After evaluation of therapies and treatments, 80 trauma patients (51%) were intubated on a mechanical ventilator (P < .001). Of the trauma patients with documented fever, 22 (22%) received administration of blood products. Nineteen patients received antipyretics during their flight (19%), 9 received intravenous fluids (9%), and 2 received nonpharmacologic cooling interventions, such as cooling blankets or icepacks. We identified 1 trauma patient with neurologic changes (1%), 6 with hypotension (6%), 48 with tachycardia (48%), 33 with decreased urinary output (33%), and 1 with an episode of shivering or sweating (1%). We did not detect any transfusion reactions or deaths during flight. CONCLUSION Fever occurred in 41% of critically ill combat-injured patients evacuated out of the combat theater in Iraq and Afghanistan. Fewer than 20% of patients with a documented elevated temperature received treatments to reduce the temperature. Intubation of patients with ventilators in use during the transport was the only factor significantly associated with fever. Serious complications were rare, and there were no deaths during these transports.
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Burns S, York A, Niemtzow RC, Garner BK, Steele N, Walter JA. Moving Acupuncture to the Frontline of Military Medical Care: A Feasibility Study. Med Acupunct 2013. [DOI: 10.1089/acu.2012.0933] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | | | | | - Nancy Steele
- Landstuhl Regional Medical Center, Landstuhl, Germany
- Current affiliation: Womack Army Medical Center, Fort Bragg, NC
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Supplemental oxygen attenuates the increase in wound bacterial growth during simulated aeromedical evacuation in goats. J Trauma Acute Care Surg 2012; 73:80-6. [PMID: 22743376 DOI: 10.1097/ta.0b013e31824cf215] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Bacterial growth in soft tissue and open fractures is a known risk factor for tissue loss and complications in contaminated musculoskeletal wounds. Current care for battlefield casualties with soft tissue and musculoskeletal wounds includes tactical and strategic aeromedical evacuation (AE). This exposes patients to a hypobaric, hypoxic environment. In this study, we sought to determine whether exposure to AE alters bacterial growth in contaminated complex musculoskeletal wounds and whether supplemental oxygen had any effect on wound infections during simulated AE. METHODS A caprine model of a contaminated complex musculoskeletal wound was used. Complex musculoskeletal wounds were created and inoculated with bioluminescent Pseudomonas aeruginosa. Goats were divided into three experimental groups: ground control, simulated AE, and simulated AE with supplemental oxygen. Simulated AE was induced in a hypobaric chamber pressurized to 8,800 feet for 7 hours. Bacterial luminescence was measured using a photon counting camera at three time points: preflight (20 hours postsurgery), postflight (7 hours from preflight and 27 hours postsurgery), and necropsy (24 hours from preflight and 44 hours postsurgery). RESULTS There was a significant increase in bacterial growth in the AE group compared with the ground control group measured postflight and at necropsy. Simulated AE induced hypoxia with oxygen saturation less than 93%. Supplemental oxygen corrected the hypoxia and significantly reduced bacterial growth in wounds at necropsy. CONCLUSIONS Hypoxia induced during simulated AE enhances bacterial growth in complex musculoskeletal wounds which can be prevented with the application of supplemental oxygen to the host.
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Makley AT, Belizaire R, Campion EM, Goodman MD, Sonnier DI, Friend LA, Schuster RM, Bailey SR, Johannigman JA, Dorlac WC, Lentsch AB, Pritts TA. Simulated aeromedical evacuation does not affect systemic inflammation or organ injury in a murine model of hemorrhagic shock. Mil Med 2012; 177:911-6. [PMID: 22934369 PMCID: PMC4615718 DOI: 10.7205/milmed-d-11-00385] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Hemorrhagic shock is a primary injury amongst combat casualties. Aeromedical evacuation (AE) of casualties exposes patients to a hypobaric, hypoxic environment. The effect of this environment on the host response to hemorrhagic shock is unknown. In the present study, we sought to determine the effect of simulated AE on systemic inflammation and organ injury using a murine model of hemorrhagic shock. Mice underwent femoral artery cannulation and were hemorrhaged for 60 minutes. Mice were then resuscitated with a 1:1 ratio of plasma:packed red blood cells. At 1 or 24 hours after resuscitation, mice were exposed to a 5-hour simulated AE or remained at ground level (control). Serum was analyzed for cytokine concentrations and organs were assessed for neutrophil accumulation and vascular permeability. Mice in the simulated AE groups demonstrated reduced arterial oxygen saturation compared to ground controls. Serum cytokine concentrations, neutrophil recruitment, and vascular permeability in the lung, ileum, and colon in the simulated AE groups were not different from the ground controls. Our results demonstrate that mice exposed to simulated AE following hemorrhagic shock do not exhibit worsened systemic inflammation or organ injury compared to controls. The data suggest that AE has no adverse effect on isolated hemorrhagic shock.
