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Guarding America — Defending Freedom The Air National Guard Aeromedical Evacuation Col Charlie Chappuis State Air Surgeon-Louisiana.

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Presentation on theme: "Guarding America — Defending Freedom The Air National Guard Aeromedical Evacuation Col Charlie Chappuis State Air Surgeon-Louisiana."— Presentation transcript:

1 Guarding America — Defending Freedom The Air National Guard Aeromedical Evacuation Col Charlie Chappuis State Air Surgeon-Louisiana

2 Flight Surgeon Readiness Skills Verification Requirements 2

3 Objectives  1. Summarize clearance for aeromedical evacuation  2. Translate physiological knowledge into concrete AE action Guarding America – Defending Freedom 3

4 Overview  Mission & Function  Area of Responsibility  Organization & Structure  Patient Movement Process/TRAC2ES  Precedence/Classification  Roles and Responsibilities; Risks and Safety  Clinical Considerations/PMR submission  Clinical Decision-aid Tools  Workload and Demographics 4

5 AE System: Mission and Vision MISSION Move Stable/Stabilized patients with the correct personal and equipment VISION Right Patient, Right Time, Right Place, Right Mode 5

6 6 AE TERMINOLOGY Aeromedical Evacuation (AE) – is the AF system for moving patients via fixed wing aircraft Medical Evacuation (MEDEVAC) – term used to describe Army’s system for moving patients via rotary aircraft Casualty Evacuation (CASEVAC) – generic term used to describe patient movement regardless of mode of transportation. Unregulated movement

7 7  INTRATHEATER - TACTICAL  Flying within theater  CENTCOM/CENTCOM  1 day worth of patient medical supplies  INTERTHEATER - STRATEGIC  Theater to CONUS  EUCOM/Andrews AFB  3 days worth of patient medical supplies AE TERMINOLOGY AE TERMINOLOGY

8 UNCLASSIFED IRAN SAUDI ARABIA ETHIOPIA SUDAN EGYPT JORDAN OMAN BAHRAIN AFGHANISTAN IRAQ QATAR KUWAIT DJIBOUTI PAKISTAN TURKMENISTAN UZBEKISTAN KYRGYZ KAZAKHSTAN KENYA SOMALIA YEMEN UAE TAJIKISTAN ERITREA SEYCHELLES USCENTCOM & NATO OPERATING IN TOUGH AREAS

9 AIRFRAME INTRATHEATER C-17 C-130 C-21 KC-135 WEAPON SYSTEM = MISSION DESIGN SERIES = AIRCRAFT INTERTHEATER C-17 KC-135 NON- TRADITIONALS C-5, KC-10, B-767 (Civil Reserve Air Fleet)

10 KC-135

11 C-17 Globemaster 11

12 12 USTRANSCOM  Air Mobility Command (AMC) Air component of Patient Movement Lead command for AE Tanker Airlift Control Center (TACC): Executes, Tasks Crews, Controls AMC’s Global Air Missions

13 PATIENT MOVEMENT REQUIREMENTS CENTERS (PMRC) - Joint activity responsible for patient movement (PM), management, and coordination - Validates PM requests, regulates patients to appropriate medical facilities for continued medical care and determines the mode of transportation (air, ground, or sea)

14 14 PMRC  GLOBAL PATIENT MOVEMENT REQUIREMENTS CENTER (GPMRC) - Scott AFB, IL  THEATER PATIENT MOVEMENT REQUIREMENTS CENTER (TPMRC) - Ramstein AB GE - Hickam AB HI  JOINT PATIENT MOVEMENT REQUIREMENTS CENTER (JPMRC) - Qatar (SWA)

15 Patient Movement Area of Responsibility-A Team Effort 15

16 16 Command/Control of patient movement by air Specialized medical crews and augmentees In-flight equipment En-route facilities on or near flight lines for patient care. AE patient tracking AE PROVIDES

17 17 AE UTC’s  AE Crew Members (AECM)  Critical Care Air Transport Team (CCATT) Mobile Aeromedical Staging Facility (MASF) Contingency Aeromedical Staging Facility (CASF) Aeromedical Evacuation Liaison Team (AELT) Aeromedical Evacuation Operations Team (AEOT)

