NCC Pediatrics Continuity Clinic Curriculum: USNS Comfort
Pre-Meeting Preparation: Please read/review the following enclosures: • “USNS Comfort: Care of the Sick on the Sea” (AMSUS presentation, 2010) • “Profile of Pediatric Admissions to the USNS Comfort” (Poster, 2010)
Conference Agenda:
• Field trip to Baltimore to tour the USNS Comfort • Complete USNS Comfort Quiz & Discussion Questions
(Discuss answers during car rides to and from the Comfort) Extra-Credit:
• “Practicing Internal Medicine Onboard the USNS COMFORT in the Aftermath of the Haitian Earthquake” (Annals of Internal Medicine)
• Fun facts about the USNS Comfort
© Developed by LCDR Amanda Higginson & CDR Gregory Gorman, with source materials from CDR Matthew McLean (NMCP). Formatted by CPT Jennifer Hepps.
UNCLAS//FOUO Federal Physician / SMACF Program, AMSUS 2010
USNS COMFORT– D.R. Capabilities from the Sea
Curare Aegra Permarinum “Care of the sick on the Sea”
Overall Classification: UNCLAS/FOUO
LCDR Matthew D. McLean, M.D., Ph.D. Pediatrician, Naval Medical Center Portsmouth
Continuing Promise, 2009 Operation Unified Response - JTF Haiti, 2010
UNCLAS//FOUO Federal Physician / SMACF Program, AMSUS 2010
LEARNING OBJECTIVE
Understand the adaptable
capabilities of the USNS
COMFORT with specific
focus on
Operation Unified
Response, JTF- Haiti
UNCLAS//FOUO Federal Physician / SMACF Program, AMSUS 2010
• 894 feet long • 106 feet wide • Max Speed 17.5 knots • 4 water distilling plants =
300,000 gallons/day. • Holds 2 MH-60 helicopters • Draft- 33 ft • Power 3000KW (4 generators) • Range 113,420 NM
Ship’s Master = Military Sealift Fleet Support Command
Delivered December 1 1987
USNS COMFORT: The Ship
UNCLAS//FOUO Federal Physician / SMACF Program, AMSUS 2010
One of the largest trauma facilities in the U.S. 1) Full Spectrum of Medical and Surgical Services 2) 10 Operating Rooms with C-Arms 4) 1 CAT Scan suite 5) 1 Dental suite (2 OR’s) 6) Optometry and Lens Laboratory 7) Physical Therapy Center 8) Pharmacy 9) 2 Oxygen producing plants 10) Blood bank (holds up to 5000 units) 11) Angiography Suite (under construction during OUR-Haiti)
USNS COMFORT: The MTF
UNCLAS//FOUO Federal Physician / SMACF Program, AMSUS 2010
BED CAPACITY 20 Recovery beds 80: ICU Beds 400 Immediate care 500 Minimal care 1000 Total beds
+ 40 Casualty
Receiving Beds
Theoretical Capacity
Mobile Afloat Medical-Surgical Hospital
USNS COMFORT: The MTF
UNCLAS//FOUO Federal Physician / SMACF Program, AMSUS 2010
PATIENT FLOW
UNCLAS//FOUO Federal Physician / SMACF Program, AMSUS 2010
Real Life Capability- Haiti Experience
“The hospital ship, COMFORT, is expected to arrive in Haiti, Jan 20th and will
essentially provide all the assets and services of [a naval hospital] at sea”
US Fleet Forces Public Affairs 19 Jan 2010 NNS100119-18, Navy.mil
UNCLAS//FOUO Federal Physician / SMACF Program, AMSUS 2010
CAPABILITY: MOBILIZATION
Reduced Operating Status (ROS)
• 17 Civilian Mariners (CIVMAR) • 58 Military Medical Personnel
Full Operating Status (FOS)
• 13 January- verbal order to deploy • 16 January – set sail, 76 ½ hrs later
- 550 medical personnel - 140 non-medical personnel - 67 CIVMAR
•19 January ~2200- 1st Pt aboard
UNCLAS//FOUO Federal Physician / SMACF Program, AMSUS 2010
COMFORT Medical Capabilities First 72 hours.