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Affiliation(s)
- Amy T Makley
- Department of Surgery, Institute for Military Medicine, University of Cincinnati, 231 Albert Sabin Way, Mail Location 0558, Cincinnati, OH 45267-0558, USA
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Borne M, Tourtier JP, Ramsang S, Grasser L, Pats B. Collective air medical evacuation: the French tool. Air Med J 2012; 31:124-128. [PMID: 22541346 DOI: 10.1016/j.amj.2011.09.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 09/12/2011] [Indexed: 05/31/2023]
Affiliation(s)
- Marc Borne
- Military Hospital Val-De-Grace, Department of Anesthesia and Intensive Care, Paris, France
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Schoenfeld AJ. The combat experience of military surgical assets in Iraq and Afghanistan: a historical review. Am J Surg 2012; 204:377-83. [PMID: 22440274 DOI: 10.1016/j.amjsurg.2011.09.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 09/26/2011] [Accepted: 09/26/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND The Forward Surgical Team and Combat Support Hospital have been used extensively only during the past decade in Iraq and Afghanistan. The scope of their operational experience and historical development remain to be described. METHODS The literature was searched to obtain publications regarding the historical development of Forward Surgical Teams and Combat Support Hospitals, as well as their surgical experiences in Iraq and Afghanistan. Relevant publications were reviewed in full and their results summarized. RESULTS The doctrine behind the use of modern military surgical assets was not well developed at the start of the Iraq and Afghanistan conflicts. The Forward Surgical Team and Combat Support Hospital were used in practice only over the past decade. Because of the nature of these conflicts, both types of modern military surgical assets have not been used as intended and such units have operated in various roles, including combat support elements and civilian medical treatment facilities. CONCLUSIONS As more research comes to light, a better appreciation for the future of American military medicine and surgery will develop.
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Affiliation(s)
- Andrew J Schoenfeld
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, 5005 N. Piedras St., El Paso, TX 79920, USA.
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Shah K, Pirie S, Compton L, McAlister V, Church B, Kao R. Utilization profile of the trauma intensive care unit at the Role 3 Multinational Medical Unit at Kandahar Airfield between May 1 and Oct. 15, 2009. Can J Surg 2012; 54:S130-4. [PMID: 22099326 DOI: 10.1503/cjs.006611] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND In the war against the Taliban, Canada was the lead North Atlantic Treaty Organization (NATO) nation to provide medical and surgical care to NATO soldiers, Afghanistan National Army soldiers, Afghanistan Nation Police, civilians working in and outside Kandahar Airfield and Afghanistan civilians at the Role 3 Multinational Medical Unit (R3MMU) from February 2006 to October 2009. METHODS We obtained data from the Joint Theatre Trauma Registry between May 1 and Oct. 15, 2009; 188 patients were admitted to the R3MMU intensive care unit (ICU). We analyzed the ICU data according to types and causes of trauma, mechanical ventilation prevalence, ICU medical and surgical complications, blood products utilization, length of stay in the ICU and mortality. RESULTS The admitting services were general surgery (35%), neurosurgery (29%), orthopedic surgery (18%) and internal medicine (3%). Improvised explosive devices (46%) and gunshot wounds (26%) were the main causes of ICU admissions. The mean injury severity score for all patients admitted to the ICU was 37, and 81% of ICU patients required mechanical ventilation for a mean duration of 3 days. The main ICU complications were coagulopathy (6.4%), aspiration pneumonia (4.3%), pneumothorax (3.7%) and wound infection (2.7%). The following blood products were most used: packed red blood cells (55%), fresh frozen plasma (54%), platelets (29%) and cryoprecipitate (23%). The average length of stay in the ICU was 4.3 days, and the survival rate was 93%. CONCLUSION The high survival rate suggests that ICU care is a necessary and vital resource for a trauma hospital in a war zone.
