Dan Mirski, MD Director TPMRC-Europe 12 SEP 2013 Oslo, Norway CENTCOM AOR (JPMRC) NORTHCOM AOR (GPMRC) EUCOM AOR (TPMRC-E, CASF, LRMC,) AFRICOM AOR (TPMRC-E)

Dan Mirski, MD Director TPMRC-Europe

12 SEP 2013 Oslo, Norway

CENTCOM AOR(JPMRC)

NORTHCOM AOR(GPMRC)

EUCOM AOR(TPMRC-E, CASF, LRMC,)

AFRICOM AOR(TPMRC-E)

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This information is furnished on the condition that it will not be released to another nation without specific authority of the Department of the Air Force of the United States , that it will be used for military purposes only, that individual or corporate rights originating in the information, whether patented or not, will be respected, that the recipient will report promptly to the United States any known or suspected compromise, and that the information will be provided substantially the same degree of security afforded it by the Department of Defense of the United States. Also, regardless of any other markings on the document, it will not be downgraded or declassified without written approval of the originating agency. USAFE N0885-13//20130909

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OutlineUSAF Flight SurgeonOverview of US System Aeromedical

Evacuation (AE)Patient Tracking: TRAC2ESMedical Lessons Learned

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Dan Mirski, MD, MPHEmergency MedicineAerospace Medicine

LtCol, US Air Force, Chief Flight SurgeonDirector, TPMRC-Europe

Time

Wounded Self Aid &

Buddy Care

BAS

First Responder

Forward Surgical teams

Forward Resuscitative

CSH, EMEDS, EMFTheater Hospitals

Definitive Care

Enroute Care

GOAL: Maintain Equal Or

Greater Level Of CareDuring Intra/Inter-Theater

Air Evacuation

Continuous Increase in Level of Care Provided

Leve

l of C

are

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Aeromedical Evacuation (AE)Overview

CASEVAC, MEDEVAC, Aeromedical Evacuation (AE)Role 1-4: Installation Capabilities

3 = Life-saving med/surg/psych care)Urgent, Priority(24h), Routine (72h)AE crew = 2 RNs, 3 techs

CCAT = 1 MD, 1 RN, 1 RTC17, C21, KC135, C130“Stressors of Flight”

Patient Categories 1-5EMR: TRAC2ES

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First Responder

Role 1Forward Resuscitative

CapabilityRole 2 Theater Hospitalization

Capability(CSH, EMEDS, EMF)

Role 3 Definitive CapabilityRole 4

Current Route from Point of Injury to Definitive Capability

SURGICAL CAPABILITY PUSHED FAR FORWARD

CASEVAC or MEDEVAC MEDEVAC or

INTRATHEATER AE

INTERTHEATER AE

PM Route

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10/2001 – 8/12/13 BI= 14,875 NBI= 46,346

DoD Patient Movement System

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TRAC2ESTRANSCOM Regulating

Command/Control Evacuation System

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DoD Patient Movement SystemTRAC2ESTRANSCOM Regulating Command/Control

Evacuation System (TRAC2ES)Web-based/Consolidated ServerAutomates Patient RegulatingNetwork for In-Transit Visibility of patient

movement

Originating Hospital

Patient Movement Requirements

Center

Patient Movement Requirements

Center

Destination Hospital


Patient Movement Requirements Center

CENTCOM: Joint PMRC, Al Udeid, Qatar

NORTH/SOUTHCOM: Global PMRC, Scott AFB, Illinois

PACOM: Theater PMRC, Hickam AFB, Hawaii

EUCOM: Theater PMRC, Ramstein AB, Germany

Military Medical Treatment Facilities (MTF)s

Submit Patient Movement Requests (PMRs)

Coordinate arrival/departure of patients

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PMRC Areas of Responsibility

USNORTHCOM

Validate/Coordinate/Communicate patient movement to/from/within geographic Area of Responsibility


Aeromedical Evacuation Squadrons

Provide in-flight medical or specialty care

2 flight nurses, 3 medical technicians

Air Mobility Division (AMD), AE Control Team (AECT)

Interface with airlifters for AE movement

USAFE for intra-theater movement

Tanker Airlift Control Center (TACC) for inter-theater lift

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Referring MTF/Hospital:

Submit Patient

Movement Request (PMR)

PMRC: Validate PMR, Coordinate

airlift, Communicate

mission itinerary

AECT/TACC: Task airlift/aircrews

AE Crews: Execute mission

Reception MTF: Patient arrives at destination

facility

TRAC2ESPatient Movement Request (PMR)

Clinical Data Medical Specialty/Diagnosis Patient

History/Medications/LabsPatient Demographics

Patient Name/Nationality/ID#

Rank/Age/Gender Precedence

(URGENTURGENT, , PRIORITYPRIORITY, , ROUTINEROUTINE)

TRAC2ESPatient Movement Request (PMR)

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Referring MTF/Hospital:

Submit Patient




mission itinerary




facility

TRAC2ESMission Planning/Execution


AE Control Team/Tanker Airlift Control Center Identify aircraft Task AE crew members Task specialty support Notify PMRC when mission

information is complete

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Referring MTF: Submit Patient




mission itinerary




facility


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Referring MTF: Submit Patient




mission itinerary




facility

TRAC2ES24-Hour Report

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TRAC2ES24-hr Report Destination Medical Treatment