Surgical Staff
• 1 orthopedic surgeon • 1 Emergency Medicine physician • Variety of other surgical specialties
without front load of ortho-neuro-trauma • Most had combat tour experience
Medical Staff
• Broad range of specialties based on HCA missions vice disaster-trauma
• Most with inpatient medicine skills
Nursing Services • Wards staffed for 250 beds • Filled 411 beds with critical care pts • Few pediatric trained nurses • all with adaptable RN/HM skills
Develop JMD tailored to provide medical capabilities for disaster response missions
Deployed with standard Humanitarian Civil Assistance mission capabilities.
UNCLAS//FOUO Federal Physician / SMACF Program, AMSUS 2010
Admissions, discharges, deaths
USNS Comfort Opereration Unified Response Haiti
Patient Admissions, Discharges, Deaths 19 Jan - 3 Mar
2
81
181
242
316
356
375
389399
411
393383
348
318309
290
273
242
225 221 218
186
167
143
117
10088
72
56 56 61 5966
58 5947
2315
90
0 0 13 3
5
1 0 1 2 1 20 0
42 1 0 0 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
-5
15
35
55
75
95
115
Ad
mis
sio
n/D
isch
arg
e, n
-30
20
70
120
170
220
270
320
370
420
Admissions
Discharges
Census
Deaths
Admissions 2 79 103 69 82 61 64 30 53 35 9 11 9 17 13 21 9 16 13 19 15 4 9 12 7 15 5 1 6 4 16 13 19 3 1 6 0 4 5 2
Discharges 0 0 2 5 5 16 44 16 42 21 26 19 44 47 18 38 25 47 30 22 18 36 27 36 33 31 17 17 22 4 11 15 12 11 0 18 24 12 11 11
Census 2 81 181 242 316 356 375 389 399 411 393 383 348 318 309 290 273 242 225 221 218 186 167 143 117 100 88 72 56 56 61 59 66 58 59 47 23 15 9 0
Deaths 0 0 1 3 3 5 1 0 1 2 1 2 0 0 4 2 1 0 0 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
19-Jan
20-Jan
21-Jan
22-Jan
23-Jan
24-Jan
25-Jan
26-Jan
27-Jan
28-Jan
29-Jan
30-Jan
31-Jan
1-Feb 2-Feb
3-Feb
4-Feb
5-Feb
6-Feb
7-Feb
8-Feb
9-Feb
10-Feb
11-Feb
12-Feb
13-Feb
14-Feb
15-Feb
16-Feb
17-Feb
18-Feb
19-Feb
20-Feb
21-Feb
22-Feb
23-Feb
24-Feb
25-Feb
26-Feb
27-Feb
2nd wave providers
Project Hope
2nd group NGO, Reservists and Mental Health
UNCLAS//FOUO Federal Physician / SMACF Program, AMSUS 2010
USNS Comfort Pediatric Population
020406080
100120140
19-Jan
23-Jan
27-Jan
31-Jan
4-Feb
8-Feb
12-Feb
16-Feb
20-Feb
24-Feb
28-Feb
Date
Ped
iatr
ic P
ati
en
t TOTAL PEDS CENSUS
2FWD PEDS
3FWD PEDS
5FWD PEDS
ICU PEDSCENSUS
Project Hope Arrives 2nd Group NGO's, Reservists, and Mental Health providers Arrive
PEDIATRIC ADMISSIONS
UNCLAS//FOUO Federal Physician / SMACF Program, AMSUS 2010
Ancillary Services USNS Comfort 20 Jan - 28 Feb 2010
• Radiology Studies – 3,896 – Plain film x-rays – 3,296 – CT Scans – 482 – Ultrasound – 118
• Prescriptions – 70,286 – Inpatient – 64,840 – Outpatient – 5,446
• Blood Products – 376 units – Red Blood Cells – 348 – Plasma – 16 – Platelets – 12
• Laboratory Studies – 4,257 • Physical Therapy - 1,318 • Discharge Planning
– Key coordination between network of NGO/Haitian facilities- 16 different sites
UNCLAS//FOUO Federal Physician / SMACF Program, AMSUS 2010
Security
Transportation
Supply Mgmt
Knowledge Mgmt
Operations
Personnel
Medical-Surgical Coordination
Joint Medical-Surgical Capability
