MEDICAL SUPPORT TO THE WARFIGHTER: FROM BATTLEFIELD TO TERTIARY CARE. LtGen (Dr.) Douglas J. Robb, DO, MPH CCOM Class of 84 April 2015
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1 MEDICAL SUPPORT TO THE WARFIGHTER: FROM BATTLEFIELD TO TERTIARY CARE LtGen (Dr.) Douglas J. Robb, DO, MPH CCOM Class of 84 April
2 Agenda Continuum of Care Enroute Patient Care from: Force Health Protection to Combat Casualty Care to Forward Resuscitative Care to Theater Hospital Care to Definitive Care Integrated Joint/Coalition System of Systems Concept is to maintain equal or greater level/ quality of care with each level of movement Destination: World Class NATO/Military/VA Healthcare System 2
3 TODAY S AGENDA AGENDA
4 We ve Got to Be Ready
5
6 Combatant Commanders Areas Of Responsibility Northern Command European Command Central Command Southern Command Africa Command Pacific Command Special Operations Command Joint Forces Command Strategic Command Transportation Command 6
7 Full Spectrum Healthcare Force Health Protection Tactical Combat Causality Care (TCCC) CASEVAC/MEDEVAC Forward Surgical Care MEDEVAC Expeditionary Theater Hospital Care Aeromedical Evacuation (AE) Critical Care Air Transport Teams (CCATT) Joint Theater Support Teams Joint Theater Trauma System Joint Theater Medical Information Program/Electronic Health Record Telemedicine/Teleradiology Joint Logistics Joint Blood Program Destination: World Class Military/VA Healthcare System 7
8 Translates To Lowest Disease Non-Battle Injury (DNBI) rates in recent recorded conflict Lowest Lethality Rates in recorded conflict WWII 30% Vietnam/Gulf War 24% OEF/OIF <10% 8
9 AIR & SEA DISTANCES AIR 7,000 MI 24 HOURS SEA 8,600 MI 20+ DAYS SEA 12,000 MI 26+ DAYS
10 Continuous En-route Care Historical Route From Injury to Definitive Care STRATEGIC EVAC - Evac Policy - 15 Days CASUALTY EVAC - Evac Policy - 1 Day TACTICAL EVAC - Evac Policy - 7 Days In Theater Hospital Level 3 Definitive Care Level 4 Field Hospital Level 2 Battalion Aid Station Level 1 10
11 Continuous En-route Care: Stabilized Stabilizing CASEVAC/MEDEVAC 1 Hour INTRA-THEATER Tactical AE TACTICAL MEDEVAC/AE 1-24 Hours AE Crews & CCATT AE Crews & CCATT INTER-THEATER Strategic AE TACTICAL/STRATEGIC AE Hours Overseas Medical Center ASF US Medical Center MASF RCCET & CCATT minus EMEDS MASF Theater Hospital CASF Theater Hospital Care Definitive Care Battalion Aid Station First Responder Care Forward Resuscitative Care 11
12 Force Health Protection Begins BEFORE You Step to the Jet! Deployment Medical Guidance Deployment Health Assessments Pre and Post PDHRA after 90 and before 180 days Immunizations Chemoprophylaxis CBRNE and Vector Occupational Environmental Health Surveillance Air, Water, Soil Food Occupational and Industrial Hygiene CBRNE 12
13 T+ 00:00 HMMV is struck and disabled 13
14 First Responder Care: Tactical Combat Causality Care Correct Intervention At The Correct Time In The Continuum Of Combat Care! Rapid Casualty Assessment (ABCs) Control Hemorrhage (CABs) Treat penetrating chest trauma Maintain airway Package casualty for transport Care Under Fire Combat Application Tourniquet (CAT) Hemostatic Dressing Tactical Field Care Hypothermia Prevention Combat Pill Pack Antibiotics Pain Control Combat Casualty Evac Care 14
15 T+ 00:25 Taken to Forward Surgical Care/Level II Arrival B/P 80 systolic Undergoes exploratory laparotomy: Left Nephrectomy Splenectomy Packing of abdomen 8 units PRBC s B/P 90 s systolic 15
16 MEDEVAC Mission Army Navy/AF/Coalition 16
17 Level II: Forward Surgical/ Resuscitative Care Forward Surgical Teams Shock Trauma Platoons 17
18 AVERAGE AGE (In Days) Fresher Blood is Better Start of second weekly flight to theater and improved efficiencies Shipments: N= 92 Highest Average Age: 10.6 Days (03 Nov 2012) Lowest Average Age: 3.7 Days (19 Apr 2012) Average Age past 12 Months: 7.5 Days Most Recent Shipments: 7 Nov Days 10 Nov Days GOAL IS FOR RBCS TO ARRIVE AT THE BTC WITHIN 7 DAYS OF COLLECTION 13-Aug May Feb Nov Aug May Feb Nov Aug May Feb Nov Aug May Feb Nov Aug May Feb Nov-07 SHIPMENT ARRIVAL DATE (in Weeks) 2001: Day RBCs, Saline 2013: < 21 day RBCs, plasma, platelets 18 18
19 Blood Lifeline Ramstein AFB DoD Donor Centers ASWBPL-E McGuire AFB 2001: 14 days 2013: 7.5 days EMF Kuwait Bagram AB BSD Al Udeid AB CENTCOM 379 th EBTC Kandahar AB BSD 19
20 T+ 03:00 Arrives LV III Theater Hosp Cold Coagulopathic Acidotic Taken straight to OR 20
21 Level II/III: Theater Expeditionary Hospitals 21
22 Medical Support: Afghanistan Combat Casuality Care Forward Resuscitative Surgical Care Coalition/Theater Hospitals MEDEVAC Tactical AE Hubs Strategic AE Hubs 22
23 Injury Cause Trends: Percentage of Total by Cause 15.1% 8.7% EXPLOSIVE DEVICE 51.1% GSW MVC OTHER 25.0% 23
24 THE POWER OF COALITION MEDICAL!
25 T+ 03:00 to T + 06:00 Re-explored Packed, surgical control gained Urgent blood drive for AB+ blood Patient warmed to 38 degrees 25
26 T+ 06:00 Transported to ICU CT scan of spine Completion of resuscitation Urgent evacuation request placed 26
27 JOINT THEATER SUPPORT: TELEMEDICINE & TELERADIOLOGY - WRMC MAMC 18 th MEDCOM 121 st General Hospital ERMC LRMC Germany Air Force MEDCENS NARMC WAMC WRAMC PRMC TAMC NAVY MEDCENS Afghanistan GPRMC BAMC SERMC DDEAMC LEGEND Radiologist Workflow/workloads Overflow Exams/Medevac Iraq Kuwait
28 T+ 10:00 C-17 arrives from Germany Cargo unloaded CCATT team alerted Patient prepared for transport 28
29 Aeromedical Evacuation Cargo In Patients Out! 29
30 MASF/CASF Mobile Aeromedical Staging Facility (MASF) Mobile 24hr staging at tactical airheads Rapid response staging Contingency Aeromedical Staging Facility (CASF) 24hr staging at strategic airheads Support to Theater Hospital Transport to AE aircraft 30
31 Tactical AE: Intra-theater Hub & Spoke C-130/NATO Opportune A/C 31
32 GE GE Karshi Khanabad Strategic AE: Inter-theater Keleft Termez Balkh Shir Khan Sar-e Pol Samangan Meymaneh Pol-e Khomri Feyzabad Jeyretan Eshkashem Mazar-e-Sharif Konduz Taloqan Baghlan Herat Shindand Farah Zaranj Delaram Qal eh-ye Now Geresk Lashkar Gah Chaghcharan Baghran Deh Rawod Tarin Kowt Garmabak Charikar Bamian Kabul Jalalabad Kandahar Spin Boldak Ghazni Baraki Bagram Gardez Khowst Orgun-e Miram Shah Shkin Qalat UK/GE Shamsi Jacobabad 32
33 Global Patient Movement Patient Movement Requests CCATT TMS CCATT PTS# CENTCOM EUCOM NORTHCOM SOUTHCOM* PACOM Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
34 AE: Lifeline Home Travis Scott Andrews Ramstein EUCOM CENTCOM Kadena PACOM Hickam 34
35 T+ 10:00 CCATT arrives at ICU CCATT moves patient to AMBUS to flight line Patient loaded for flight 35
36 Critical Care Air Transport FLYING ICUs 36
37 Transforming Combat Casualty Care Wartime US Lethality Rate (%) Rev War War of 1812 Civil War WW I WW II Korea Viet Nam Gulf War I OEF/OIF Body Armor/Tactical Combat Casualty Care/ Damage Control Surgery & Resuscitation/CCATT 37
38 Impact of DoD Trauma System: Data from US Joint Trauma System (JTS) 38
39 T+ 12:00 Patient loaded for flight 7 hour mission to Germany AMBUS transfer to Landstuhl Regional Medical Center, Germany 39
40 T+ 24:00 Taken to OR Re-explored/wash outs 40
41 T + 48:00 Patient transferred to Walter Reed National Capital Region with CCATT team 41
42 TEAM MEDICS VA DoD COMMUNITY 42
43 Awesome (z) Great Ideas as a Function of Time World War I IV fluids Blood transfusions Motorized ambulances Topical antisepsis World War II Whole blood/plasma available Specialty-specific surgical groups Antibiotics Fixed wing aeromedical evacuation Korean Conflict Improved fluid resuscitation Forward availability of definitive surgery Helicopters for patient evac/transport Primary repair/grafts for vascular injury Vietnam Improved use of helicopters Improved laboratory support Portable radiology equipment Mechanical ventilators in theater Time (t) Desert Shield/Storm Burn team augmentation of evacuation hospitals to provide theater-wide burn care Intercontinental aeromedical transport of burn patients GWOT/OCO Military trauma system (JTTS/JTTR) Improved tourniquets Hemostatic agents Common use of external fixators Damage control resuscitation Damage control surgery 43
44 SUMMARY: CONTINUUM OF CARE INTEGRATED JOINT/COALITION SYSTEM of SYSTEMS
45 The why we do what we do!
46 the Why Not
47 There s No Coming Home.
48 Without you! Study hard focus on the patient... and we ll see you on the High Ground!
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