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Affiliation(s)
- Kalpa Shah
- General Surgery and Department of Anesthesia, Division of Critical Care, University of Western Ontario, London Health Sciences Centre, 800 Commissioner’s Road East, London, Ontario
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Aeromobile modular critical care, resuscitation, and surgical suites for operational medicine. ACTA ACUST UNITED AC 2012; 71:S494-500. [PMID: 22072009 DOI: 10.1097/ta.0b013e318232ea00] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Closing the "care in the air" capability gap for severe lung injury: the Landstuhl Acute Lung Rescue Team and extracorporeal lung support. ACTA ACUST UNITED AC 2011; 71:S91-7. [PMID: 21795885 DOI: 10.1097/ta.0b013e3182218f97] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The success of US Air Force Critical Care Air Transport Teams (CCATT) in transporting critically ill and injured patients enabled changes in military medical force deployment and casualty care practice. Even so, a subset of casualties remains who exceed even CCATT capabilities for movement. These patients led to the creation of the Landstuhl Acute Lung Rescue Team (ALeRT) to close the "care in the air" capability gap. METHODS The ALeRT Registry was queried for the period between November 1, 2005, and June 30, 2010. Additionally, Landstuhl Regional Medical Center critical care patient transfers to host nation medical centers were reviewed for cases using extracorporeal lung support systems. RESULTS For the review period, US Central Command activated the ALeRT on 40 occasions. The ALeRT successfully evacuated patients on 24 of 27 missions launched (89%). Three patients were too unstable for ALeRT evacuation. Of the 13 remaining activations, four patients died and nine patients improved sufficiently for standard CCATT movement. The ALeRT initiated pumpless extracorporeal lung assistance six times, but only once to facilitate evacuation. Two patients were supported with full extracorporeal membrane oxygenation support after evacuation due to progressive respiratory failure. CONCLUSIONS ALeRT successfully transported 24 casualties from the combat zones to Germany. Without the ALeRT, these patients would have remained in the combat theater as significant consumers of limited deployed medical resources. Pumpless extracorporeal lung assistance is already within the ALeRT armamentarium, but has only been used for one aeromedical evacuation. Modern extracorporeal membrane oxygenation systems hold promise as a feasible capability for aeromedical evacuation.
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Tourtier JP, Franck L, Cirodde A, Coste S, Debien B. Flight ventilation and Boyle–Mariotte law. Resuscitation 2011; 82:1112. [DOI: 10.1016/j.resuscitation.2011.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Accepted: 03/24/2011] [Indexed: 10/18/2022]
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Ordoñez CA, Badiel M, SÁNchez ÁLI, Granados M, GarcÍA AF, Ospina G, Blanco G, Parra V, GutiÉRrez-MartÍNez MI, Peitzman AB, Puyana JC. Improving Mortality Predictions in Trauma Patients Undergoing Damage Control Strategies. Am Surg 2011. [DOI: 10.1177/000313481107700637] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The increased use of damage control surgery in complex trauma patients requires accurate prognostic indicators. We compared the discriminatory capacity of commonly used trauma and intensive care unit (ICU) scores, including revised trauma score, injury severity scores, trauma score-injury severity scores, acute physiology and chronic health evaluations II, and clinical and laboratory parameters, on 83 consecutive trauma patients admitted to the ICU, undergoing damage control. Logistic regressions were built for mortality prediction within 30 days. Performances of the models were assessed in terms of discrimination and calibration. Areas under the receiver operating characteristic curve from the models were compared. Overall mortality was 38.5 per cent. A “clinical” model was constructed including ICU admission pH and hypothermia (≤ 35 C °) and the number of packed red blood cells during the first 24 hours. This model was adjusted for age and demonstrated better discrimination for mortality prediction (areas under the receiver operating characteristic curve = 0.8054) than injury severity score ( P value = 0.049), abdominal trauma index ( P value = 0.049), and acute physiology and chronic health evaluations II ( P value = 0.001). There was no statistically significant difference in discrimination for mortality prediction between the “clinical” model and revised trauma score ( P value = 0.4) and trauma score-injury severity score ( P value = 0.4). We concluded that the combination of ICU admission pH and hypothermia and blood transfusions during 24 hours provided an excellent discriminatory capacity for mortality prediction in this complex patient population.