Delivered and Coordinated Care for 794 Haitan Nationals 185 patient escorts 52 Active Duty 3 Allied Troops 23 American Citizens 1057 Total Admissions
- 7 OR’s 12 hours/day - 3 OR’s 24 hours/day - 820 Surgeries - 931 total procedures 16 Craniotomy 44 Spinal 33 Pelvis 676 Extremity 122 Femur Fracture surgeries
48% of pediatric patients did not require surgery
UNCLAS//FOUO Federal Physician / SMACF Program, AMSUS 2010
•Medicine Capabilities: Internal Medicine, Pediatrics, Family Practice, Neurology
•Sub-specialties: Cardiology, Nephrology, Infectious Disease, GI,
Thank You
Profile of Pediatric Admissions to the USNS COMFORT Following the 2010 Haiti Earthquake: Lessons for Future Hospital Ship Based Disaster Relief missions.
LCDR Matthew D. McLean MD, PhD1, CDR William Scouten MD1, CAPT Daniel Shmorhun MD2, LCDR Erika Beard-Irvine MD2, CAPT Arne Anderson MD2, 1NAVAL MEDICAL CENTER PORTSMOUTH, PORTSMOUTH, VA; 2NATIONAL NAVAL MEDICAL CENTER, BETHESDA, MD
BACKGROUND
• 12 January 2010 at 16:53:09 a 7.2 magnitude earthquake centered 15 miles SW of Port-au-Prince, Haiti results in nearly 300,000 deaths.
• 16 January, 76 hours after receiving verbal order to activate, the USNS COMFORT sails for Haiti staffed for a bed capacity of 250.
• 19 January – First patients accepted aboard. Within 7 days the COMFORT becomes the largest trauma center on the East Coast nearly doubling its originally planned bed capacity.
• 5 Pediatricians, 3 Pediatric Nurse Practitioners, 1 Pediatric Surgeon, 1 Pediatric Orthopedist, 1 Pediatric Plastic Surgeon, 1 Pediatric Radiologist and 1 Pediatric Anesthesiologist are part of the initial crew of 757 for this surgically focused Disaster Relief Mission.
OBJECTIVE
• Define pediatric resource utilization to assist in future resource related disaster relief planning.
INCLUSION CRITERIA • All pediatric patients 17 years old or less,
admitted to the USNS COMFORT from 19 January 2010 through 27 February 2010.
DESIGN
• 100% Retrospective Chart Review
VARIABLES • Age distribution, Number of PICU admissions,
Time to first surgery, Number not needing surgery and reason, Blood transfusion rate, Injury profile with underlying causation
SETTING
USNS COMFORT Hospital Ship off the coast of Port-au-Prince, Haiti during the Haitian earthquake disaster relief mission 2010
RESULTS
1. 224 (28.5%) of the 787 total humanitarian admissions were pediatric patients. (Figure 1 and 2).
2. Pediatric census peaked at 126 patients on 29 January prior to arrival of additional pediatric providers and nursing staff from Project Hope. Initial limited staff spread over 3 separate wards with a peak single ward census of 50 patients. (Figure 2).
3. 156 (69%) of pediatric admissions were classified as quake related injuries. These patients were significantly older (9.2 vs 5.5 yrs) and admissions longer (10.4 vs 8.2 days) than non-quake related admissions. (Figure 3).
4. 167 (75%) of pediatric admissions were for trauma related injuries. These patients were significantly older than those admitted for medical reasons (9.53 vs 3.25 years. (Figure 3).
