MEDICAL SUPPORT TO THE WARFIGHTER: FROM BATTLEFIELD TO TERTIARY CARE & BEYOND Lt Gen (ret) Douglas J. Robb, DO, MPH Chicago College of Osteopathic Medicine ’84 1
The “why”… AGENDA 2
…the “Why Not” 3
…and always keeping the “End State” in mind Why we are really here today!
DISCLAIMER • The opinions expressed are those of myself and do not represent the views of USU or the DoD • I am not a trauma surgeon nor a critical care specialist nor a first responder… • But…I was the on -scene medical director for the Khobar Towers Saudi Arabia Bombing…US Central Command senior medical advisor…Air Mobility Command senior medical advisor…Chairman of the Joint Chiefs of Staff senior medical advisor…Director Defense Health Agency • But, most important…I listened to the trauma mafia* *Trauma Mafia: an endearing term referring to pre-hospital/enroute care/hospital professionals
Learning Objectives • Understand the Military Health System’s Full Spectrum of Heath Care Support to the Warfighter • Know the resourcing requirements to support • Describe the Military Heath Systems leadership transformation required to transform “silos” of excellence to a “continuum” of excellence • Examine “Lessons Learning”: Challenges facing our Wounded Warriors
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 to maintain equal or greater level/quality of care at each level of movement • Destination: World Class NATO/Military/VA/Civilian Healthcare System • Lessons “Learning” 7
Mission of the Military Health System (operative word is “system”) To provide Combatant Commands & Service Components with: A Medically Ready Force (lean mean fighting machine) & A Ready Medical Force (lean mean saving lives machine)
BLUF: Medical Support to the Combatant Commands “Our Referral Network!”
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/Coalition/VA/Civilian Healthcare System 11
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% 12
AIR & SEA DISTANCES AIR AIR SEA SEA 7,00 7,000 0 MI MI 8,600 8,60 0 MI MI 24 H 24 HOU OURS RS 20+ 20 + DAYS SEA SEA 12 12,000 ,000 MI MI 26+ 26 + DAYS 13
Continuous En-route Care Historical Route From Injury to Definitive Care STRATEGIC EVAC - Evac Policy - 15 Days TACTICAL EVAC Definitive Care - Evac Policy - “Level 4” CASUALTY EVAC 7 Days - Evac Policy - In Theater 1 Day Hospital “Level 3” Field Hospital “Level 2” Battalion Aid Station “Level 1” 14
Continuous En-route Care: Stable … Stabilized… Stabilizing TACTICAL/STRATEGIC AE 24-72 Hours TACTICAL MEDEVAC/AE 1-24 Hours US Medical Center CASEVAC/MEDEVAC Overseas Medical Center 1 Hour ASF Theater Hospital Definitive CASF Care EMEDS Theater MASF Hospital Care Battalion Forward Aid Station Resuscitative Care First Responder Care 15
Force Health Protection Begins BEFORE You Step to the Jet! • Deployment Medical Guidance • Pre/Post Deployment Health Assessments • Immunizations • Chemoprophylaxis • Occupational Environmental Health Surveillance 16
T+ 00:00 • HMMV is struck & disabled 17
First Responder Care: Tactical Combat Causality Care “Correct Intervention At The Correct Time In The Continuum Of Combat Care!” • • Care Under Fire • Combat Application Tourniquet (CAT) • Hemostatic Dressing • Tactical Field Care • Hypothermia Prevention • Combat Pill Pack: Antibiotics/ Pain Control • Combat Casualty Evac Care • Rapid Casualty Assessment (ABCs) • Control Hemorrhage (CABs) • Treat penetrating chest trauma • Maintain airway/package for transport 18
MEDEVAC & Tactical Operations Center 19
T+ 00:25 • Taken to LV II Forward Surgical Care • Arrival B/P 80 systolic • Undergoes exploratory laparotomy: • Left Nephrectomy • Splenectomy • Packing of abdomen • 8 units PRBC’s • B/P 90’s systolic 20