Facilities Visibility for in-bound…

Missions Itineraries Patient loads

Plan patient reception/care

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Global Patient MovementA Team Effort

USNORTHCOM

From the last 10 years of Patient Movement

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Medical Advancements &Lessons Learned

1. Resuscitation with blood products2. LIFO Blood Usage3. Damage Control Surgery4. Burn Management5. Ventilatory Control with Decreased Tidal

Volume6. Massive Blood Transfusion Triggers7. Epidurals & Nerve Blocks8. Tourniquets9. No Steroids in Blunt Spinal / Head Trauma

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Blood Component TherapyPrior typical "resuscitation protocol" = lots of

LR or NS then 1-2 units of blood (3:1) This practice contributed to the lethal triad of

coagulopathy, hypothermia & acidosis Now, high suspicion patient is bleeding =

proceed directly to blood products. 1. Repine TB, Perkins JG, Kauvar DS, Blackborne L. The use of fresh whole blood in massive

transfusion. J Trauma. 2006;60:S59-S69. 2. Spinella PC, Perkins JG, Grathwohl JG, Beekley AC, Holcomb JG. Warm fresh whole blood is

independently associated with improved survival for patients with combat-related traumatic injuries. J Trauma. 2009;66:S69-S76.

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Blood Tx: LIFONew blood over old blood

Previously, the oldest blood in the theater was given first for transfusions should be used before it goes bad.

Fresh blood has been shown to be superior complications of transfusion with "older" units of PRBCs "storage lesion": increase pro-inflammatory factors, acidosis,

increased free hemoglobin, and decreased RBC deformability, 2,3 DPG & ATP

The people most likely to suffer the consequences of complications of "older" units of blood are those requiring a higher dose

In patients requiring massive transfusion , effort made to transfuse fresh units of PRBCs Preferably < 14 days old, but the freshest available nonetheless

Now, LAST IN, FIRST OUT (LIFO) Blood Policy Donation to availability in theater averaging 7 days

1. Spinella PC, Perkins JG, et al. Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries. J Trauma. 2009;66:S69-76.

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Damage Control SurgeryWe now transport patients with “unfinished

surgeries” - open abdomens bleeding stopped via clamping and/or packing.

They are moved to higher levels for more definitive care

Further damage control surgeries done“Final” closure surgery

Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, Mallett O, Zubko T, Oetjen-Gerdes L, Rasmussen T, Butler FK, Kotwal RS, Holcomb JB, Wade C, Champion H, Lawnick M, Moores L and Blackbourne LH. Death on the battlefield (2001-2011): Implications for the future of combat casualty care. J Trauma. 2012;73:S431-S437,

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Burn ManagementRule of 10's and 6 ml/kg/%BSA burned in thermal injury

burn managementBasically, now we don’t pour in the fluid.Start with an initial amount

Then adjust it up or down up to 25% per hour (not more!) Result = far less incidents of abdominal compartment

syndrome CCATT transported patients with burns up to 98% and they

have survived.

1. Ennis JL, Chung KK, Renz EM, Barillo DJ, Albrecht MC, Jones JA, Blackbourne LH, Cancio LC, Eastridge BJ, Flaherty SF, Dorlac WC, Kelleher KS, Wade CE, Wolf SE, Jenkins DH, Holcomb JB. Joint Theater Trauma System implementation of burn resuscitation guidelines improves outcomes in severely burned military casualties. J Trauma. 2008;64(2):S146-51; discussion 151-2.

2. Markell KW, Renz EM, White CE, Albrecht ME, Blackbourne LH, Park MS, Barillo DA, Chung KK, Kozar RA, Minei JP, Cohn SM, Herndon DN, Cancio LC, Holcomb JB,Wolf SE. Abdominal complications after severe burns. J Am Coll Surg. 2009;208(5):940-7; discussion 947-9.

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Vents: Decreased TVLung protective strategies in ARDS / ICU /

Difficult to Ventilate ptsTidal Volume: 4-6 cc/Kg

Not 10-12 cc/Kg, as priorIdeal BWIncrease PEEP and/or FiO2

Essentially ARDSNetUsed very often by US CCATT

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Other Advances7. Massive transfusion triggersHigher quantities of blood up frontMcLaughlin DF, Niles SE, Salinas J, et al. A predictive model for massive transfusion in combat casualty patients. J Trauma.2008;64:S57-63.

6. PCA, Epidural and nerve blocks We fly these all the time now

Waiver x 10yrs, Official since 2012 Mepivacaine 250 vs 400ml IV bagsKatz J, Cohen L, Schmid R, et al. Postoperative Morphine Use and hyperalgesia are Reduced by Preoperative but not Intraoperative Epidural Anagesia: Implications for Preemptive Analgesia and the Prevention of Central Sensitization. Anesthesiology. 2003;98:1449-1460.

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Lessons Learned (con’t)8. Re-emergence of tourniquets

9. No steroids in blunt spinal cord or TBINo proven benefitWorsen outcomes in patients with severe head

injuryFrequent associated open or contaminated

wounds of battle casualties further complicate steroid administration

[email protected]

“VALIDATE…COORDINATE…COMMUNICATE”

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Documents

Dan Mirski, MD Director TPMRC-Europe 12 SEP 2013 Oslo, Norway CENTCOM AOR (JPMRC) NORTHCOM AOR (GPMRC) EUCOM AOR (TPMRC-E, CASF, LRMC,) AFRICOM AOR (TPMRC-E)