5. A Bimodal Age Distribution of pediatric patients was observed with peak admissions for infants < 1 year and children 12 years of age. (Figure 4).
6. The anatomic location of injuries profile in pediatric patients admitted to the COMFORT was similar to that seen at field hospitals during other earthquake disasters (Figure 5).
7. Only 113 patients (51%) required surgery and 68% of these had their 1st procedure in one day or less (Figure 6).
8. 48% of the patients not requiring surgery were evaluated by a surgeon although 35% could have been treated ashore had basic plain film radiology services been available before transfer to the ship. 25% had already been treated prior to transfer or had an inoperable chronic disease unrelated to the earthquake (Figure 7).
9. Fifty-six patients (25%) were admitted to the PICU, the majority (44%) for non-quake related (Figure 8) and non-traumatic injuries. (Figure 9).
10. A CBC was obtained on 106 patients (47%) with no relationship to type of injury. The average hemoglobin concentration (9mg/dL) was identical across injury profile groups. (Figure 10).
11. The packed RBC per patient index was comparable to that seen in Operation Iraqi Freedom using the OIF Mass Casualty Resource Assessment. (Figure 10).
Total Census vs Admissions & Discharges
USNS Comfort Opereration Unifie d Response Haiti
Patient Admissions, Discharges, Deaths 19 Jan - 3 Mar
2
81
181
242
316
356
375389
399411
393383
348
318309
290
273
242
225 221 218
186
167
143
117
10088
72
56 56 61 5966
58 5947
2315 9
00 0 1
3 35
1 0 1 2 1 20 0
42 1 0 0 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
-5
15
35
55
75
95
115
Ad
mis
sio
n/D
isch
arg
e, n
-30
20
70
120
170
220
270
320
370
420
Admissions
Discharges
Census
Deaths
Admis sions 2 79 10 3 69 8 2 61 64 30 53 3 5 9 11 9 17 13 21 9 16 13 19 15 4 9 12 7 15 5 1 6 4 16 13 19 3 1 6 0 4 5 2
Dis charge s 0 0 2 5 5 16 44 16 42 2 1 26 19 44 47 18 3 8 25 47 30 22 18 36 27 36 33 3 1 17 17 22 4 11 15 12 11 0 18 24 12 11 11
C ensus 2 81 181 242 316 356 375 3 89 3 99 411 393 383 348 318 309 290 273 24 2 2 25 221 218 186 167 143 117 100 88 72 56 56 61 59 6 6 58 59 47 23 15 9 0
Dea ths 0 0 1 3 3 5 1 0 1 2 1 2 0 0 4 2 1 0 0 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
19-J an
20-Ja n
21-Ja n
22-Ja n
23-Ja n
24 -Ja n
25-Ja n
2 6-J an
27-J an
28-J an
29-J an
30-J an
31-J an 1-Feb
2-Fe b
3-Fe b
4-Fe b
5-Fe b
6-F eb
7-F eb
8-Fe b
9-Fe b
10 -Fe b
11-F eb
12-Feb
13-Feb
14-Feb
15-Feb
16-Fe b
17-Fe b
18-Fe b
19-Fe b
20-Fe b
21-Fe b
22-F eb
23-F eb
24-Feb
25-Feb
26 -Feb
2 7-Feb
2nd wave NMCP
Project Hope
2nd group NGO, Reservists and Mental Health
USNS Comfort Pediatric Population
020406080
100120140
19-Jan
23-Jan
27-Jan
31-Jan
4-Feb
8-Feb
12-Feb
16-Feb
20-Feb
24-Feb
28-Feb
Date
Pedia
tric
Patien
t TOTAL PEDS CENSUS
2FWD PEDS
3FWD PEDS
5FWD PEDS
ICU PEDSCENSUS
Project Hope Arrives 2nd Group NGO's, Reservists, and Mental HealthNMCP Arrives
PEDIATRIC ADMISSIONS
Pediatric patients = 28.5% of all admissions
Demographics*Significant Findings
1. Quake related injury patients Older and Admission longer than non-quake patients