Level II: Forward Surgical/Resuscitative Care Forward Surgical Teams Shock Trauma Platoons 21
T+ 03:00 • Arrives LV III Theater Hospital • Cold • Coagulopathic • Acidotic • Taken straight to OR
Level II/III: Theater Expeditionary Hospitals 23
Injury Cause Trends: Percentage of Total by Cause 15.1% 8.7% EXPLOSIVE DEVICE 51.1% GSW MVC OTHER 25.0% 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 26
T+ 06:00 • Transported to ICU • CT scan of spine • Ongoing DCR/DCS • “Urgent” evacuation request placed 27
JOINT THEATER SUPPORT: TELEMEDICINE & TELERADIOLOGY - ERM RMC LRMC Germany WRMC WRM 18 th MEDCOM MAMC 121 st General Hospital Ai Air Force MEDCENS NARMC NARM WAMC WRAMC Afghanistan tan PRM RMC TAMC NAVY NAVY MEDCENS GPR GPRMC SERM RMC BAMC DDEAMC Iraq raq Ku Kuwait LEGEND Radiologist Workflow/workloads Overflow Exams/Medevac
T+ 10:00 • C-17 arrives from Germany • Cargo unloaded • CCATT team alerted • Patient prepared for transport 29
Aeromedical Evacuation Cargo In… …Patients Out! 30
En Route Patient Staging System (ERPSS) • ERPSS-10 bed • Mobile 24hr staging at tactical airheads • Rapid response staging • ERPSS – 50/100 bed • 24hr staging at strategic airheads • Support to Theater Hospital • Transport to AE aircraft 31
Tactical Aeromedical Evacuation (AE): Intra-theater Hub & Spoke • C-130/NATO • Opportune A/C 32
Strategic AE: Inter-theater Kar arshi shi Kha hana naba bad Ter ermez mez Shir Shir Khan GE Feyzab yzabad Ke Keleft ft Balkh Ba lkh Jeyr yretan Esh shkash shem Taloqan Konduz Mazar-e-Sharif GE Ba Baghlan lan Sar-e Pol Sama mangan Pol-e Kh Khomr mri Meyma ymaneh Bagram Cha hari rika kar Qal’eh -ye ye No Now Ba Bamian mian Herat Chaghcharan Cha Jalal alalaba bad Kabul Bar arak aki Gardez Khowst st Shindand Shind Baghran Ba Gh Ghazni Orgun-e Deh Raw De Rawod Mir iram m Sha Shah Shk Shkin in Tarin in Kowt Qala lat Farah Farah Delar Delaram Garma Ga mabak Geresk sk Kandahar Lash shkar Ga Gah Zar Zaranj Spin Spin Bo Bolda ldak UK/GE Jacobabad Sha Shamsi msi 33
Global Patient Movement 3000 ▪ CENTCOM ▪ EUCOM ▪ NORTHCOM ▪ SOUTHCOM* 2500 ▪ PACOM Patient Movement Requests 2000 946 977 865 896 802 878 1500 843 877 884 804 881 720 865 1000 653 698 827 721 703 745 812 779 752 643 728 614 686 500 41 166 40 31 45 47 52 47 131 56 48 35 48 56 31 320 318 303 297 303 271 257 251 313 276 242 261 238 0 34
Aeromedical Evacuation: Lifeline Home
Critical Care Air Transport (CCAT) “FLYING ICUs” 36
T+ 10:00 • CCATT arrives at ICU • CCATT moves patient to AMBUS to flight line • Patient loaded for flight 37
‘Stabilized…stabilizing’ AE Pt Transportation • Secured airway • Shock treated/Hemorrhage controlled • Fractures Immobilized/splinted • Damage control surgery • Initial control of contamination • Damage Control Resuscitation: prevent “lethal triad” acidosis, coagulopathy and hypothermia • Subsequent re-exploration & definitive repair 38
T+ 12:00 • Patient loaded for flight • 7 hour mission to Germany • AMBUS transfer to Landstuhl Regional Medical Center, Germany 39
T+ 24:00 • Taken to OR • Re-explored/wash outs 40
T + 36:00 • Patient transferred to WRNMMC with CCATT 41
T + 4,500:00 hrs Joint Trauma System…got him there!
What have we learned…learning 43
PTSD, mTBI , “other” MH Diagnosis Yesterday’s Understanding Chronic Pain/ PTSD Substance Abuse/ Other MH dx mTBI PTSD: Post Traumatic Stress Disorder mTBI: Mild Traumatic Brain Injury MH: Mental Health 44
PTSD, mTBI , “other” MH Diagnosis Today’s Understanding Chronic Pain/ PTSD Substance Abuse/ Other MH dx PTSD: Post Traumatic Stress Disorder mTBI mTBI: Mild Traumatic Brain Injury MH: Mental Health 45
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