CASEVAC MEDEVAC CATF ESG Surgeon Course by liaoqinmei

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									Component Detachment of Naval Operational Medicine Institute


        CASEVAC / MEDEVAC
   CATF / ESG Surgeon Course 2005


               CDR LOU GILLERAN, MC (FS), USN
                      Head, Operations
                    Objectives

• The student will develop
  an understanding of
  aeromedical concerns
  relevant to medical
  movement including
  patient preparation and
  care, resources, training
  and planning.

• So there!



                                 2
                AGENDA
• Echelons of Care and HSS System , (aka things
  that you would have learned during C4, had you
  been paying attention)
• Evacuation Principles
• Patient Selection and Preparation
• Issues with Specific Medical Conditions
• USN/USMC Evacuation Platforms
• USN/USMC Medical Capabilities
• Marine Corps Developments
• Case scenarios (aka lessons from other’s
  mistakes)

                                                   3
             REFERENCES
  • US NFS Manual: Third Edition, Ch 16
⇒ • Joint Pub 4-02.2 Joint Tactics, Techniques
    and Procedures for Patient Movement in
    Joint Operations
  • AFR 164-5/AR 40-535/OPNAVINST
    4630.9C/MCO P4630.9A Worldwide
    Aeromedical Evacuation
  • FM 8-55 Planning for Health Service
    Support
  • FM 8-10 HSS in a Theater of Operations
⇒ • FM 8-10-6 Medical Evacuation In A
    Theater Of Operations
                                                 4
              Important!
Currently, the Navy and
 Marine Corps have no
 dedicated aeromedical
 evacuation resources
    and no defined
Aeromedical Evacuation
doctrine (outside of the
      joint pubs).




                           5
               DEFINITIONS
At times, a bit confusing, overlapping and subject to change



• Medical Evacuation (MEDEVAC):
     –Movement of patient, ground and air
• Aerial / Air Evacuation (AIREVAC):
     –Movement of patient by Air Assets, more specifically the
     USAF role.
• Aeromedical Evacuation:
     –Movement of patient by Air Assets
• Casualty Evacuation (CASEVAC):
     –Evacuate patient from combat zone by air or ground
• En Route Care System (ERCS):
     –MEDEVAC/AIREVAC package for evacuation from L2
• Stabilized Patient:
     –Airway secured, hemorrhage controlled, shock treated,
     fractures immobilized.
                                                                 6
           Levels of Care
• Self Aid-Buddy Aid
• Level 1: 1st Aid, Sickcall, Emergency Care:
  ACLS/ATLS
• Level 2: Initial resuscitation, Surgery for life, limb
  and sight and stabilize for transport.
• Level 3: Resuscitative Care, Surgery + Definitive
  Care in low threat with multiple specialties.
• Level 4: Definitive Phase of treatment with
  comprehensive Med-Surg Care.
• Level 5: Convalescence, Restoration and
  Rehabilitation. In CONUS


                                                           7
Casualty Evacuation (CASEVAC)
• Historically Lift of Opportunity with FS, HM or
  non-medical assets as available
• Pick-up at Casualty Collection Point (CCP) or in
  combat / hot zone, evacuate to E2+.
• Currently Marine Corps has dedicated aircraft,
  CH46, with trained and equipped HMs. Pending
  incorporation in doctrine.




                                                     8
     En Route Care System
            (ERCS)

• An equipment package for trained personnel,
  Critical Care Nurses and HMs, to provide post-
  operative care in transit.

• Capability to care for 2, critically ill / injured, but
  stabilized, casualties during transport aboard
  USMC Aircraft (CH46) from elements ashore to
  elements at sea or ashore.

• Currently in use and pending incorporation into
  doctrine. First approved course by NOMI Jan 05.


                                                            9
         Worldwide AirEvac
         Evacuation System

• USAF is lead in movement out of theater – AOR,
  by the Air Mobility Command (AMC), falls under
  TRANSCOM
• Global Patient Movement Requirements Center
  (GPMRC).
• Joint Medical Regulating Office (JRMO) Planning
• Theater Patient Movement Requirement Center
  (TPMRC: Yokota Japan+Ramstein, Germany)
• Joint Patient Movement Requirement Center
  (JPMRC) Subset of TPMRC in theater



                                                    10
11
SH-60B
SEAHAWK


   • 4 Litter and 1 Ambulatory (+1 Medical)
       or
   • 7 Ambulatory
   • Range: 373NM
   • Speed 184K
                                              12
CH-46 SEA KNIGHT
• 15 Litter Patients
  or
• 25 Ambulatory
  (+2 Medical)
• Range: 132NM
• Speed 132K




                       13
                                                           Golden Rule, ooops, Goal
                                      The patient should not experience a degradation in the level of care
                                      received in transit.

                                                                                        Golden Hour
                                            Immedia te: CNS injury or he a rt a nd
                                         grea t vesse l injury
                                 50
Pe rc e nt of tra uma de a ths




                                                          Ea rly: Ma jor He morrha ge
                                 40

                                 30                                                      a
                                                                                        L te: Infe c tion a nd
                                                                                        Multiorga n fa ilure


                                 20


                                 10

                                 0
                                        0         1         2        3        4         1-2           5-6

                                            Hours a fte r injury                            e
                                                                                           W e ks


                                                                                                                 14
Categories of MEDEVAC
• Emergency:
     • Critical wound, illness or injury requiring
       immediate evacuation. Life/Limb/Sight
• Priority:
     • Serious wound, injury or illness requiring
       early hospitalization
• Routine:
     • Wound, injury or illness of minor nature
       requiring other than local medical resources
 Evacuation Principles 1
• Other missions may diminish patient
  evacuation priority. CO approval!
• Operational Risk Management (ORM)
  principles apply
  – Medical necessity, Aircraft availability,
    personnel req, weather, distance, day-night
• En Route Care, limited, but be prepared
• True or not, you are seen as an expert



                                                  16
LANDING CRAFT AIR CUSHION
(LCAC)




Normal Configuration:    Personnel Transport Module:
• 3 litter patients     • One per Amphibious
• Range: 200NM            Landing Group
• Speed 45K             • 100 litter patients        17
  Evacuation Principles 2
• In most circumstances the Lower Level of
  care transports to higher level
  – Doctrine states higher level is responsible
• Move patient to next level of care based on
  patient condition, facility capability and
  current circumstances
• Rapid, efficient movement
• EPWs should be searched, secured as
  applicable and remain physically segregated
• Fatalities remain physically segregated

                                                  18
CH-53D/E SEA STALLION




• 24 Litter (+2)
  or
• 37 Ambulatory (+2)
• (55 w/center line seating)
• Range: 1,120NM
• Speed 150K
                               19
        MEDEVAC Planning
• Standard Operating Procedure
• Medical Facility/Capability Listings with
  contacts
• Practice, practice, practice
• Prepared MEDEVAC Packages
  – Checklist of all required items and contacts
  – Cost TAD Order request for pt + attendant
  – List of personal items for pt + attendant
  – MEDEVAC Msg Worksheet IAW AOR req
  – Air Transportation Request and Aircrew
    brief sheet as required
                                                   20
Key to all Patient Transport:
Prior Planning and Training!
                  Communications

• CoC Must Contacts: CO, XO, Air Ops, Weapons (Elevators)

• Medical Contacts: Fleet Surgeon, Group Surgeon,
  Receiving Facility, NOK, etc.

• Comms plan must be ready (SOP and MEDEVAC package)
  and include
   – Primary / Alternate / Contingency / Emergency


• In flight comms: headset, hand-signals, yelling, lip-reading

                                                             22
 THEATER EVACUATION
       POLICY
Establishes, in number
of days, the maximum
period of
noneffectiveness
(hospitalization and
convalescence) that
patients may be held
within the theater for
treatment.


                         23
•   Not equipped to evacuate litter patients,
    but in a pinch…
•   28 Ambulatory (+2)
•   Range: 1,300NM
•   Speed 343K




                                    C-2 (COD)
                                    Greyhound   24
Physiologic / Environmental Factors

•   Decreased oxygen tension
•   Decreased ambient pressure
•   Dehydration
•   Motion Sickness
•   Fatigue, Anxiety and Inactivity
•   Cold, Noise, Vibration and space
    limitations
                                       25
P-3 ORION




     •   10 Litter Patients
     •   or
     •   19 Ambulatory (+2)
     •   Range: 2,380NM
     •   Speed 328K
                              26
MEDICAL/PATIENT CONDITION

 Desirable conditions:
  –Stable cardiopulmonary status
  –Stable hemoglobin
  –Stable vital signs
  –Adequate hydration


                                   27
CABIN ALTITUDE RESTRICTIONS
 • Only absolute contraindication for AE is
   decompression sickness and gas embolism --
 • Fly at sea level or destination air field elevation
   – May be required for:
      • impaired tissue oxygenation
      • trapped gas disorders (absent bowel sounds, crepitus at
        injury site)
      • head trauma
      • unable to valsalva
 • Cost
   – increased fuel consumption, prolonged flight time,
     limited range, turbulence and adverse weather


                                                                  28
PATIENT CLASSIFICATION
  1 - Neuropsychiatric
    1A - Severe Psychiatric Litter Patient
    1B - Psychiatric Litter Patient
    1C - Psychiatric Walking Patient
  2- Litter Patients
    2A - Immobile
    2B - Mobile
  3 - Ambulatory
  4 - Infants
  5 - Outpatients
  6 - Attendants
                                             29
C-130 HERCULES




• 74 Litter Patients (+2)
  or
• 85 Ambulatory (+2)
• Range: 2,350NM
• Speed 374K

                            30
  Patient Preparation 1
• Patients stabilized to extent possible
• Coordinate with receiving facility
• 30 Day Cost TAD orders - Money for
  enroute meals, incidentals, etc
• Copies of Pertinent Medical Records, Labs
  and X-rays
• 3+ day supply of meds (USAF AE)
• Weapons are not transported with patient
• PPE (CBR / NBC gear) is transported with
  patient

                                              31
    Patient Preparation 2
• Empty urine bag
• IVs on infusion
• Label lines
• ETT / Foley
• ETT / Foley cuff water
  filled, not air
• Heimlich valve on
  chest tube
• Restrain patient
• Attach monitor leads


                            32
  Patient Preparation 3
• Blood pressure
  cuff on non IV arm
• Blankets
• Switch O2 to
  transport source
• Brief patient
• Record last set of
  vitals


                          33
              UH 60A BlackHawk

• 6 Litter Patients
  or
• 7 Ambulatory
  or
• 3 Litter and 4
  Ambulatory
• Range 315 NM
• Speed 150 K



                                 34
AMBULATORY vs. LITTER
• Patient must be able to walk to the
  aircraft or be on a litter
• “Litter for comfort” may be required
  for patients who cannot tolerate
  prolonged sitting or who fatigue
  easily due to the stresses of flight




                                         35
      Alcohol and Drug
        Dependence
• Detoxify at least 72 hrs prior to flight


             Diabetes
• Order:
  – Proper meals
  – Sliding scale
• Properly counsel the patient
                                             36
               ANEMIA
• Most can be safely transported with
  supplemental oxygen
• Consider transfusion if hemoglobin
  <8.0g/100ml
• Sickle Cell
  – 10,000 ft altitude can precipitate a crisis
  – Mitigate with supplemental O2 and hydration
                  Hemoglobin        Supplemental O2
                  8.5 – 10.0 g/dl   O2 available
                  7.0 – 8.5 g/dl    2 l/min
                  <7.0 g/dl         4 l/min
                                                      37
                 BURNS
• Report degree and percent burns,
  resuscitative measures taken, respiratory
  status
• Stressors
  –   Decreased FIO2
  –   Decreased humidity
  –   Thermal stress
  –   Motion sickness
  –   Hydration status
  –   Pain

                                              38
        CARDIAC PATIENTS
• Required history
  –   Date of MI, cardiac history
  –   Date of last symptoms
  –   Activity restrictions
  –   Current cardiac status, meds, BP/HR+R
  –   Monitor - ACLS medical attendant and IV line
• Decreased FIO2 is the challenge- cabin alt
  <6000 MSL (2000’ w/o supp O2)
• Good to wait five days post MI - complication
  prior to transport
• Monitored patients require an ACLS medical
  attendant
                                                     39
 DECOMPRESSION SICKNESS
• Required history: Type of DCS, treatment
  measures taken and current status
• Decreased barometric pressure is the
  challenge
• Must have:
  – IV line
  – Altitude restriction equal to elevation of destination
    treatment facility
  – 100% O2 by tight fitting aviators mask
• Coordinate with hyperbaric specialist/DMO
                                                             40
EARS, NOSE AND THROAT
• Decreased barometric pressure and
  motion sickness are the challenges
• Should be able to clear ears and
  ventilate sinuses
• Wired jaws required a quick release
  mechanism or wire cutters
• Countermeasures: altitude
  restriction, topical decongestants,
  myringotomy, anti-emetics

                                        41
         EYE INJURY
• After surgery or trauma, air may be
  introduced
• Restrict cabin altitude to prevent
  barotrauma to eye
• In choroidal or retinal disease or
  injury, use oxygen above 4000 MSL




                                        42
   GASTROINTESTINAL
• Acute GI processes (appendicitis,
  strangulated hernias, diverticulitis, etc.)
  are poor air evacuation candidates
• Trapped gas phenomenon (ileus, volvulus,
  unreduced hernia, intussusception)
• 10-14 day recovery post-op if possible
• Countermeasures: NG tube / rectal tube,
  NPO with good IV hydration, suction,
  altitude restriction

                                                43
 INFECTIOUS DISEASE
• Universal precautions.
• Tuberculosis and other diseases
  spread through airborne
  aerosolization.
  – Wait till no longer infectious prior to
    transport




                                              44
        NEUROLOGICAL
• Craniotomy - wait at least 48 hrs post-op prior to
  transportation
• All recent head trauma must be evaluated for air in
  the cranial vault; transport at sea level
• Increased ICP should not valsalva
   – myringotomy tubes?
• Seizures may be precipitated by the decreased
  barometric pressure, noise, vibration, thermal
  stress, flickering lights
• Spinal injuries usually transported on a Stryker
  frame - vibration can cause additional injury
• Neuro exam very difficult to perform in the airplane

                                                         45
           NUTRITION

• Total Parenteral Nutrition (TPN) not
  generally given during AE (glass).
• Joint Nutritional Support Task Force
  recommends switching from TPN to
  D10NS for the duration of the AE




                                         46
          OBSTETRICS
• Typically flown safely through 36th week.
• Report vital signs to include fetal heart
  tones, any complications, status of
  membranes.
• At higher risk for dehydration and motion
  sickness.
• If on a drip for pre-ecclampsia or pre-
  mature labor, a medical attendant able to
  perform a delivery is required.

                                              47
         ORTHOPEDICS
• Fluid shifts at altitude cause increased
  swelling
• Bivalve cast, and frequent neurovascular
  checks
• Avoid air splints
• Traction - no swinging weights
  – Collins traction (springs) used in aeromedical
    evacuation should be applied by a physician
  – Hare traction is preferred
• Vibration = increased pain

                                                     48
          PSYCHIATRIC
• Currently acting out?
• Homicidal / suicidal?
• Elopement risk?
• Restraints - chemical or physical?
• How does patient respond to authority figures?
• If legal action pending, has law enforcement
  authorized permission to transport out of local
  jurisdiction? Will law enforcement accompany the
  patient?
• NOTE: Female psychiatric patients requiring an
  attendant should have a female attendant

                                                     49
          PULMONARY
• Pneumothorax - chest tube
  – Wait 72-96 hrs after removing tube prior to
    flight if possible
  – Otherwise leave tube in place with Heimlich
    Valve
  – Confirm resolution of pneumothorax with
    chest X-ray
  – Send X-rays with patient
• Ventilator patients need a medical
  attendant proficient in ventilator use and
  capable of re-intubating if necessary

                                                  50
  V-22 OSPREY




• 12 Litter (+2)
  or
• 24 Ambulatory (+2)
• Range: 500NM
• Speed 327K
                       51
MEDEVAC CONFIGURATION
 OF V-22 WITH 12 LITTERS
                                      Litters (12)
Life Rafts                                           Upper Stanchion
                                                     Support Fitting


                                                            Support Struts

             UP
    FWD

                                                              Support Strap

           Winch                                                  Stanchion
      Accessories
         Stowage
              Lower Stanchion
               Support Fitting

                                                                              52
                                 Cabin Floor
USN/USMC MEDICAL
    FACILITY
  CAPABILITIES
HOSPITAL SHIP (T-AH)
 (USS COMFORT and USS MERCY)


• Patients received by helicopter
• Initial triage area for 50 patients




                              •   12 Operating rooms
                              •   80 ICU beds
                 L3           •   20 Recovery beds
                              •   1000 Total beds
                                                   54
        AMPHIBIOUS ASSAULT SHIP
    •   1,800+ troops with                LHD
        helicopters, boats and   •   604 beds
        amphibious vehicles      •   Largest medical
        required to land them        capability
    •   Capable of receiving     •   6 ORs
        both helicopter and           – 26 ICU
        waterborne casualties         – 4 quiet room
                                      – 46 ward
                                      – 528 overflow
                                 •   Medical aug: 342

             LHA
•   366 beds
•   4 OR
     – 15 ICU
     – 2 quiet room


                                         L2
     – 45 Ward
     – 300 overflow
•   Medical augmentation: 178                           55
AIRCRAFT CARRIER
• 1 operating room
  – Gen Surgeon, Oral Surgeon, Anesthesia Provider and
    2 OR Techs
  – Clinical Psychologist, Physical Therapist
• 3 ICU beds
• 8 Isolation beds
• 42 Ward beds



                                             L2
                                                     56
SURFACE COMBATANT SHIPS
 • Independent Duty
   Corpsman (IDC)




                          L1
                           57
  COMBAT ZONE FLEET HOSPITAL /
 EXPEDITIONARY MEDICAL FACILITY

• “Ground based” MTF
• 500 beds (max)
  – 900 personnel
  – 3 ORs (2 tables each)
  – 60 days Initial supply
• Modular
• Logistically difficult to relocate
• EMF has smaller footprint 2 acres
  vice 28 acres
                                       L3
                                            58
         Surgical Company
•   Provides health service
    support - medical and
    surgical care and
    temporary holding of
    casualties.
•   Consists of: HQ Platoon,
    Triage/EVAC, Surgical,
    Holding, Combat Stress, &
    Ancillary Service
•   3 OR’s, 3 Wards (20 beds
    ea.), 2 ea. Ancillary Service
•   T/O – 204 Ortho, GS, IM,


                             L2
    Psych, Neurosurg, etc.


                                    59
   Forward Resuscitative Surgical
          System (FRSS)

“The FRSS is a highly mobile, rapidly deployable, TRAUMA
SURGICAL UNIT that will provide emergency surgical
interventions required to stabilize casualties who might
otherwise die or loose limbs before reaching treatment.”

•2 General Surgeons
•1 Anesthesiologist
•Critical Care Nurse
•1 IDC                                      L2
•2 OR Techs
•1 HM 8404
       Shock Trauma Platoon (STP)
• ATLS intensive
  – Highly mobile
  – Stabilization Section
  – Collecting/Evacuation
    Section

  –   2 Emg Med physicians
  –   1 PA
  –   1 ER Nurse
  –   14 HMs 8404

                             L1+
  –   7 Marines

                                    61
       Battalion Aid Station
        Group Aid Station
         Wing Aid Station
•   GMO-FS / PA / IDC
•   ATLS
•   Sickcall, no admissions
•   +/- Lab, X-Ray, Prev Med Tech

• Satellites
    – Flight Line Aid Station, etc

                                     L1
                                          62
63
Things to do from a MEDEVAC
 perspective when you get to
        your ship /unit

• Review the Disaster and any MEDEVAC plan
• Practice the plan regularly
• Set-up, if applicable, a MEDEVAC bag with
  airway kit, monitors, drugs, etc.
   – Place it in a secure place, perform inventory
• Train your Marines and Sailors in Buddy Aid/Self
  Aid, GITMO 8, Combat Lifesaver, etc.
• Train your Corpsmen, train them again, think
  PHTLS, TCCC, etc.


                                                     64
                     Lagniappe
•   Politics--do the right thing
    for the right reason and
    communicate
•   Can’t assume that info on
    patient condition is
    accurate
•   Can’t assume that combat
    medics are knowledgeable
•   Chances are, the patient
    will not be ready for
    transport when you arrive
•   You can do very little once
    airborne
•   Practice, practice, practice
•   Prepackage, prepackage,
    prepackage
•   Sailors and Marines will
    always find ways to get
    injured
                                   65
                       Sample Cases

•   Appendicitis 25 NM off SOCAL

•   Pregnant out of Helo Range to HI, enroute to Yokosuka

•   R/O Ectopic

•   Fx Fibula, Helo range of DG, 7 days to Sydney

•   Salivary Mass

•   Acute MI, 2 days off SOCAL, 3 days to HI

•   Amputated Thumb

•   Suicidal Ideation, will not contract for safety after attempt with Tylenol OD
•
•   LE Amputation and UE partial Amputation In-port NASNI



                                                                                    66

								
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