2. 49% of pediatric patients didn’t need surgery
3. 23% of admissions for non-trauma related illness
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
Quake Related Not Quake Related No Trauma Trauma
Me
an
(S
E)
Ag
e i
n Y
ea
rs
quake not quake No Trauma Trauma
Mea
n A
ge in
yea
rs9.25
5.5
9.53
3.25
Total Peds Patients
n (%)
Quaken(%)
Not Quaken(%)
Total 224 (28.5%) 156 (69%) 68(30%)#females 110 (49%) 85 (54) 25 (37)ALOS* 9.7 days 10.4 days 8.2 days
avg age- all* 8.1 yrs 9.2 yrs 5.5 yrsAvg age- no births* 8.4 yrs 8.7 yrs 6.2 yrs
Escorted 143 (64) 91(58) 52 (76)non-traumatic 56 (25%) 9 (6) 47 (69)
Age Distribution of PatientsNumber of patients per age
16
26
10
5
87
98 8 8
12
1716
22
1413
89
14
0
5
10
15
20
25
30
<30d
<1yr 1yo
2yo
3yo
4yo
5yo
6yo
7yo
8yo
9yo
10yo
11yo
12yo
13yo
14yo
15yo
16yr
17yr
Age
Nu
mb
er
Bimodal age distribution
Infants <1 year
Children 10-12 years
Profile of injuries compared to other earthquake disasters
Injury Location
Haiti
2010*
Kashmir
2005
Marmara
1999
% Total head/face 25 24 18% total trunk 9 11
% total limb trauma 52 50 66.6
* Represents pediatric patients only
Days to first surgery
49% of pediatric patients did not need
surgery
Despite overwhelming number of admissions
necessary surgery occurred in a timely
fashion.
Number of patients vs days from admission to first surgery
0
5
10
15
2 0
2 5
3 0
3 5
4 0
0 d ays wait 1- d ay 2 d ays 3 d ays 4 o r mo re
Days from admission to 1st surgery
Nu
mb
er
of
pati
en
ts
Total Peds Patients
Quaken(%)
Not Quaken(%)
Total 224 156 (69%) 68(30%)# needing surgery 113 (51%) 96(62) 18(26)avg # surgeries 2.2 2.3 1.9
PICU Admissions vs Census
PICU Daily Admissions vs Census
02468
10121416182022242628
19-J
an
22-J
an
25-J
an
28-J
an
31-J
an
3-Fe
b
6-Fe
b
9-Fe
b
12-F
eb
15-F
eb
18-F
eb
21-F
eb
24-F
eb
27-F
eb
Date
Cen
sus
0
2
4
6
8
10
12
Adm
issi
ons
Series1 Series2ADMISSIONS CENSUS
Total % of admits in PICU56/224= 25%
Quaken(%)
Not Quaken(%)
# in ICU 26 (16%) 30 (44%)Avg days in ICU 8 7
Profile of PICU Admissions by Injury
Non Trauma Indications for PICU Admission
Seizures14%
Infections43% Malnutrition
7%
Sickle Cell7%
Renal Failure4%
Cardiac4%
Prematurity21%
41
19
4
35
0
5
10
15
20
25
30
35
40
45
Perc
en
tag
e
Non-Trauma Limb Axial Head andFace
Location of traumatic injury
Percentage of ICU admissions by injury
Packed Cells Per Patient Index
RBC ONLY Pediatric Adult Total# Pts transfused 26 111 137
# units transfused 50 275 325% of all patients
transfused 11.6% 19.8% 17.4%*PPI 1.92 +/- 0.23 2.48+/- 0.15 2.37 +/- 0.13
* Packed Cells per Patient Index
% of all peds with CBC106/224 = 47%
Quaken(%)
Not Quaken(%)
admission cbc 68 (44%) 38 (56%)avg hgb 9 9
OPERATION IRAQI FREEDOM MASS CASUALTY ASSESSMENT = PPI 1.4 +/- 0.8
22% of all casualties evacuated required transfusion in OIF
CONCLUSIONS
1. Despite the challenges in transferring patients to a ship based hospital platform, the percentage of pediatric patients and the overall injury profile was similar to that seen at land based hospitals during previous earthquake disasters. This should be considered when planning resources for future missions.
