Maintaining the continuum of en route care

Division of Trauma and Surgical Critical Care, Department of Surgery, University Hospital, Cincinnati, OH, USA.
Critical care medicine (Impact Factor: 6.31). 08/2008; 36(7 Suppl):S377-82. DOI: 10.1097/CCM.0b013e31817e31e1
Source: PubMed


As life-sustaining and life-preserving surgical capability is moved far forward, it creates the opportunity to salvage casualties who may have otherwise died of their wounds. The remarkable capabilities and effectiveness of the small, austere surgical resuscitation teams (mobile forward surgical team, flying ambulance surgical trauma, forward resuscitative surgery system teams) has been amply demonstrated during the recent conflicts of Operation Iraqi Freedom and Operation Enduring Freedom.
The life-saving capability of far-forward surgery creates the need for a new and unique capability, which is the cornerstone of the en route care continuum, namely, the ability to move stabilized, but not necessarily stable, patients. The current system of en route care serves as a primary and indispensable portion of the continuum of critical care.
The scope of this article describes the origins, composition, equipment sets, medical considerations, and future directions of the en route care support process and the U.S. Air Force Critical Care Aeromedical Transport Teams.

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    • "Closed-loop controller algorithms are being developed to manage administration of oxygen, resuscitative fluids, sedatives, and analgesics [10]. Closed-loop critical care systems will be especially advantageous in the dark, noisy environments common to medical evacuation [7] [10]. Use of fully autonomous, closed-loop critical care devices for enroute care offers several potential benefits, including faster intervention; consistent, physiology-based treatment; appropriate ventilator operation and management independent of the medical attendant's skill level; and conservation of limited consumable resources such as resuscitative fluids, oxygen, and electrical power [10 ]. "
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    ABSTRACT: The combination of far-forward surgical hospitals, which vastly shorten time between injury and life-saving surgery, and employment of damage control surgery/resuscitation practices have been significant factors in the much improved survival rates observed during Operations Enduring and Iraqi Freedom as evidenced by the roughly 40% reduction in case fatality rate observed for OEF and OIF over the 2001-2005 period compared to that of the Viet Nam conflict. Post-operative patients coming out of these forward surgical hospitals are often moved within just a few hours following surgery and require high acuity care during transport. These patients are stabilized, but not necessarily stable, and are particularly vulnerable during Interfacility transport between theater hospitals, i.e., between Role 2 and Role 3 facilities or between Role 3 facilities. Interfacility transport of critical patients in theater normally takes place on US Army rotary-wing aircraft, but ground ambulances or even watercraft may be used if necessary. To help ensure positive patient outcomes during these transport missions the originating theater hospital provides an appropriately skilled critical care provider and medical equipment to support the patient during transport. The medical devices provided are the same portable patient monitor and therapeutic devices used in the originating hospital. Use of multiple portable medical devices during Interfacility transport of critical patients is problematic, especially in the rotary-wing environment, which is characterized by high noise levels, extreme vibration, confined space, and low-to-no-light conditions all of which impede patient assessment and prompt intervention. This is troublesome as several adverse events can occur during transport including exsanguination, hypotension, hypoxemia, accidental extubation or loss of intravenous access, inadequate sedation / analgesia, hypothermia, and ventilator malfunction. Furthermore, portable medical devices must be attached to the litter or airframe prior to flight. The practice of distributing medical devices on and around the patient creates a considerable burden for both patient and providers. Use of multiple medical devices also poses significant logistical burdens due to the need to satisfy the various power and maintenance requirements of the individual pieces of equipment, including the need for multiple types of batteries. Therefore, use of an integrated critical care device providing both patient monitoring and therapeutic interventions would aid in overcoming these shortcomings.
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    ABSTRACT: Disasters come in all shapes and forms, and in varying magnitudes and intensities. Nevertheless, they offer many of the same lessons for critical care practitioners and responders. Among these, the most important is that well thought out risk assessment and focused planning are vital. Such assessment and planning require proper training for providers to recognize and treat injury from disaster, while maintaining safety for themselves and others. This article discusses risk assessment and planning in the context of disasters. The article also elaborates on the progress toward the creation of portable, credible, sustainable, and sophisticated critical care outside the walls of an intensive care unit. Finally, the article summarizes yields from military-civilian collaboration in disaster planning and response.
    No preview · Article · Feb 2009 · Critical care clinics
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    ABSTRACT: Transport of mechanically ventilated patients in a combat zone presents challenges, including conservation of resources. In the battlefield setting, provision of oxygen supplies remains an important issue. Autonomous control of oxygen concentration can allow a reduction in oxygen usage and reduced mission weight. Trauma patients requiring ventilation and inspired oxygen concentration (FIO(2)) > 0.40 were evaluated for study. Patients were randomized to consecutive 4-hour periods of closed loop control or standard care. The system for autonomous control consisted of a ventilator, oximeter, and a portable computer. The computer housed the control algorithm and collected data every 5 seconds. The controller goal was to maintain pulse oximetry (SpO(2)) at 94 +/- 2% through discrete changes of 1% to 5% every 30 seconds. Ventilator settings and SpO(2) were recorded every 5 seconds for analysis. Forty-five patients were enrolled in this study. Oxygen saturation was maintained in the 92% to 96% saturation range 33 +/- 36% of the time during clinician control versus 83 +/- 21% during closed loop control. Time spent at the target SpO(2) 92% to 96% was 193.3 +/- 59.18 minutes during closed loop control and 87.08 +/- 87.95 minutes during clinician control (p < 0.001). Hyperoxemia was more frequent during clinician control (144.29 +/- 90.09 minutes) than during closed loop control (38.91 +/- 55.86 minutes; p < 0.001). There were no differences in the number of episodes of SpO(2) < 88%. Oxygen usage was reduced by 32% during closed loop control. Closed loop control of FIO(2) offers the opportunity for maximizing oxygen resources, reducing mission weight, and providing targeted normoxemia without increasing risk of hypoxemia in ventilated trauma patients.
    Preview · Article · May 2009 · Journal of the American College of Surgeons
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