PREPARATION FOR WAR: An Anesthesiologist Perspective
DON DANIELS M.D. COL MC Deputy Commander for Clinical Services USA Medical Activity
Heidelberg, Germany
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PREPARATION FOR WAR: An Anesthesiologist Perspective
• “The state of world peace is still just a Dream.”
– Azriel Perel. Battlefield Anesthsesia 1987.
• “War never goes away, and we are never ready for its return.”
– Frederick Courington. Anesthesia at the Battlefield:The Present and the Future. Seminars in Anesthesia 1988; VII: 26-32.
• “And ye shall hear of wars and rumors of wars…For nations shall rise, and kingdom against kingdom”
– Jesus. Matthew 24:6-7. King James Version
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PREPARATION FOR WAR: An Anesthesiologist Perspective
• OBJECTIVES
– – – – – – – – Preparation/Readiness Problems related to war Workload DEPMEDS Anesthesia Equipment Anesthesia supplies Casualties Personnel
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PREPARATION FOR WAR: An Anesthesiologist Perspective
• Deployed Medical Assets since 1982
– – – – – – –
Grenada 1983 Panama Persian Gulf 1990-91 Somalia 1993-94 Haiti Bosnia Kosovo
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PREPARATION FOR WAR: An Anesthesiologist Perspective on Readiness
• • • • MEDRETTE/ARTEP JRTC (Ft Polk) JTTC (Ben Taub, Houston) SURGEX
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PREPARATION FOR WAR: An Anesthesiologist Perspective on Readiness
• Common Soldier Skills • EFMB
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PREPARATION FOR WAR: An Anesthesiologist Perspective on Readiness
• Physical training
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PREPARATION FOR WAR: An Anesthesiologist Perspective on Readiness
• Nuclear, Biological & Chemical Survival Skills
– How long can you wear MOPP? – Do you know to use the bathroom? – Anthrax vaccine – What will your enemy use?
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PREPARATION FOR WAR: An Anesthesiologist Perspective on Readiness
• ATLS • Chemical Casualty Course • Trauma Anesthesia Seminars • Combat Casualty Courses C4 & C4A
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PREPARATION FOR WAR: An Anesthesiologist Perspective on Readiness
• Wills, Power of Attorney • Insurance Disability, Life (Beware of war clause trap) • Shots
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Predeployment preparation: An Anesthesiologist Perspective
• Low intensity vs Land/Air/Sea Battle • Operations other than war (OOTW) • NBC threat
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Predeployment preparation: An Anesthesiologist Perspective
• Condition of Anesthesia Equipment
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Predeployment Preparation: Environmental hazards
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Predeployment preparation: Environmental hazards
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Predeployment Preparation: Environmental hazards
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PREPARATION FOR WAR: Planning for Contigencies
• • • • 5 day 15 day Pushpacks Leapfrogging fast teams • Resuppling other MTF’s
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War Anesthesia Supplies and Equipment
• Usually outdated
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War Anesthesia Supplies and Equipment
• Lack ped and Ob supplies • Dantrolene is unavailable
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War Anesthesia Supplies and Equipment • Equipment is usually not state of art
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War Anesthesia Supplies and Equipment
• • • • • • • • • • • Item 6515-01-210-7846 6515-01-262-7222 6515-01-269-6698 651501-174-9895 6515-01-257-1892 6515-01-368-1830 6515-01-180-8860 6515-01-036-9035 6515-01-1562494 6515-00-458-8416 Nomenclature PERC SHEATH INTRO KT PUNCTURE KIT JUGULAR CATH CENTRAL VENOUS CATHETER CARDIO 4FR TUBE TRACH 28F 100 TUBE TRACH 10 TUBE TRACH 14F 100 TUBE TRACH 8.5 100 ANESTHESIA SET 10S CATHETER&CON TRAC18FR UI EA EA EA EA PG PG PG PG PG PG Quantity 1 1 1 3 1 3 3 1 1 8 Unit Price $19.00 $16.67 $18.00 $27.40 $12.91 $18.41 $12.91 $12.91 $187.16 $13.02
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War Anesthesia Supplies and Equipment: Oxygen Supply
• Large O2 tanks presented logistical and back breaking problems
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War Anesthesia Supplies and Equipment: Oxygen Supply
• Oxygen cylinder placement?
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War Anesthesia Supplies and Equipment: Oxygen Supply
• There has to be a better way!!!
– Oxygen concentrators – Liquid oxygen – Air compressors to drive ventilators
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Deployable Medical Systems:DEPMEDS
• Not very mobile • Provide excellent facilities • Assembly required, officers help • Takes up land space • Basic MMS contains 3 days supplies
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DEPMEDS: Assembly required
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DEPMEDS: Assembly required
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DEPMEDS: Assembly required
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DEPMEDS: Assembly required
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DEPMEDS: Assembly required
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DEPMEDS: Assembly required
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DEPMEDS: Assembly required
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DEPMEDS: Assembly required
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DEPMEDS: TEMPER Ward
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DEPMEDS: OR Isoshelter Equipment
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DEPMEDS: OR Isoshelter Equipment
• Impact suction x 2 • Portable K-thermia
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DEPMEDS: OR Isoshelter Equipment
• 1 Cardiac monitor/defibrillator per 2 beds • Manual BP cuff x 2 • Field Anesthesia machine x 2
– reusable rubber circuits and mask
• Cell Saver
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Anesthesia Personnel
• 1990 Combat Support Hospital
– 4-6 CRNA/ 1 Anesthesiologist – No anesthesia Techs
• no low density MOS • OR personnel: maybe,usually not
– Anesthesiologist usually has additional roles – Creates staffing issues during mass cals
• May have to use non anesthesia personnel
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Medical Force 2000 Anesthesia Staffing
• Hospital
– – – – –
–
Anesthesiologist
0 1 3 1 3
CRNA
2 4 15 2 15
FST MASH(delete) CSH Field Hosp Gen Hosp
Perkins D. Deployable Hospitals. In Zajtchuk R &Grande CM (eds). Text of Military Medicine Washington DC: US Department of theArmy, Medical Department, Office of theSurgeon General; 1995: 134.
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Preparation for War: Laboratory Support at 3rd & 4th Echelon • Basic hematology (Hgb, Hct, PT, PTT, Plts,Fibrinogen & Fibrin split products) • Chemistry (Na, K, CL, HCO3) • Urinalysis • Blood gases
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Ohmeda 885A Field Anesthesia Machine
• Powered by compressed oxygen & N2O • Universal vernitrol vaporizer • Circle system with soda lime • No ventilator • No fail safe • New models have jerry rigged moniter • Being replaced by Narkomed M Field Anesthesia Machine
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Ohmeda 885A Field Anesthesia Machine
• 7000 ventilator can be jerry rigged • Ventilator uses 12 L/min compressed gas • Dental section has compressed air generator
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Preparation for War: Methods of Resuscitation
• Crystalloid, Hespan, & albumin • Blood products limited – PRBC’s – Platelets & FFP very limited • One Level 1 per two beds • Cell saver • Aline & CVP transducers may not be available
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Preparation for War: Anatomic Distribution of battle wounds
• Location
– – – – – – Multiple Head/Neck/Face Chest Abdomen Upper Extremities Lower Extremities
WWII
11% 12 8 4 26 39
RVN
20% 14 7 5 18 36
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Preparation for War: Anatomic Distribution of battle wounds
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Preparation for War: Anatomic Distribution of battle wounds
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Anesthesia on or near the Battlefield: Condition of Casualties
• Will depend on MTF • Most will be extremity wound and multiple wound • Full stomachs • Blood and fluid depletion in all patients • Hypothermia in cold climates • Burns in Armored patients
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Anesthesia on or near the Battlefield: Condition of Casualties
• Enemy air superiority creates delays in friendly evac • More necrotic tissue results • More patients die • More likely to see septic patients in OR
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Anesthesia on or near the Battlefield: Condition of Casualties
• High velocity weapons destroy vast amounts of tissue • If hit in chest creates ARDS
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Anesthesia on or near the Battlefield: Condition of Casualties
• 15% if all casualties need immediate surgery or resuscitation
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Anesthesia on or near the Battlefield: Condition of Casualties
• 41 CSH ODS 1991
– GSW Chest, Spleen, open skull fx – GSW thigh w fx femur & tib – Traumatic arm amputation, GSW foot & buttock – Lac lung, hilum & heart
• Falklands experience
– 65% extremities – 75% of all GETA for excision & debridement of extremity wounds – 4% GETA for laparotomy – 1% intrathoracic procedures
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41 CSH Desert Storm Statistics
• • • • • • Anes time (av) Surg time (av) EBL (av) Crystalloid (av) Hespan (av) PRBC (range) 133 min 81 min 596 ml 2385 ml 790 ml
1-27 unit
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Preparation for War: Anesthesia Induction
• • • • • • Thiopentothal Ketamine Propofol Etomidate Cricoid pressure during induction Succinylcholine
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Preparation for war: Anesthesia Maintenance
• • • • • Forane/halothane Nitrous/Narcotic Ketamine infusion Scopolamine Ether in austere conditions • Ketamine infusion:
– – – – – Ketamine 200 mg Midazolam 5 mg Vecuronium 12 mg in 50 ml solution 2 mg/kg/hr ketamine = pt kg wt/2
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Battlefield anesthesia supply conservation: Low flow anesthesia
• Conserves volatile anesthetics • Conserves fresh gas supplies • Uses up Soda Lime
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Battlefield Anesthesia: Role of regionals
• Geta manpower intensive, regionals are not • Block nerves ahead of surgeons • Regionals well described in war literature since early 1900’s • Use neuraxial blocks only in well resuscitated patients
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Battlefield Anesthesia: Out of OR utilization
• Radiology support or resuscitation • Emergency medical treatment temper • Triage • ICU
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Battlefield Anesthesia: Out of OR anesthetics
• Burn debridement • Sympathetic block
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Peri-Battlefield Anesthesia: Chemical Warfare
• Interaction between muscle relaxants, nerve agents & prophylactic medications are unknown Pyridostigmine bromide exacerbates reactive airway disease Bulky chemical suits restrict our practice How does one protect the patient on table? Is the OR isoshelter hardened?
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• •
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Battlefield Anesthesia: Present & Future
• Drawover Vaporizer • Narcomed M Field Anesthesia Machine • Portable monitoring systems • New MTF designs
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Narkomed M Field Anesthesia Machine
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Anesthesia near or on the Battlefield: Summary and Conclusion
• “Combat anesthesia resembles anesthesia in civil practice with the following exceptions - the patient is not prepared for operation: induction must be rapid and recovery must follow quickly; a large number of cases require treatment at one time, and, finally, the anesthetic is often administered under trying conditions with improvished apparatus. If these difficulties are recognized and met, the well trained anesthetist in civil life will not fail to render his country a great service when called to the battle line.”
– Courington. Seminars inAnesthesia. 1988.
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Questions or Comments
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