Critical Care on Rotary Wing Aircraft The Experience at ：在旋转翼飞机的经验，在重症监护

Critical Care on Rotary Wing Aircraft The Experience at ：在旋转翼飞机的经验，在重症监护 Critical Care on Rotary Wing Aircraft: The Experience at Balad, Iraq Maj. (Dr.) Mark A. Nassir Col. (Dr.) Kenneth K. Knight Office of the Command Surgeon, HQ Air Combat Command 162 Dodd Blvd, Langley Air Force Base, VA 23665 USA Mark.Nassir@us.af.mil / Kenneth.Knight@us.af.mil ABSTRACT Managing a critical care patient in the rotary wing flight environment is a unique and challenging experience. As an example of joint medical support in our current theater of operations, United States Air Force (USAF) flight surgeons are currently flying on selected missions as physician medical attendants alongside United States (US) Army medical evacuation (MEDEVAC) crews, specifically working with flight medics to provide en-route patient care across the spectrum from stable to critical. Air Combat Command (ACC) currently manages the USAF personnel for our deployed Expeditionary Medical Support/Air Force Theater Hospital (EMEDS/AFTH) system, including flight surgeon support to these rotary wing missions. During a recent deployment to the Balad AFTH in 2008, we noted that the US Army flew an average of 331 patients per month by inbound and outbound helicopter transport. Relatively few in comparison, an average of 9 patients per month, required the presence of a physician medical attendant. Most commonly, medical attendants flew missions with Iraqi civilian patients who had a diagnosis of head trauma. As we anticipate continued support by USAF flight surgeons in the future, our proposed concept is to add Rotary Wing Critical Care Knowledge and Equipment for Emergency Transport (ROCKET) capability to our currently deployed personnel. The ROCKET concept is a standardization of training and equipment for USAF flight surgeons augmenting US Army MEDEVAC crews in rotary wing transport of critical care patients, thereby enhancing joint medical operations. 1.0 PATIENT AIR EVACUATION OPERATIONS 1.1 Basic Types of Patient Movement [1] Patient movement through increasing echelons of care has been generally described with the following categories (Figure 1): • Casualty Evacuation (CASEVAC): Movement from point of injury to medical treatment by non- medical personnel. • Medical Evacuation (MEDEVAC): Movement from battlefield to Medical Treatment Facility (MTF), or MTF to MTF (such as ship to shore) – en route care provided by medical personnel using equipped vehicles or aircraft. • Aeromedical Evacuation (AE): USAF fixed-wing aircraft, en route care provided by AE crewmembers and Critical Care Air Transport Teams (CCATT). RTO-MP-HFM-157 16 - 1 Critical Care on Rotary Wing Aircraft: The Experience at Balad, Iraq Figure 1: Echelons of Care [1] 1.2 MEDEVAC current operations The MEDEVAC rotary wing mission has historically and continues to be led by the US Army DUSTOFF aviation units, generally using the UH-60 Blackhawk helicopter configured for patient transport (Figure 2). As we continue to develop joint medical support in our current theater of operations, USAF flight surgeons are currently flying on selected missions as physician medical attendants alongside US Army MEDEVAC crews, specifically working with flight medics to provide en-route patient care across the spectrum from stable to critical. As we look to the future of continued USAF flight surgeon support on rotary wing transport missions, we propose a formal standardization of flight surgeon training and equipment, as an added capability for our currently deployed forces. 16 - 2 RTO-MP-HFM-157 Critical Care on Rotary Wing Aircraft: The Experience at Balad, Iraq Figure 2: UH-60 Blackhawk configuration for patient transport 2.0 EXPEDITIONARY MEDICAL SUPPORT 2.1 Overview of the Expeditionary Medical Support/Air Force Theater Hospital (EMEDS/AFTH) concept [2,3] An Aerospace Expeditionary Force (AEF) is a package of aerospace capabilities that provides tailored forces to meet theater requirements across the full spectrum of military operations. AEF forces respond to sustainment and crisis action contingency operations. The Air Force Medical Service (AFMS) provides medical capabilities to the AEF identified in unit type codes (UTCs) to support needed requirements. As such, medical UTCs are assigned and deployed as the mission dictates. Regarding medical capability, the EMEDS/AFTH system includes the entire spectrum of health care in a theater of operations, to include deployment scenarios, war operations, deterrence and contingency operations, peacetime engagement, crisis response, and humanitarian relief operations. Because the EMEDS/AFTH concept is designed to provide essential care, rather than definitive care in theater, timely aeromedical evacuation support is critical to mission success. As part of this process, the USAF provides fixed-wing, common user aircraft for patient evacuation. AE assets are postured to support casualty requirements. RTO-MP-HFM-157 16 - 3 Critical Care on Rotary Wing Aircraft: The Experience at Balad, Iraq 2.2 EMEDS transport capability [2,3] Air Mobility Command (AMC) is the lead