2. Pediatric providers were integral in supporting the surgical team effort by managing most of the pre- and post-surgical pediatric care on the wards allowing surgeons to focus efforts in the operating suite. This hospitalist approach contributed to the minimal delays seen from time of admission to first surgical procedure despite the initial overwhelming influx of patients.
3) Manning documents for future disaster relief missions should include pediatric intensivists given an expected early surge and sustained PICU census with a step down area to more efficiently utilize limited critical care resources.
4) Future studies should evaluate the referral process to the COMFORT during disaster relief missions to optimize utilization of its advanced level 3 medical capabilities and maximize support available for referring field hospitals.
References
1. Mulvey, JM, SU Awan, AA Qadri and MA Maqsood. Profile of injuries arising from the 2005 Kashmir Earthquake: The first 72 hours. 2008. Injury 39(5) 554-560
2. Beekley AC, MJ Martin, PC Spinella, SP Telian and JB Holcomb 2009. Predicting Resource Needs for Multiple and Mass Casualty Events in Combat: lessons learned from combat support hospital experience in Operation Iraqi Freedom. J. Trauma 66(4): S129-137
3. Yasin, MA, SA Malik, G Hasreen and CA Safdar. 2009. Experience with mass casualties in a subcontinent earthquake. Turkish Journal of Trauma and Emergency Surgery. 15(5) 487-492
(1)
(2)
(4)
(5)
(10) Profile of Pediatric Injuries not requiring Surgery
CATEGORIZATION OF ADMISSIONS
NOT NEEDING SURGERY
OTHER
MEDICAL
DISEASE
22%
PREMATURITY-
NEWBORN
12%
SURGEON
EVALUATED -
NO SURGERY
NEEDED
48%
INFECTION
14%
MALNUTRITION
4%Profile of Surgical Injuries that did not
need Surgery
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
1
CASTEDNEUROSURGICALSOFT TISSUE INJURYALREADY TREATEDOPHTHALMOLOGICCHRONIC PROBLEM
(6)
(8)
(9)
(7)
The views expressed in this presentation are those of the authors and do not necessarily reflect the official policy or
position of the Department of the Navy, Department of Defense or the United States Government
Research data derived from an approved National Naval Medical Center, Bethesda, MD IRB [IACUC] protocol
(3)
USNS Comfort Quiz Some questions are based on the readings; some will need to be completed during the tour.
1. What day had the most admissions during the Haiti operation?
2. What day had the highest census in the Haiti op? Highest pediatric census?
3. How many football fields long is the Comfort?
4. How fast is the max speed of the Comfort when translated to miles per hour for a car?
5. Name a type of Navy vessel that has a max speed faster than the Comfort?
6. Name a type of Navy vessel with a max speed slower than the Comfort?
7. What's the average water usage of a person living in DC and how does it compare to the daily water available to personnel on the Comfort when underway with a full crew?
8. If you were designing a hospital ship, where would you locate the ORs and why?
9. How many ships have been named COMFORT? What was the name of this ship before she was converted to the USNS Comfort? (Hint: Look around the mess deck walls)
10. How many hospital beds does the Comfort have? OR’s? Lifeboats? Patient elevators?
USNS Comfort Discussion Questions You are on a humanitarian mission to a developing nation devastated by a natural disaster:
1. As a pediatrician, what diseases should you prepare for? 2. What supplies would you need? 3. Onboard, where would you set up your MTFs to triage, treat, and manage children? 4. Describe the movement of patients on the COMFORT. If a patient arrives by helo, and needs triage, decontamination, emergency care, an operation and then recovery, what areas of the ship would he pass through to accomplish all this? List and diagram below: