Disaster Aeromedical Evacuation

Transcription

1 MILITARY MEDICINE, 176, 10:1128, 2011 Disaster Aeromedical Evacuation Col Nicholas G. Lezama, USAF MC * ; Col Lawrence M. Riddles, USAF MC ; Col William A. Pollan, USAF MC ; Col Leonardo C. Profenna, USAF MC ABSTRACT Successful disaster aeromedical evacuation depends on applying the principles learned by moving patients since World War II, culminating in today s global patient movement system. This article describes the role of the Department of Defense patient movement system in providing defense support to civil authorities during the 2008 hurricane season and the international disaster response to the 2010 Haiti earthquake. Adapting and applying the principles of active partnerships, establishing patient movement requirements, patient preparation, and in-transit visibility have resulted in the successful aeromedical evacuation of over 1,600 patients since the federal response to Hurricane Katrina. INTRODUCTION The primary mission of the Department of Defense (DoD) Patient Movement System is to transport wounded, injured, or ill DoD beneficiaries from deployed or in-garrison medical treatment facilities to medical facilities around the globe where needed health care services can be rendered. 1 In addition to its primary mission, and as a key element of the National Disaster Medical System (NDMS), the National Response Framework calls for the DoD to support state, local, and tribal civilian authorities when appropriate requests for federal assistance are made. 2 Successful disaster aeromedical evacuation depends on applying the principles learned by moving patients since World War II, culminating in today s global patient movement system. This article briefly describes the aeromedical evacuation responses to the 2008 Hurricanes Gustav and Ike and the 2010 Haiti earthquake and describes how the principles of active partnerships, establishing patient movement requirements, patient preparation, and in-transit visibility contributed to the successful evacuation of over 1,600 patients. 3 FEDERAL DISASTER RESPONSE Disaster response is largely a state and local responsibility. The federal government can provide assistance when state and local governments are overwhelmed. The Federal Emergency Management Agency, within the Department of Homeland Security, is the lead coordinating agency for federal emergency assistance. The federal government can provide medical resources, such as emergency medical care and the evacuation of hospital patients during disasters through the NDMS, which is a partnership of Department of Homeland * Department of Preventive Medicine and Biometrics, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD US Transportation Command, Command Surgeon Office, 203 West Losey St. Suite 1700, Scott AFB, IL Air Mobility Command, Command Surgeon Office, 203 West Losey St. Suite 1600, Scott AFB, IL USAF School of Aerospace Medicine, Aeromedical Consult Service, 2507 Kennedy Circle, Brooks City-Base, San Antonio, TX Security, the DoD, the Department of Veterans Affairs, and the Department of Health and Human Services (DHHS). 4 The NDMS supplements Federal, Tribal, State, and Local capabilities by funding, organizing, training, equipping, deploying, and sustaining a specialized and focused range of public health and medical capabilities. The DHHS Assistant Secretary of Preparedness and Response has the authority to activate the NDMS. The three components of the NDMS are: Medical response to a disaster area in the form of personnel (teams and individuals), supplies, and equipment Patient movement from a disaster site to unaffected areas of the nation Definitive medical care at participating hospitals in unaffected areas U.S. Transportation Command (USTRANSCOM) is a DoD Combatant Command and is the DoD s Single Manager for Patient Movement. It provides disaster patient movement in support of the NDMS at the direction of the President or upon approval of the Secretary of Defense. During domestic disaster response, USTRANSCOM supports U.S. Northern Command (USNORTHCOM), the Geographic Combatant Command responsible for providing defense support to civilian authorities. Disaster patient movement is coordinated through the USTRANSCOM Global Patient Movement Requirements Center (GPMRC) located at Scott Air Force Base, Illinois. GPMRC personnel are trained to deploy as joint patient movement expeditionary team members to coordinate patient movement requests (PMRs) from civilian authorities and to track patient movement at aeromedical staging facilities (ASFs). The 18th Air Force (Air Forces Transportation), the Numbered Air Force of Air Mobility Command (AMC), is the air component to USTRANSCOM. It provides airframes, air crews, aeromedical evacuation medical personnel, and ASFs in support of NDMS patient movement. States may also use National Guard aeromedical assets during disaster response. Aeromedical evacuation oversight responsibilities are illustrated in Figure 1. Upon activation of the patient movement component of NDMS, GPMRC regulates aeromedical evacuation from Aerial 1128 MILITARY MEDICINE, Vol. 176, October 2011

2 medical teams provided initial medical response and evacuated patients out of Haiti to Florida until a mobile aeromedical staging facility (MASF) supplemented with a USTRANSCOM Joint Patient Movement team (JPMT) was in place. 7 A small portable expeditionary aeromedical rapid response team assisted the MASF team to stabilize patients for flight and coordinated air evacuation to the United States. An expeditionary medical support hospital was set up and assisted in patient movement to and from the USNS (U.S. Naval Ship) Comfort hospital ship. USTRANSCOM patient movement situational awareness team members and AMC Command Surgeon medical planners augmented the U.S. Southern Command Surgeon s Office in Miami and the Florida State Emergency Operations Centers (EOCs) in Tallahassee. GPMRC worked with Florida emergency management and health officials to regulate patients to Florida hospitals. Once the definitive care portion of the NDMS was activated, the FCCs were activated in Tampa, Florida, and Atlanta, Georgia, and over 360 patients were evacuated from Haiti utilizing DoD aeromedical assets. FIGURE 1. This diagram illustrates the aeromedical evacuation responsibilities of USTRANSCOM, Air Force Surgeon General, AMC Surgeon General, and AMC A3 (Directorate of Operations). Ports of Embarkation to predesignated Federal Coordinating Centers (FCCs) and associated Aerial Ports of Debarkation. There are 72 FCC locations nationwide. The FCCs work with state and local health officials to transport patients to NDMS participating hospitals for definitive care. DISASTER PATIENT EVACUATION The aftermath of Hurricane Katrina in 2005 set the stage for health officials to review their plans for evacuating patients before hurricanes. As a result of Hurricane Katrina, hospitals in the New Orleans area were significantly affected by the flooding that followed the city s levee breaks. Approximately 12,000 hospital patients and caregivers from 25 hospitals in the New Orleans area were evacuated from Katrina, including approximately 2,600 patients who were aeromedically evacuated from New Orleans via DoD airlift. 5,6 DoD supported prehurricane patient evacuation in Texas and Louisiana for Hurricanes Gustav and Ike in Hurricane Gustav formed on August 26, 2008 southeast of Haiti and made landfall in Louisiana on September 1, Active duty and Air National Guard aeromedical evacuation personnel transported 833 patients from three ASFs in Texas and Louisiana before landfall. As Hurricane Gustav was making landfall in Louisiana, Hurricane Ike was forming in the Atlantic Ocean and made landfall in Galveston, Texas, on September 13, DoD support was again requested, and 428 patients were evacuated from three Texas ASFs before landfall. On January 12, 2010, a 7.0 magnitude earthquake occurred in Haiti and the DoD participated in the international disaster response efforts. Air Force Special Operations Command ACTIVE PARTNERSHIPS GPMRC is one of four DoD Patient Movement Requirement Centers (PMRCs). PMRCs receive PMRs, validate the requirement for aeromedical evacuation, ensure patient preparation and movement precedence (routine, priority, urgent), and submit the requirement to the appropriate airlift center. PMRCs have ongoing communications with regional medical treatment facilities to ensure safe and responsive aeromedical evacuation. Similar partnerships have been established with federal and state health officials. Coastal states that are vulnerable to hurricanes have assessed their requirements for patient evacuation and have determined if they will need federal support for prehurricane patient evacuation. State emergency management officials work with a Defense Coordinating Officer (DCO) to establish requirements and plans for DoD disaster support. The DCO, a senior military officer, is supported by a staff which includes Joint Regional Medical Planners who plan, coordinate, and integrate Defense Support of Civil Authorities with Local, State, and Federal agencies. Each Federal Emergency Management Agency region has a full time DCO. 8 In 2008, Texas and Louisiana had identified the requirement for federal assistance during prehurricane evacuations. USTRANSCOM deployed GPMRC patient movement enabler teams to Texas and Louisiana to work with Joint Regional Medical Planners, National Guard, federal, and state health officials to plan and regulate patient movement during the response to Hurricanes Gustav and Ike. These teams provided situational awareness, participated in planning at the Joint Field Office and State EOCs, and provided a vital link between ASFs, State EOCs, and GPMRC. Lessons learned and recommendations from the federal response to the 2008 hurricane season were presented at the 2009 Integrated Training Summit, sponsored by DHHS. 9 MILITARY MEDICINE, Vol. 176, October

3 These annual summits provide a forum for thoughtful analysis and review of how the federal government responds to disasters and are a key element of ongoing federal and state disaster planning and preparation These relationships were again utilized during the Haitian earthquake response. Daily interagency conferences including TRANSCOM, DHHS, U.S. Southern Command, Joint Task Force Haiti, and other federal and state partners proved invaluable in providing situational awareness and establishing response priorities. Recognize that interface points are potential areas of communications challenges Establish and maintain state, DoD, and interagency relationships before disasters occur ESTABLISHING PATIENT MOVEMENT REQUIREMENT The DoD patient movement system is driven by patient movement requirements. In nondisaster scenarios, medical providers submit PMRs to a designated PMRC. During a disaster, GPMRC can deploy JPMTs to facilitate disaster patient movement regulation. Lessons learned from Hurricanes Gustav, Ike, and ongoing planning and exercises involving GPMRC and the states have resulted in improved processes to generate disaster PMRs and to accomplish timely patient movement. Prehurricane patient movement presents several unique operational challenges. State health officials and hospital CEOs assess the risks of shelter in place vs. hospital evacuation. With modern technology, storm paths can be predicted; however, the exact location and timing of hurricane landfall is still largely uncertain and delays in making a decision to evacuate reduce the number of patients that can be moved as the evacuation window narrows. During the early stages of the Haiti response, situational awareness regarding casualty estimates, medical care requirements, and available local medical care was lacking. DoD pushed large amounts of nonmedical assets to Haiti, which resulted in the delay of DoD medical assets reaching Haiti. Initially, there was not adequate screening of passengers on nonaeromedical airlift missions from Haiti. This resulted in receiving locations having to quickly arrange medical care for ill passengers upon arrival to the United States. The establishment of the MASF and JPMT team and arrival of DoD medical forces resulted in improved situational awareness and a better estimate of patient movement requirements. Identify patients that can and cannot be evacuated Establish evacuation options and requirements for special needs of patients (neonatal, critical care, psychiatric, dialysis, nursing home) Anticipate medical personnel and equipment requirements to transport a wide range of civilian patient categories APPROPRIATE PATIENT PREPARATION The DoD aeromedical evacuation system moves stabilized patients (airway protected, breathing, and circulation controlled) with specialized equipment and aeromedical evacuation crews, comprised of flight nurses and aeromedical evacuation technicians. For movement of critical care patients, a Critical Care Air Transport Teams (CCATTs) comprising of a physician, nurse, and respiratory technician is added to augment the aeromedical evacuation crew. Patients moved in disasters are often high acuity critical care patients. Although there are no absolute contraindications to aeromedical evacuation, patient selection and preparation are key elements in safe patient movement. The major medical risks associated with air transport are hypoxia and gas expansion. Other factors that may affect patients include noise, temperature variations, vibration, low lighting, and the stresses of multiple patient transfers. GPMRC patient movement guidelines are listed in Table 1. During a disaster, the sending physician has to believe the level of care will be improved by transferring the patient from one medical facility to another and be willing to accept the risk associated with the transfer. This being said, a disaster may mandate hospital evacuation because of loss of infrastructure. The transferring physician should consider that it may take up to 12 hours before the patient is back in a hospital comparable with the one the patient left. Patients are typically transported to some form of an ASF at a designated airport before being loaded onto the aircraft. ASF medical personnel ensure that patients are appropriately prepared and stabilized. Determining the ideal location of an ASF in a prehurricane scenario is challenging because of the uncertainty of the storm path, uncertainty regarding a hospital s decision to evacuate vs. shelter in place, and air lift operational requirements. The time required to mobilize forces, transport them to the location, and set up the facility has to be factored into the overall plan. The ASF is usually located in a building of opportunity at a predesignated airport and has limited patient care and holding capability. The lack of an appropriately staffed ASF can negatively impact patient preparation and proper patient loading. DoD is working with DHHS to train NDMS civilian emergency medical teams to augment domestic disaster ASF military personnel. Patients air evacuated from Hurricanes Ike and Gustav had significant requirements for critical care and patient stabilization at the ASF that impeded the military personnel assigned from performing their primary duty of air transport. Civilian critical care personnel can work alongside military ASF personnel to stabilize and prepare critical care patients for transportation. This will allow the USAF CCATTs to focus their efforts on patient transportation and 1130 MILITARY MEDICINE, Vol. 176, October 2011

4 TABLE I. GPMRC NDMS Patient Movement Clinical Guidelines7 Airway protected? CCATTs are trained to manage ventilated patients and can monitor endotracheal tube cuff pressure. Patients who have been recently extubated should be monitored for at least 4 hours before evacuation. Breathing adequately supported? Normally, oxygenation at altitude is impaired. Do not move vented patients with high oxygen requirements (FiO 2 greater than 60%). Circulation acceptable? Do not transport patients with hemoglobin levels <7 g/dl. Hemoglobin of 9 g/dl is the lowest that is safe without either significant supplemental oxygen or transfusion. Disability Brain injuries swell and seizure thresholds lower at altitude. Take precautions and premedicate to prevent seizures, if needed. Ensure the aeromedical evacuation crews have the tools they need to address seizures if they develop (i.e., IV Ativan and IV access). Expansion, as in trapped air Specifically consider intra-abdominal (i.e., postop ileus, postop laparoscopic procedures), intracranial, intrathoracic, and trapped air within the sinuses, ears, or eyes. Fixation Ensure careful fixation and stabilization of all lines and tubes. plaster casts should be at least 48-hours old to allow for possible soft tissue expansion after an acute injury or should be bivalved if swelling is expected. There can be no hanging weights for traction in flight; other traction devices must be used if required. Other considerations Equipment and supplies If the patient is dependent on continuous treatment, the transferring facility should send additional medications and supplies with the patient. Only authorized medical equipment is allowed on aeromedical evacuation missions. Patients will be switched over to approved medical equipment before flight. There is a waiver process for unapproved medical equipment; call GPMRC at for equipment questions. Psychiatric patients Psychiatric patients are likely to need attendants, they must not be disruptive, and they must be able to follow directions. will allow more efficient use of resources and personnel. Additionally, AMC is working to redesign the staging facility concept to increase flexibility while maximizing patient throughput. The Haiti ASF was located at the Port of Prince Airport. Various medical facilities, including the USNS Comfort and civilian Non-Governmental Organization medical treatment facilities either brought patients to the AF medical facilities at the airport for entry into the air evacuation system, or often, USAF flight surgeons and ambulance teams retrieved the patients from the facilities and transported them back to the facilities for care. The involvement of Air Force Flight Surgeons working with the ASF and GPMRC providing patient care, screening, and clearance before flight was essential to the successful aeromedical evacuation of these patients. Patient acuity was extremely high and included several patients with tetanus. 10 Interagency medical criteria were subsequently established to determine which Haitian patients would be eligible to be aeromedically evacuated to U.S. hospitals. Train selected disaster medical assistance teams to be interoperable with DoD critical care transport teams Anticipate a higher percentage of critical care patients compared with nondisaster aeromedical evacuation Deploy MASF early if aeromedical evacuation is anticipated Recognize the inherent risks of patient movement, the physiologic stressors of aeromedical evacuation, and the importance of proper patient selection, preparation, and en route care IN-TRANSIT VISIBILITY The concept of in-transit visibility plays a vital role in successful aeromedical operations. The DoD patient movement system provides a continuum of care and coordinates the movement of patients from site of injury or onset of disease, through successive levels of medical care, to a medical treatment facility that can meet the needs of the patient. During wartime, patients often are transported long distances and may experience multiple stops en route to their final destination. The TRANSCOM Regulating and Command and Control Evacuation System (TRAC2ES) is a web-based system that allows sending facilities, receiving facilities, and PMRCs to submit and view PMRs and to update changes in patient condition. TRAC2ES is used to build missions and communicate patient movement requirements to the appropriate airlift operations center. TRAC2ES combines transportation, logistics, and clinical decision elements into a seamless information system that prioritizes requirements, assigns proper resources, and distributes relevant data to efficiently deliver patients. All branches of the Services and the Department of Veterans Affairs use the web-based TRAC2ES to track and coordinate the movement of sick or injured service men and women throughout the entire patient movement process, during war and peace, and contingency operations worldwide. 11 TRAC2ES is adaptable to disaster patient movement. During the Hurricane Gustav response, the TRAC2ES mobile disaster PMR process did not function according to expectations and system process changes were quickly implemented during the brief interval between Hurricanes Gustav and Ike. GPMRC successfully processed large numbers of Hurricane Ike PMRs using TRAC2ES web. GPMRC has worked with state emergency operations officials to make improvements in the disaster PMR process and participates in state hurricane response exercises. The amount of information required MILITARY MEDICINE, Vol. 176, October

5 to generate a disaster PMR has been reduced to that which is essential for disaster patient movement. Activation of the NDMS definitive care component during the Haiti earthquake resulted in improved receiving facility situational awareness and optimal selection of receiving hospitals. TRANSCOM JPMTs facilitated the rapid generation of disaster PMRs in Haiti, and this information was passed on to Florida and Georgia state health officials and the Atlanta and Tampa FCCs. Hospitals were able to review medical information and determine if they had the required medical capability to receive the incoming patients. Continue to work with state health officials to improve the disaster PMR process and patient tracking Ensure that FCC personnel have current TRAC2ES training and access CONCLUSION DoD will be called upon to support domestic and international disaster response. The DoD patient movement system provides life saving disaster patient movement through the expertise of its multidisciplinary teams and by applying the time tested principles of active partnerships, establishing patient movement requirements, patient preparation, and in-transit visibility. Continuing interaction between the DoD, NDMS, and state organizations is critical to building on the recent improvements made to the system. REFERENCES 1. DoD Joint Publication 4-02, Health Service Support, October 31, National Response Framework, Department of Homeland Security, January National Disaster Medical System Federal Coordinating Center Guide, July 7, Haulman DL : The US Air Force Response to Hurricane Katrina, November Available at ument/afd pdf ; accessed January 13, Henry J : Incomplete Evacuation. Joint Center for Operational Analysis Quarterly Bulletin, Vol. VIII, Issue 2, June GAO : DoD Can Enhance Efforts to Identify Capabilities to Support Civil Authorities during Disasters : Government Accountability Office GAO , March National Disaster Medical System Aeromedical Evacuation : A Guide for Healthcare Providers. Available at public/files/ndms_aeromedical_evacuation_clinical_guidelines.pdf ; accessed January 13, HHS Training Summit. Patient Movement Lessons Learned Panel Presentation. Available at sentations/2009/main_training_summit/54_-_hurricane_scenario_-_les sons_learned.pdf ; accessed April 27, Stuart JJ, Johnson D : Air Force disaster response: Haiti experience. J Surg Orthop Adv 2011 ; 20 (1) : Archer N, Moschovis PP, Le PV, Farmer P : Postearthquake Haiti renews the call for global health training in medical education. Acad Med 2011 ; 86 (7) : TRAC2ES Functional Management Office. Available at transcom.mil/tcsg_public/ ; accessed February 4, MILITARY MEDICINE, Vol. 176, October 2011