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Affiliation(s)
- Carlos A. Ordoñez
- Department of Surgery and Critical Care, Fundación Valle del Lili, Cali, Colombia
- Department of Surgery, Universidad del Valle, Cali, Colombia
| | - Marisol Badiel
- Instituto de Investigaciones Clinicas, Fundación Valle del Lili, Cali, Colombia
| | - ÁLvaro I. SÁNchez
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- CISALVA Institute, Universidad del Valle, Cali, Colombia
| | - Marcela Granados
- Department of Surgery and Critical Care, Fundación Valle del Lili, Cali, Colombia
| | - Alberto F. GarcÍA
- Department of Surgery and Critical Care, Fundación Valle del Lili, Cali, Colombia
- Department of Surgery, Universidad del Valle, Cali, Colombia
| | - Gustavo Ospina
- Department of Surgery and Critical Care, Fundación Valle del Lili, Cali, Colombia
| | - Gonzalo Blanco
- School of Medicine, Universidad del Valle, Cali, Colombia
| | - Viviana Parra
- School of Medicine, Universidad del Valle, Cali, Colombia
| | | | - Andrew B. Peitzman
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Juan-Carlos Puyana
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Advancing critical care: joint combat casualty research team and joint theater trauma system. AACN Adv Crit Care 2011; 21:260-76; quiz 278. [PMID: 20683227 DOI: 10.1097/nci.0b013e3181e67385] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Despite the severity and complexity of injuries, survival rates among combat casualties are equal to or better than those from civilian trauma. This article summarizes the evidence regarding innovations from the battlefield that contribute to these extraordinary survival rates, including preventing hemorrhage with the use of tourniquets and hemostatic dressings, damage control resuscitation, and the rapid evacuation of casualties via MEDEVAC and the US Air Force Critical Care Air Transport Teams. Care in the air for critically injured casualties with pulmonary injuries and traumatic brain injury is discussed to demonstrate the unique considerations required to ensure safe en route care. Innovations being studied to decrease sequelae associated with complex orthopedic and extremity trauma are also presented. The role and contributions of the Joint Combat Casualty Research Team and the Joint Theater Trauma System are also discussed.
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Fang R, Dorlac GR, Allan PF, Dorlac WC. Intercontinental aeromedical evacuation of patients with traumatic brain injuries during Operations Iraqi Freedom and Enduring Freedom. Neurosurg Focus 2010; 28:E11. [PMID: 20568927 DOI: 10.3171/2010.2.focus1043] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Traumatic brain injury contributes significantly to military combat morbidity and mortality. No longer maintaining comprehensive medical care facilities throughout the world, the US military developed a worldwide trauma care system making the patient the moving part of the system. Life-saving interventions are performed early, and essential care is delivered at forward locations. Patients then proceed successively through increasingly capable levels of care culminating with arrival in the US. Proper patient selection and thorough mission preparation are crucial to the safe and successful intercontinental aeromedical evacuation of critical brain-injured patients during Operations Iraqi Freedom and Enduring Freedom.
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Affiliation(s)
- Raymond Fang
- Division of Surgery, Landstuhl Regional Medical Center, Landstuhl, Germany.
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Martin JE, Teff RJ, Spinella PC. Care of pediatric neurosurgical patients in Iraq in 2007: clinical and ethical experience of a field hospital. J Neurosurg Pediatr 2010; 6:250-6. [PMID: 20809709 DOI: 10.3171/2010.6.peds1031] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Care for host-nation pediatric casualties and disease or nonbattle injuries is an essential mission of deployed military medical assets. Clinical experience with pediatric patients at field hospitals has been increasingly reported since 2001, with neurotrauma identified as a major cause of morbidity and death in this population. A concentrated pediatric neurosurgical experience at a deployed medical facility has not been reported. The authors reviewed their experience with pediatric neurosurgical patients at a field hospital in Iraq in 2007 to provide insight into the management of this patient population. METHODS A retrospective review was conducted using a prospective database constructed by the authors for quality improvement during a single combat rotation in 2007. RESULTS Forty-two patients among 287 consultations were 17 years of age or younger. Twenty-six of these children were 8 years old or younger. Penetrating head injuries were the most common indication for consultation (22 of 42 patients). Twenty-eight of 130 surgical procedures were performed in the children. One patient died in the perioperative period, for a trauma-related operative mortality rate of 4%. Seven patients received palliative care based on the extent of presenting injuries. Twenty-five patients were discharged with minimal or no neurological deficits. CONCLUSIONS Pediatric patients represent a significant proportion of the neurosurgical patient volume at field medical hospitals in the Iraqi theater. The mature medical theater environment present in 2007 allowed for remarkable diagnostic evaluation and treatment of these patients. Penetrating and closed craniospinal injuries were the most common indication for consultation. Disease and nonbattle injuries were also encountered, with care provided when deemed appropriate. The deployed environment presents unique medical and ethical challenges to neurosurgeons serving in forward medical facilities.
