Heart of America Association of Blood Banks Spring 2012 Meeting Use of Blood Products at a US Army Forward Surgical Team in Afghanistan, Feb 2010-Feb 2011 Presentation by Chris Vanfosson, MAJ, US Army RN, MSN, MHA
Disclaimer The views expressed in this presentation are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government.
Agenda Introduction What is a Forward Surgical Team My Afghanistan Experience Protocols and Clinical Practice Guidelines Our Operating Environment Our Challenges and Limitations New Ideas Cases Conclusions
Introduction Army Nurse since Dec 2000 Married with four children Two combat deployments 2003-2004 in support of Operation Iraqi Freedom (combat support hospital) 2010-2011 in support of Operation Enduring Freedom (forward surgical team) Currently a student at the U.S. Army Command and General Staff College, Fort Leavenworth, KS
What is a Forward Surgical Team? Called a FST 20-person team trained in resuscitative trauma surgery Placed close to the battlefield to improve chances of survival after traumatic injury Idea born in Vietnam* 3 general surgeons 1 orthopedic surgeon 5 RNs (2 CRNA, 2 ER/ICU, 1 OR) 3 OR techs 3 LPN/LVNs 4 EMT-Bs 1 administrative officer * USN and USAF have developed similar type units
Not Much Room, Huh? Source: Army Field Manual 4-02.25, Employment of a Forward Surgical Team
ulates. Unit provides for the attachment of an in-line humidifier. ered to the patient for use by producing oxygen rich gas mixture nd extracting the oxygen. This is a large, easy-to-read flow r accurate flow settings. The built-in handles make it easy to asters glide easily over virtually any flooring surface. Non Invasive BP 2 Channel Invasive BP Temperature Pulse Oximetry Respiration Standard FST Equipment Ease of use Modular Ruggedized Automatic senso CONCENTRATOR OXYGEN MODEL# AS119-1D NSN 6515-01-552-9967 MONITOR PATIENT VITAL SIGNS MODEL# PROPAQ 206EL NSN 6515-01-432-2711 7 PUMP INTRAVENOUS INFUSION MODEL# MEDSYSTEM III NSN 6515-01-550-5669 53
Description: Simple, rugged, lightweight, draw over anesthesia device with a SONOSITE, d, temperature-compensated, INC flow-over (with wick), low resistance vaporizer. MODEL# orizer USAMMA is designed 180Plus for use in non-rebreathing POC: type circuits Customer and is classified as Relations Management 301-619-4301/431 on-specific. E: (425) 951-1243 FAX: (801) 751-1135 w.sonosite.com/content/view/37/185/ UNIT PRICE: $6,403.38 erformed: All anesthesia cases with a Standard single agent vaporizer. FST Equipment TEM NSN 6525-01-503-7182 267B, 901A, 905A, 912A ions Management 301-619-4301/4316, DSN 343-4301/4316 portable diagnostic ultrasound device used to assist in sessm ent of trauma (FAST), visualization of on of pericardial or pleural effusions and tamponade, n and abnormal uterine bleeding, rapid evaluation of lithiasis), and easy emergency obstetric exams (IUP, M is available. S VAPORIZER ANESTHESIA MODEL# DRAWOVER NSN 6515-01-355-6479 133 es s
FST Blood Capabilities 50 units of product O-type PRBCs Type-specific FFP I-Stat for labs Eldon Card-based type and cross For plasma (if available) and whole blood Dog tags are wrong 20% of the time
Standard FST Blood Equipment REFRIGERATOR BLOOD COOLING & STORAGE, BLOOD BAG BASKET PART# 100000 REFRIGERATOR BLOOD COOLING & STORAGE REFRIGERATOR BLOOD REFRIGERATOR BLOOD COOLING & STORAGE
LYZER BLOOD GAS W/HARD CASE I-STAT MODEL# 04J48-20 NSN 6630-01-526-7377 pump, a compact blood and fluid warmer, air detection and removal, and p monitoring in a 26 pound package, which mounts to an IV pole. The syste use, quick to set up with nearly instantaneous infusion, and fluid heating. pressure control turns off pump, and alerts the Operator if the fluid line is o single pass through the induction heater brings fluid to normathermia in se Operator controlled fluid delivery rates of 1- - 750 ml per minute at physio temperatures. Standard FST Blood Equipment DOWNLOADER/RECHARGER SERIAL W/i-STAT ANALYZER & BATTERY PART# 06F23-45 3-BAG SPIKE DISPOSABLE SET PART# 903-00006 NOT INCLUDED W/NSN FLUID WARMING SYSTEM PART# 903-00001B NSN 6515-01-465-2059 ANALYZER BLOOD GAS PART# 6F16-10 31
My Afghanistan Experience Clinical Practice Guidelines Based on combat data since 2001 Effects at the FST Only O-type PRBCs and Type-specific FFP available Fresh whole blood transfusions in mass transfusion scenario (>10 products expected need) Only American blood except in extremis Keep these in mind as we go on
My Afghanistan Experience Role III (German) & US FST Role II (German) Pol-e- Khumri Role III (US), TFME, 62nd Orgun-E Previous location (Qalat)
My Afghanistan Experience
The FST
Our Emergency Room
The OR
The ICU
In the Middle of a Trauma
My Afghanistan Experience Our Challenges and Limitations Blood storage Had to monitor refrigerators Manual q4 hour checks, 24/7/365 Blood warming Blood delivery to our location (regular and emergent delivery) Blood disposal after expiration German vs American blood products
Our Plasma Thawing Tool
My Afghanistan Experience Our Challenges and Limitations Blood disposal after expiration Burn-pit Regularly destroyed 5-10 units unused PRBCs FRUSTRATING!?! Delivery to our location German products Freeze-dried plasma German PRBC from Mazar-e-Sharif Emergency deliveries Whole Blood Drives (physician approval needed)
Blood Delivery Route Role III (German) & US FST Role II (German) Pol-e- Khumri Role III (US), TFME, 62nd Orgun-E Previous location (Qalat)
My Afghanistan Experience Cases where Whole Blood may have helped Uncontrollable bleeding from chest wound GSW to R. lateral chest Holes in major vessels sealed Nearly exhausted blood products Leakage from smaller vessels along spine Expired upon arrival to next higher level of care Should we have evacuated?
My Afghanistan Experience Cases where Whole Blood may have helped Uncontrollable bleeding from liver laceration Non-combat related MVC Incoming 2 combat casualties Nearly exhausted blood products Had to triage to prepare for combat related soldiers coming Expired while preparing patients with combat injuries for surgery
Conclusion Blood products in combat are surprisingly available When shortages exist, we have work arounds Military healthcare pushes the envelope of policy at times, along the way discovering new and exciting ways to treat patients
Personal Bibliography Vanfosson, C. A. & Seery, J. (2011). Simultaneous surgeries in a split forward surgical team: a case study. Military Medicine, 176(12), 1447-1449. Vanfosson, C. A. (2011). Letters from Afghanistan: Welcome Home. American Journal of Nursing, 111(8), 67-69. Vanfosson, C. A. (2011). 541 st Medical Detachment, Forward Surgical (Airborne): A Team History. Raleigh, North Carolina: Lulu Enterprises. Vanfosson, C. A. (2011). Lost in Translation: An Army Nurse s Story in Operation Enduring Freedom, Afghanistan, 2010 to 2011. San Francisco: Blurb.com. Beitler, A., Butera, J., Jeanette, J., Vanfosson, C. A., Seery, J., & McGraw, A. (2011). Emergency Canine Surgery in a Deployed Forward Surgical Team: Report of a Case. Military Medicine, 176(4), 477-480. Vanfosson, C. A. (2011). Letters from Afghanistan: Preparing to Return Home. American Journal of Nursing, 111(4), 47-49. Vanfosson, C. A. (2011). Letters from Afghanistan: Daily Life and Dirty Work. American Journal of Nursing, 111(2), 55-57. Seery, J. M. & Vanfosson, C. A. (2011, January 20). Fort Bragg-based surgical team teaches lifesaver course to international audience. The Paraglide (Fort Bragg, NC), 3B. Vanfosson, C. A. (2010) Letters from Afghanistan: The Road to the Front. American Journal of Nursing, 110(12), 46-48. Vanfosson, C. A. (2010). Letters from Afghanistan: Preparing for a Year on the Battlefield. American Journal of Nursing, 110(11), 52-54. Vanfosson, C. A. (2010, September 23). Fort Bragg based forward surgical team saves Hungarian working dog. The Paraglide (Fort Bragg, NC), 1B and 3B. A blog of my journal while deployed can be read at: http://perpetualpontifications.blogspot.com/. To contact: christopher.vanfosson@us.army.mil