18 Guarding America — Defending Freedom The Air National Guard

19 Guarding America — Defending Freedom The Air National Guard

20 Guarding America — Defending Freedom The Air National Guard

21 FORCE STRUCTURE COMPONENT TOTAL AMC PACAF USAFE ANG AFRES ACTIVE DUTY ARC~90%

22 Air Evacuation Team  Sets up the plane and crews AE missions  3 flight nurses, 4 medical technicians  Provide in-flight medical care to all AE patients, assist medical attendants Who Cares for the patient? Critical Care Air Transport Team (CCATT)  Provide enroute ICU level care  Physician, ICU Nurse, Resp. Therapist

23 23 AEROMEDICAL EVACUATION AE MEDICAL CREW: STANDARD o MEDICAL CREW DIRECTOR (Flight Nurse - MCD) o FLIGHT NURSE (FN) o CHARGE MEDICAL TECHNICIAN (CMT) o AEROMEDICAL EVACUATION TECHNICIAN (2 AET) o AEROMEDICAL EVACUATION TECHNICIAN (3 AET) AUGMENTED o FLIGHT NURSE o 2 AEROMEDICAL EVACUATION TECHNICIANS

24 24 CCATT Critical Care Air Transport Team (CCATT) 3 person team Ready to move when patient is validated needing critical care transport o Not subject to rules and regulations of line flyers Co-located/strategically placed with AE in theater Potential for augmentation with CCATT-E o Adds 2 personnel – 2 CCRN’s with additional PMI/AS to support 5 ventilator patients or up to 10 lower acuity stabilized patients CCATT team chief – usually MD heading CCAT team o Medical authority on board aircraft o Can provide care to other patients during mission if need arises

25 OIF Patient Movement

26 OEF Patient Movement

27

28 So you need a Patient Movement?  Forward Operating Base:  Use what ever system is in place.  Dust off or land vehicle  Ask questions prior to needing it!  Unstable patients may require a provider to go with them.  If you need fixed wing movement, then who are your friends?  Fellow providers and staff = experience!  Your AE or PAD clerk  Can obtain the 3899 (movement request form)  Will be your liaison to the Joint Patient Movement Requirement Center (JPMRC) at Al Udeid, Qatar (who controls movements)

29 29 … let’s fly the patient How do we shop for a plane?

30 30 The Tools ToolFunction TRAC2ES Transcom Regulation and Command/ Control Evacuation System Provides In-transit Visibility (ITV) AF/DD 3899 Provides in-transit record of patient care

31 31 Key Personnel NameJob Sending Physician Initiates Patient Movement Request (PMR) /AF 3899 Patient Administration Director (PAD) Aeromedical Liaison Team (AELT) Enters PMR in computer (TRAC2ES) PMRC Patient Movement Clinical Coordinator/ Flight Clinical Coordinator Validates patient for movement Provides Nursing Input into Mission planning TACCGets the plane/crew

32 Patient Movement Precedence  Determines time til mission start, not complexity  URGENT – Move ASAP to save life, limb or eyesight – Goal: start flight within 12 hours of PMR validation – Cargo missions diverted/disrupted (In-System Select/ISS)  PRIORITY – Mission within 24 hours of PMR validation, to move patient to higher care not available locally/to prevent deterioration – ISS is often used; patients with cargo, not instead of cargo  ROUTINE – Movement required, but can wait for a scheduled AE mission – Goal: within 72 hours of PMR validation 32

33 33 PATIENT CLASSIFICATION Standardized “AE” codes to identify patients who… Must travel on a litter May need help during an aircraft emergency May pose a threat to themselves or others  1A-C – Psychiatric  2A/B – Litter  3A-C – Ambulatory  4A-E - Infant (under 3 years)  5A-F – Outpatient  6A/B - Attendant

34 Litter v/s Ambulatory  Litter  Medicine patient in a bed  Post-Surgical  Back pain patient  Fractured extremities  Mod/Sev psych patients  Ambulatory  Walkie, Talkies  Mild psych patients  Can tolerate sitting  Can be getting IV fluids/meds

35 PMR Process AF Form 3899 – Patient Movement Record  Initial patient information completed by physician  Legal record in TRAC2ES  Paper AE Patient Record, travels with Patient  Permanent Medical Record PMR – Patient Movement Request  Based on a completed AF 3899  Primary product of TRAC2ES  Electronic picture of all AE data  ‘Visibility ‘of patient to destination 35

36 PMR Process  MTF Does AF 3899; submits PMR to JPMRC via TRAC2ES JPMRC sees & validates PMR, send requirements to AECT AECT plans missions to meet time requirement JPMRC manifests patient on mission; notifies MTF of Times MTF/CASF ensure patient is ready for mission and transferred to AE Crew and Plane 36

37 Validating Flight Surgeon Role  Clinical validation of PMR – determines ‘fitness to fly’ based on PMR clinical information + many phone calls!  Clinically validates all Urgent and Priority PMRs, advises JPMRC Flight RNs on Routines where required.  Validates precedence, classification, in/out-patient.  Provides AE/Av Med advice to clinics, referring Docs – Daily phone calls, weekly , monthly newsletter to all players  Write orders for flight – 02, Rx, alt restrict, stops?, neuro checks, etc  Attending physician for all patients in AE—but never see**  Special requirements? CCATT, Burn Team? 37

38 Top ½ of AF Form 3899

39 PMR: Clinical Considerations  History/clinical summary/projected needs in AE  Vital signs, Labs/trends (Hgb, blood gas, CT/x-rays)  Vent settings + O2 sats; trends (no-fly zone>65%FiO2)  Trauma – CT spine cleared, chest, abdomen (FAST)  No trapped air – globe, brain, lungs, sinus, bowel  Drains, chest tubes, NGT/Foley, wound-V.A.C***  Surgeries; windows of risk/opportunity – Date/time out of OR; when completed transfusion – ‘4 hour rule’—stabilized : after surgery/before flight 39

40 Clinical Considerations Created by NGB/CFX Guarding America – Defending Freedom 40

41 Bottom ½ of AF Form 3899

42 ABC’s of AIREVAC Patient Validation  Airway  Normally do not like to fly patients within 24 hours of extubation  Reverse: Do not extubate if flying within 24 hours  Can the airway remain stable for 4-6 hours  If any questions then sedate and intubate!  Breathing  Oxygenation at 8000 ft is impaired for everyone!  If on oxygen = will need more for flight  Recent Cardiac or Surgery = consider adding oxygen (great drug)  Traumatic wounds – O2 may also be analgesic – minimize ischemia

43  Circulation  Lower hemoglobin oxygen saturation at 8000 feet  Hgb of 9 g/dl is minimum without oxygen  Hgb of 8 g/dl is minimum on oxygen  Recommend transfuse if Hgb < 8 g/dl  Limits may be lower if anemia is chronic vs acute  Expansion  Wait to Fly > 24 hours after removal of chest tubes (+ Chest xray)  Lower air pressure at altitude (things swell)  Surgery/Trauma = leaky vessels (third spacing of fluids)  Fresh cast need to be bi-valved (possible swelling)  Air in enclosed area (cranium, eyes and ears) “NOT GOOD” ABC’s of AIREVAC Patient Validation

44  Fractures  Need to be stabilized (external fixators the best)  Vibration causes pain, possible hemorrhage  Bi-valved cast!!!!  Gastrointestinal  Air within the GI system can cause pain or injury  Consider orogastric or nasogastric tube  Nausea is common on flights = consider antiemetic pre-flight or prn ABC’s of AIREVAC Patient Validation

45  Hypo/hyperthermia  Aircraft are climate controlled, but can be cool  Must consider the environment during transport  Hot or cold can be found at various points  Keep patient’s hydrated = IV fluids can be your “friend”  “Jiminies”  Psych patients are a special class of patient!  Might consider chemical and/or physical restraint  Might consider sending a medical attendant  Some are claustrophobic or anxious = consider Valium or Ativan  Balance patient and flight safety with desire to be as little restrictive as possible ABC’s of AIREVAC Patient Validation

46 PATIENT MOVEMENT  Time from “battlefield” to combat surgical intervention:  Currently: 20 to 75 min  Time from “battlefield” to Landstuhl Medical Center, GE:  Currently: 24 to 48 hrs  Time from “battlefield” to United States facility:  Viet Nam: 45 days  First months of OEF: Avg 8 days  Currently: 2 to 4 days

47 Questions? 47


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