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Dan Mirski , MD Director TPMRC-Europe 12 SEP 2013 Oslo, Norway

UNCLASSIFIED//FOUO. Dan Mirski , MD Director TPMRC-Europe 12 SEP 2013 Oslo, Norway. EUCOM AOR (TPMRC-E, CASF, LRMC, ). NORTHCOM AOR (GPMRC). CENTCOM AOR (JPMRC). AFRICOM AOR (TPMRC-E).

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Dan Mirski , MD Director TPMRC-Europe 12 SEP 2013 Oslo, Norway

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  1. UNCLASSIFIED//FOUO Dan Mirski, MD Director TPMRC-Europe12 SEP 2013 Oslo, Norway EUCOM AOR (TPMRC-E, CASF, LRMC,) NORTHCOM AOR (GPMRC) CENTCOM AOR (JPMRC) AFRICOM AOR (TPMRC-E) This information is furnished on the condition that it will not be released to another nation without specific authority of the Department of the Air Force of the United States , that it will be used for military purposes only, that individual or corporate rights originating in the information, whether patented or not, will be respected, that the recipient will report promptly to the United States any known or suspected compromise, and that the information will be provided substantially the same degree of security afforded it by the Department of Defense of the United States. Also, regardless of any other markings on the document, it will not be downgraded or declassified without written approval of the originating agency. USAFE N0885-13//20130909 UNCLASSIFIED//FOUO

  2. Outline • USAF Flight Surgeon • Overview of US System Aeromedical Evacuation (AE) • Patient Tracking: TRAC2ES • Medical Lessons Learned

  3. Dan Mirski, MD, MPH • Emergency Medicine • Aerospace Medicine • LtCol, US Air Force, Chief Flight Surgeon • Director, TPMRC-Europe

  4. Enroute Care UNCLASSIFIED//FOUO GOAL: Maintain Equal Or Greater Level Of Care During Intra/Inter-Theater Air Evacuation Definitive Care Level of Care CSH, EMEDS, EMF Theater Hospitals Forward Surgical teams Forward Resuscitative BAS First Responder Wounded Self Aid & Buddy Care Continuous Increase inLevel of Care Provided Time UNCLASSIFIED//FOUO

  5. Aeromedical Evacuation (AE)Overview • CASEVAC, MEDEVAC, Aeromedical Evacuation (AE) • Role 1-4: Installation Capabilities • 3 = Life-saving med/surg/psych care) • Urgent, Priority(24h), Routine (72h) • AE crew = 2 RNs, 3 techs • CCAT = 1 MD, 1 RN, 1 RT • C17, C21, KC135, C130 • “Stressors of Flight” • Patient Categories 1-5 • EMR: TRAC2ES

  6. SURGICAL CAPABILITY PUSHED FAR FORWARD Current Route from Point of Injury to Definitive Capability PM Route CASEVAC or MEDEVAC MEDEVAC or INTRATHEATER AE First Responder Role 1 INTERTHEATER AE Forward Resuscitative Capability Role 2 Theater Hospitalization Capability (CSH, EMEDS, EMF) Role 3 Definitive Capability Role 4

  7. 10/2001 – 8/12/13 BI= 14,875 NBI= 46,346

  8. UNCLASSIFIED//FOUO DoD Patient Movement System TRAC2ES UNCLASSIFIED//FOUO

  9. TRAC2ES TRANSCOM Regulating Command/Control Evacuation System

  10. Patient Movement Requirements Center Patient Movement Requirements Center Originating Hospital Destination Hospital DoD Patient Movement SystemTRAC2ES TRANSCOM Regulating Command/Control Evacuation System (TRAC2ES) • Web-based/Consolidated Server • Automates Patient Regulating • Network for In-Transit Visibility of patient movement

  11. UNCLASSIFIED//FOUO DoD Patient Movement System Military Medical Treatment Facilities (MTF)s • Submit Patient Movement Requests (PMRs) • Coordinate arrival/departure of patients Patient Movement Requirements Center • CENTCOM: Joint PMRC, Al Udeid, Qatar • NORTH/SOUTHCOM: Global PMRC, Scott AFB, Illinois • PACOM: Theater PMRC, Hickam AFB, Hawaii • EUCOM: Theater PMRC, Ramstein AB, Germany UNCLASSIFIED//FOUO

  12. PMRC Areas of Responsibility USNORTHCOM Validate/Coordinate/Communicate patient movement to/from/within geographic Area of Responsibility

  13. UNCLASSIFIED//FOUO DoD Patient Movement System • Air Mobility Division (AMD), AE Control Team (AECT) • Interface with airlifters for AE movement • USAFE for intra-theater movement • Tanker Airlift Control Center (TACC) forinter-theater lift • Aeromedical Evacuation Squadrons • Provide in-flight medical or specialty care • 2 flight nurses, 3 medical technicians UNCLASSIFIED//FOUO

  14. TRAC2ESPatient Movement Request (PMR) Referring MTF/Hospital: Submit Patient Movement Request (PMR) PMRC: Validate PMR, Coordinate airlift, Communicate mission itinerary AECT/TACC: Task airlift/aircrews Reception MTF: Patient arrives at destination facility AE Crews: Execute mission

  15. UNCLASSIFIED//FOUO TRAC2ESPatient Movement Request (PMR) Clinical Data • Medical Specialty/Diagnosis • Patient History/Medications/Labs Patient Demographics • Patient Name/Nationality/ID# • Rank/Age/Gender • Precedence • (URGENT, PRIORITY, ROUTINE) UNCLASSIFIED//FOUO

  16. TRAC2ESMission Planning/Execution Referring MTF/Hospital: Submit Patient Movement Request (PMR) PMRC: Validate PMR, Coordinate airlift, Communicate mission itinerary AECT/TACC: Task airlift/aircrews Reception MTF: Patient arrives at destination facility AE Crews: Execute mission

  17. UNCLASSIFIED//FOUO TRAC2ESMission Planning/Execution AE Control Team/ Tanker Airlift Control Center • Identify aircraft • Task AE crew members • Task specialty support • Notify PMRC when mission information is complete UNCLASSIFIED//FOUO

  18. TRAC2ESMission Planning/Execution Referring MTF: Submit Patient Movement Request (PMR) PMRC: Validate PMR, Coordinate airlift, Communicate mission itinerary AECT/TACC: Task airlift/aircrews Reception MTF: Patient arrives at destination facility AE Crews: Execute mission

  19. TRAC2ES24-Hour Report Referring MTF: Submit Patient Movement Request (PMR) PMRC: Validate PMR, Coordinate airlift, Communicate mission itinerary AECT/TACC: Task airlift/aircrews Reception MTF: Patient arrives at destination facility AE Crews: Execute mission

  20. TRAC2ES24-hr Report Destination Medical Treatment Facilities • Visibility for in-bound… • Missions • Itineraries • Patient loads • Plan patient reception/care

  21. Global Patient MovementA Team Effort USNORTHCOM

  22. UNCLASSIFIED//FOUO Medical Advancements &Lessons Learned From the last 10 years of Patient Movement UNCLASSIFIED//FOUO

  23. Medical Advancements &Lessons Learned • Resuscitation with blood products • LIFO Blood Usage • Damage Control Surgery • Burn Management • Ventilatory Control with Decreased Tidal Volume • Massive Blood Transfusion Triggers • Epidurals & Nerve Blocks • Tourniquets • No Steroids in Blunt Spinal / Head Trauma

  24. Blood Component Therapy • Prior typical "resuscitation protocol" = lots of LR or NS then 1-2 units of blood  (3:1) • This practice contributed to the lethal triad of coagulopathy, hypothermia & acidosis • Now, high suspicion patient is bleeding = proceed directly to blood products. • Repine TB, Perkins JG, Kauvar DS, Blackborne L. The use of fresh whole blood in massive transfusion. J Trauma. 2006;60:S59-S69.  • Spinella PC, Perkins JG, Grathwohl JG, Beekley AC, Holcomb JG. Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries. J Trauma. 2009;66:S69-S76.

  25. Blood Tx: LIFONew blood over old blood • Previously, the oldest blood in the theater was given first for transfusions • should be used before it goes bad. • Fresh blood has been shown to be superior • complications of transfusion with "older" units of PRBCs • "storage lesion": increase pro-inflammatory factors, acidosis, increased free hemoglobin, and decreased RBC deformability, 2,3 DPG & ATP • The people most likely to suffer the consequences of complications of "older" units of blood are those requiring a higher dose • In patients requiring massive transfusion , effort made to transfuse fresh units of PRBCs • Preferably < 14 days old, but the freshest available nonetheless • Now, LAST IN, FIRST OUT (LIFO) Blood Policy • Donation to availability in theater averaging 7 days • SpinellaPC, Perkins JG, et al. Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries. J Trauma. 2009;66:S69-76.

  26. Damage Control Surgery • We now transport patients with “unfinished surgeries” - open abdomens • bleeding stopped via clamping and/or packing. • They are moved to higher levels for more definitive care • Further damage control surgeries done • “Final” closure surgery • Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, Mallett O, Zubko T, Oetjen-Gerdes L, Rasmussen T, Butler FK, Kotwal RS, Holcomb JB, Wade C, Champion H, Lawnick M, Moores L and Blackbourne LH. Death on the battlefield (2001-2011): Implications for the future of combat casualty care. J Trauma. 2012;73:S431-S437,

  27. Burn Management • Rule of 10's and 6 ml/kg/%BSA burned in thermal injury burn management • Basically, now we don’t pour in the fluid. • Start with an initial amount • Then adjust it up or down up to 25% per hour (not more!) • Result = far less incidents of abdominal compartment syndrome • CCATT transported patients with burns up to 98% and they have survived. • Ennis JL, Chung KK, Renz EM, Barillo DJ, Albrecht MC, Jones JA, Blackbourne LH, Cancio LC, Eastridge BJ, Flaherty SF, Dorlac WC, Kelleher KS, Wade CE, Wolf SE, Jenkins DH, Holcomb JB. Joint Theater Trauma System implementation of burn resuscitation guidelines improves outcomes in severely burned military casualties. J Trauma. 2008;64(2):S146-51; discussion 151-2. • Markell KW, Renz EM, White CE, Albrecht ME, Blackbourne LH, Park MS, Barillo DA, Chung KK, Kozar RA, Minei JP, Cohn SM, Herndon DN, Cancio LC, Holcomb JB,Wolf SE. Abdominal complications after severe burns. J Am Coll Surg. 2009;208(5):940-7; discussion 947-9.

  28. Vents: Decreased TV • Lung protective strategies in ARDS / ICU / Difficult to Ventilate pts • Tidal Volume: 4-6 cc/Kg • Not 10-12 cc/Kg, as prior • Ideal BW • Increase PEEP and/or FiO2 • Essentially ARDSNet • Used very often by US CCATT

  29. Other Advances 7.  Massive transfusion triggers • Higher quantities of blood up front • McLaughlin DF, Niles SE, Salinas J, et al. A predictive model for massive transfusion in combat casualty patients. J Trauma.2008;64:S57-63. 6.  PCA, Epidural and nerve blocks • We fly these all the time now • Waiver x 10yrs, Official since 2012 • Mepivacaine 250 vs 400ml IV bags • Katz J, Cohen L, Schmid R, et al. Postoperative Morphine Use and hyperalgesia are Reduced by Preoperative but not Intraoperative Epidural Anagesia: Implications for Preemptive Analgesia and the Prevention of Central Sensitization. Anesthesiology. 2003;98:1449-1460.

  30. Lessons Learned (con’t) 8.  Re-emergence of tourniquets 9.  No steroids in blunt spinal cord or TBI • No proven benefit • Worsen outcomes in patients with severe head injury • Frequent associated open or contaminated wounds of battle casualties further complicate steroid administration

  31. UNCLASSIFIED//FOUO QuestionsMirski@hotmail.com “VALIDATE…COORDINATE…COMMUNICATE” UNCLASSIFIED//FOUO

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