Major Command (MAJCOM) for AE and CCATT evacuation missions. AMC provides forces and equipment to ensure personnel are organized, trained, and equipped to perform both inter-theater and intra-theater AE missions. Although there remains significant overlap in patient care concepts between various aircraft types, there is a distinct need for EMEDS to have an inherent intra-theater critical care transport capability for patient disposition. This is best achieved using rotary wing aircraft for missions of relatively shorter distance and duration as compared to standard AE missions. Air Combat Command (ACC) is the lead MAJCOM for the EMEDS/AFTH Manpower and Equipment Force Packaging System (MEFPAK). In this role, ACC manages the personnel for the deployed EMEDS, to include the physicians needed to support EMEDS based rotary wing transport missions. 3.0 THE EXPERIENCE AT BALAD, IRAQ 3.1 Flow of patients At the EMEDS/AFTH in Balad, Iraq, we received patients via Army MEDEVAC from other MTFs and from point of injury locations. After evaluation and stabilization, US and Coalition patients were generally flown by fixed wing AE to Landstuhl Regional Medical Center, Germany, for further evaluation and treatment. When medically indicated, they were then transported to their home country. After evaluation and treatment, Iraqi patients admitted to the AFTH were discharged home or to other host national medical facilities. Regularly, these patients required MEDEVAC transport to assist with patient discharge and disposition. 3.2 Patient demographics in rotary wing transport [4] During our deployment from May to August 2008, the EMEDS/AFTH in Balad saw a total of 1325 patients moved by helicopter transport (both inbound and outbound). This was an average of 331 patients per month, or approximately 11 patients per day moved by rotary wing through our facility. In comparison, the number of patients requiring the presence of a medical attendant during transport was relatively few compared to the total number of patients moved. To help describe this, we reviewed all rotary wing patient transfers with medical attendants from January to June 2008 and noted a total of 52 patients (average of 9 patients per month) were transported with medical attendants during this timeframe. Of those patients needing a medical attendant during transport, the most common patient status was Iraqi civilian, and the most common injury type was head trauma (Figures 3 and 4). Other patient status categories included Iraqi police, Iraqi Army, detainee, and contractor. Other injury types and mechanisms included non-head trauma, gunshot wounds (GSW), shrapnel wounds, burn, motor vehicle accident (MVA), and non-battle injury (NBI). Often, the flight surgeon or other medical attendant served to assist with the patient’s airway management (endotracheal tube and tracheostomy), equipment management (ventilator, suction, intravenous pump, and oxygen delivery), and administering medication during flight. 16 - 4 RTO-MP-HFM-157 Critical Care on Rotary Wing Aircraft: The Experience at Balad, Iraq Figure 3: Rotary Wing Transport with Medical Attendants – Patients by Status [4] Figure 4: Rotary Wing Transport with Medical Attendants – Patients by Injury Type/Mechanism [4] RTO-MP-HFM-157 16 - 5 Critical Care on Rotary Wing Aircraft: The Experience at Balad, Iraq 3.3 Lessons Learned from experience at Balad [5] 3.3.1 MEDEVAC experiences Our inbound MEDEVAC transports to Balad came from all directions, and reached as far to the North as Kirkuk, and as far to the South as southern Baghdad (Figure 5). Routinely patients transported out of our AFTH were from the intensive care unit (ICU) or intermediate care ward (ICW) to other Iraqi medical facilities, often in the Baghdad area. AF flight surgeons did not routinely perform point-of-injury extractions, although we were used at times to bring unstable patients back to Balad. Figure 5: Map of central Iraq [6] Handling a critical care patient in a MEDEVAC helicopter transport environment is a unique experience, and it differs from ambulance transport on the ground in several respects. Often, transport time is extended and control of the work environment is more difficult as compared to ground movement. Rotary wing transport also differs from fixed wing, large scale AE/CCATT missions, where multiple medical personnel are working together as a team. In fixed wing aircraft, the flight environment is often more permissive regarding workspace, lighting, and equipment. The skill sets needed for effective rotary wing transport require training, planning, and preparation. For the average deployed flight surgeon, the rotary wing flight environment is challenging and requires learning to 16 - 6 RTO-MP-HFM-157 Critical Care on Rotary Wing Aircraft: The Experience at Balad, Iraq function comfortably in a loud, dark, and cramped workspace. Described below are some lessons learned regarding personal skills, patient packaging, and equipment preparation. 3.3.2 Skills/personal preparation lessons learned: • Advanced Trauma Life Support (ATLS) competency and proficiency: in addition to course completion. The attendant needs to be adept in patient assessment and ATLS skills. Patient assessment in a sensory deprived environment is demanding. For example, auscultation with a stethoscope is not possible during rotary wing flight. • Pediatric Advanced Life Support (PALS) competency and proficiency: unfortunately in the deployed theater of operations, children are sometimes harmed, and require transport. • Conscious sedation: understanding the use of sedative medications, both for maintenance and for acute treatment of the agitated patient, with attention to monitoring, airway and breathing control. • Safe approach to the rotary wing aircraft: with attention and clearance from crew chief or flight medic. Once onboard, preparations should be made for personal equipment stowage, securing of the patient/litter, and seatbelt/harness locking for safe movement during flight. • Remain flexible during transport in difficult situations such as: dealing with a combative patient (common with head injury), equipment malfunction (endotracheal tube dislodgement during loading/unloading, dead battery), loss of patient airway, and prolonged flight time (diverted, cancelled). • Consider how to communicate with aircrew during the transport: radio communication sometimes is unavailable, so written notes or hand signals may be needed. When on the intercom, be deliberate, brief and aware of other conversations. 3.3.3 Patient preparation lessons learned: • Patient packaging: understanding how to package patients for warmth and security. How to effectively secure extremities, especially in the mentally altered patient. Determine the direction of loading as this will establish configuration of the monitor, ventilator, and other equipment for viewing during flight. • Secure IV access: for example, the IV hep-lock in the patient’s upper extremity can be difficult to reach if buried under blankets and on the opposite side to your seat. Saline pre-flushed IV extensions attached to the outside of the patient’s blanket and marked with tape or small chem-lights are effective. • Carefully secure the patient: litter straps ideally are placed across the legs above the knees and across the chest at the elbow level, consider soft restraints to secure the wrists and ankles to the bottom handles of the litter. • Oxygen bottle placement: consider securing between the patient’s calves with the regulator toward the feet. The bag-valve-mask assembly can be placed under or next to the patient’s head, with the oxygen hose kept under the patient’s back and pre-placed on the oxygen bottle regulator port. Consider oxygen and medication needs based on the patient’s use rate. • The EMEDS/AFTH staff (ICU/ICW) may not recognize the challenges of the in-flight environment. They may need guidance for patient packaging and preparation for transport. Confirm that the patient is prepared as you require. Review the medical record and patient flow-sheets. RTO-MP-HFM-157 16 - 7 Critical Care on Rotary Wing Aircraft: The Experience at Balad, Iraq • Patient documentation: it is helpful to have the narrative discharge summary, recent lab results, medication administration record, and recent vital signs flow-sheets ready to handoff after patient transport. 3.3.4 Equipment lessons learned (Figure 6): • Allow adequate time to inspect flight equipment. Some of our urgent transport requests came with very short notice. • Personal survival equipment: preparation in advance and familiarity of equipment is important. Check radio and battery, helmet, and survival vest contents. Consider plans for crash recovery and injury and care under fire. Practice aircraft egress, including working the windows and doors. Ensure lighting is compatible for night vision. Helmet lip lights and finger-lights are useful. • Understanding medical equipment for use in the aircraft: troubleshoot your gear in the light to prepare for use in the dark. Key items to assess are: Impact ventilator, Impact suction, Propaq cardiac monitor, IVAC IV pump, and Zoll defibrillator. Ready access to trauma shears and a knife is recommended. • Consider additional medical accessories such as: airway kit, medication kit (pain control, reversal agents, sedatives, anti-emetics, and epinephrine), finger tip pulse-oximetry, oxygen tanks (carbon- fiber bottles hold more oxygen and are lighter than steel cylinders), and a small overnight bag with personal items. 16 - 8 RTO-MP-HFM-157 Critical Care on Rotary Wing Aircraft: The Experience at Balad, Iraq Figure 6: MEDEVAC equipment commonly used by medical attendants [5] RTO-MP-HFM-157 16 - 9 Critical Care on Rotary Wing Aircraft: The Experience at Balad, Iraq 4.0 FUTURE COURSE OF ACTION – PROPOSED WAY AHEAD 4.1 Preparing for future scenarios Trauma patients brought to the EMEDS/AFTH during standard operations are evaluated, resuscitated (medically and surgically), and stabilized with a goal of long term recovery and safe transport. During mass casualty events, patient volume drives the need for expeditious clearing of beds and disposition to other treatment facilities. With the expectation of future surge scenarios, stabilized critical patients will require priority transport. The need for short distance, inherent EMEDS/AFTH rotary wing critical care transport capability has become evident, for conflicts that our military forces face. 4.2 Capability needed Given the current transport challenges, recommendations for future operations include : • Prompt ability to transport critical care patients: multiple organ damage, immediate post-operative • Assess and respond with resuscitative interventions in-flight • Manage advanced patient equipment in-flight: cardiac monitor, advanced airway, ventilator, intravenous/intraosseous access • Communicate effectively in rotary wing aircraft with other aircrew • Transport and care for patients under night conditions with limited lighting options 4.3 Rotary Wing Critical Care Knowledge and Equipment for Emergency Transport (ROCKET) In light of the need for safe and effective critical care transport, our proposed course of action is to further develop and standardize the training and equipment for flight surgeon personnel serving as medical attendants. Our proposed concept is to add Rotary Wing Critical Care Knowledge and Equipment for Emergency Transport (ROCKET) capability. ROCKET would be a UTC consisting of equipment and training, added to our currently deployed flight surgeon personnel. This added inherent EMEDS capability could provide trained medical attendants for critical care patient transport out of the AFTH to nearby locations via rotary wing aircraft. ROCKET would be separate from, and in addition to the existing AE mission, and could expand the EMEDS ability to clear patient beds especially during surge events. The intention would be for ROCKET equipped flight surgeons to be MEDEVAC compatible, thereby enhancing joint Army-Air Force medical operations. ROCKET could be established as a war related material (WRM) equipment and training capability, not a separate personnel UTC. The required ROCKET training could be associated with existing flight surgeon UTCs (such as FFPM1 and FFDAB), as mission essential task training, and as an added requirement in the line remarks of the deployment orders. The personnel utilized would be flight surgeons already deployed to the EMEDS. Specifically, we suggest that the deployed senior aerospace medicine physicians (FFPM1) and EMEDS/AFTH based flight surgeons (FFDAB) would have ROCKET training added as a requirement. Other deployed flight surgeons could have the training as a recommended option. The required ROCKET equipment could be added to the EMEDS/AFTH equipment allowance standard as indicated by location and mission. 16 - 10 RTO-MP-HFM-157 Critical Care on Rotary Wing Aircraft: The Experience at Balad, Iraq Other ROCKET options to consider might include a physician/medical technician team staffed from the EMEDS. However, in the currently flown UH-60 Blackhawk configuration, there is only room for a single medical attendant seat in addition to the basic aircrew. 4.3.1 ROCKET UTC proposed training requirements • Joint Enroute Care Course (JECC) - required • Center for Sustainment of Trauma and Readiness Skills (C-STARS) - required • Advanced Trauma Life Support (ATLS) - required • Advanced Cardiac Life Support (ACLS) - required • Pediatric Advanced Life Support (PALS) – required • In-theater Army CSH medical attendant training equivalent - optional • Operational Emergency Medical Skills (OEMS) - optional 4.3.2 ROCKET UTC proposed equipment requirements • Flight gear: helmet, survival vest, flying equipment • CCATT approved patient equipment: Impact ventilator, Impact suction, Propaq monitor, IVAC • US Army MEDEVAC standard equipment set 5.0 CONCLUSION Managing a critical care patient in the rotary wing flight environment is a unique and challenging experience. As an example of joint medical support in our current theater of operations, USAF flight surgeons are currently flying on selected missions as physician medical attendants alongside US Army MEDEVAC crews, specifically working with flight medics to provide en-route patient care. Our proposed concept is to add ROCKET capability to our currently deployed USAF flight surgeon personnel, thereby enhancing joint medical operations. 6.0 REFERENCES [1] Joint Patient Movement Requirements Center, Training presentations. Provided by former Theater Validating Flight Surgeon, Col Diane Huey, April 2008. [2] Air Force Medical Service Concept of Operations for Expeditionary Medical Support (EMEDS)/Air Force Theater Hospital(AFTH) System, HQ ACC/SGX, Langley AFB, VA, 10 Sep 1999. [3] Expeditionary Medical Support (EMEDS), Air Force Tactics, Techniques, and Procedures, 3-42.71, 27 July 2006, [4] Patient Administration Department (PAD) Summary Data, Air Force Theater Hospital, Balad, Iraq. Provided by MSgt Theresa Winland and Lt Col Thomas Hunter, AEF 3/4: May-Sep 2008. RTO-MP-HFM-157 16 - 11 Critical Care on Rotary Wing Aircraft: The Experience at Balad, Iraq [5] After Action Report Addendum on Helicopter MEDEVAC Attendant Duties, Air Force Theater Hospital, Balad, Iraq. Provided by Maj Dave Rogers, AEF 9/10: Sep 2007 - Jan 2008. [6] Map of Iraq, www.stripes.com/standing/iraqmap.pdf. 16 - 12 RTO-MP-HFM-157