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Affiliation(s)
- Jonathan E Martin
- Department of Surgery, Division of Neurosurgery, University of Connecticut School of Medicine, Connecticut Children's Medical Center, Hartford, Connecticut 06106, USA.
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Affiliation(s)
- Darcy Day
- Darcy Day is a staff nurse in the emergency department, the medical intensive care unit, and the crisis nurse program at The Queens Medical Center in Honolulu, Hawaii
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Abstract
Recently, the World Health Organization declared a pandemic mediated by the novel A H1N1 influenza virus. Soon after the first report from Mexico, the disease arrived in Chile, where it spread quickly from south to north, mimicking cold weather progression through the country. Between May and September 2009, 366,624 cases of H1N1 were reported; 12,248 were confirmed by real-time reverse-transcription polymerase chain reaction and 1562 were hospitalized. One hundred thirty-two deaths were attributable to the infection, creating a death rate of 0.78 per 100,000 inhabitants. Common comorbidities were present in 59%, including obesity, chronic obstructive pulmonary disease, hypertension, type II diabetes, and congestive heart failure. Nine percent were pregnant. Severe disease developed early; the median time to admittance was 5 days, and the most common clinical manifestations were cough, fever, dyspnea, and myalgia. Mean acute physiology and chronic health evaluation II and sequential organ failure assessment scores were 14 and 5, respectively. Highlighted laboratory data were lactate dehydrogenase and creatine kinase elevation, leukocytosis in 50%, elevated creatinine in a 25%, and thrombocytopenia in 20%. Severe respiratory failure requiring high-frequency oscillatory ventilation and extracorporeal membrane oxygenation as sophisticated modes of respiratory support was seen in 17%. Acute renal failure occurred in 25% of the intensive care unit patients, with death rates near 50%. Health systems reinforced outpatient guards with extra staff and extension of the duty schedules. Antivirals were supplied free for medically diagnosed cases. Admissions for severe cases were prioritized, reconverting hospital beds into advanced care ones; a central coordination station rationed their assignment. Recommendations for small hospitals include adding ventilators, using videoconferences, providing tutorial activity from experts, developing guidelines for disease management, and outlining criteria for transport.
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Vacchi R, Santoro E, Giugni A, Cavallo P. Interhospital transport of critically ill patient with dedicated ICU ventilator. Scand J Trauma Resusc Emerg Med 2009. [PMCID: PMC3313134 DOI: 10.1186/1757-7241-17-s3-o21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Schilling S, Follin P, Jarhall B, Tegnell A, Lastilla M, Bannister B, Fusco FM, Biselli R, Brodt HR, Puro V. European concepts for the domestic transport of highly infectious patients. Clin Microbiol Infect 2009; 15:727-33. [DOI: 10.1111/j.1469-0691.2009.02871.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Manring MM, Hawk A, Calhoun JH, Andersen RC. Treatment of war wounds: a historical review. Clin Orthop Relat Res 2009; 467:2168-91. [PMID: 19219516 PMCID: PMC2706344 DOI: 10.1007/s11999-009-0738-5] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Accepted: 01/27/2009] [Indexed: 01/31/2023]
Abstract
The treatment of war wounds is an ancient art, constantly refined to reflect improvements in weapons technology, transportation, antiseptic practices, and surgical techniques. Throughout most of the history of warfare, more soldiers died from disease than combat wounds, and misconceptions regarding the best timing and mode of treatment for injuries often resulted in more harm than good. Since the 19th century, mortality from war wounds steadily decreased as surgeons on all sides of conflicts developed systems for rapidly moving the wounded from the battlefield to frontline hospitals where surgical care is delivered. We review the most important trends in US and Western military trauma management over two centuries, including the shift from primary to delayed closure in wound management, refinement of amputation techniques, advances in evacuation philosophy and technology, the development of antiseptic practices, and the use of antibiotics. We also discuss how the lessons of history are reflected in contemporary US practices in Iraq and Afghanistan.
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Affiliation(s)
- M. M. Manring
- Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, MO USA
| | - Alan Hawk
- National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, DC USA
| | - Jason H. Calhoun
- Department of Orthopaedic Surgery, The Ohio State University, N1043 Doan Hall, 410 W 10th Ave, Columbus, OH 43210-1228 USA
| | - Romney C. Andersen
- Orthopaedic Traumatology, Walter Reed National Military Medical Center, Bethesda, MD USA
- Orthopaedic Traumatology, Walter Reed National Military Medical Center, Washington, DC USA
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