Then, Now, What`s Next

CCATT
Then,
Now,
What’s Next ?
JSC
JSC Presentation
Presentation
January
January 23,
23, 2007
2007
Jay
Jay A.
A. Johannigman
Johannigman MD
MD FACS
FACS
Colonel
Colonel USAFR
USAFR MC
MC FS
FS
University
University Hospital
Hospital Cincinnati
Cincinnati Ohio
Ohio
Causes of Combat Deaths
KIA- Blast
7%
KIA- Tension
Pneumothorax
5%
Died of WoundsInfections and
Comps.
12%
Potentially 25% of
casualties are
survivable
KIA-Surgically
Uncorrectable
trauma
25%
KIA- Airway
1%
KIA- CNS Injury
31%
KIAExsanguination
from Extremity
wounds
9%
KIA-Surgically
correctable
trauma
10%
The Gulf War Dilemma
Non-linear/Asymmetrical Warfare
The Challenge-
Create lightweight, lean and mobile
capability
Austere but adequate within a
meaningful
distance of the injured
CSH
AC/
V
E
CAS
EV
MED
AC
The MFST- Mobile Field Surgery Team
„
„
„
Self Carried Surgical
team
1-10 stabilization
procedures
Extend Survivability
„
„
„
„
„
Laparotomy
Hemorrhage control
Bowel closure
Vascular shunts
Ortho fixation
Mobile Surgical Team
„
Army- FAST
„
„
Navy- SSTP
„
„
20 personnel
15 personnel
Air Force – MFST
„
5 personnel
New Problem
„
„
Stabilized, but not
stable, patient now
sitting in the middle
of the desert
Hard to provide
resource intensity
and duration of care
in austere
environment
Evolution of Critical Care in the Air
„
„
„
„
Aeromedical Evacuation (AE)
system
„ Stable casualties only
Critically ill patients could be
transferred but the team had to be
assembled ad hoc
Mogadishu, Somalia 1993
Concept of CCATT developed and
tested
„
„
„
Lt Gen Paul K. Carlton (ret.), MD,
FACS
Col Christopher Farmer (ret.), MD
Lt Col Bill Beninati, MD
Solution - CCATT
„
Critical Care Air
Transport Team
„
„
„
Intensivist
ICU R.N
Respiratory
Therapist
Continuous En Route Care
Historical Route From Injury to Definitive Care
STRATEGIC EVAC
- Evac Policy 15 Days
TACTICAL
EVAC
CASUALTY EVAC
- Evac Policy 7 Days
- Evac Policy 1 Day
In Theater
Hospital
“Level 3”
Field Hospital
“Level 2”
Battalion Aid
Station
“Level 1”
Definitive Care
“Level 4”
Continuous En Route Care
Current Route from Injury to Definitive Care
CASEVAC
1 Hour
TACTICAL
EVAC
1-24 Hours
BAS
Level 1
STRATEGIC EVAC
24-72 Hours
Forward Surgical
teams
Level 2
Combat Support
Hospital, EMEDS, Fleet
Hospital
Level 3
Surgical Capability
Definitive Care
Level 4
Airborne Express becomes ICU
CCATT Equipment
Equipment Bags
Total Weight: 500+ lbs
Propaq
Monitor
IVAC IV
Pump
Impact
Ventilator
AC, SIMV, CPAP
PEEP
I-STAT Lab
device
Tactical CCATT
„
Light
„
Noise
„
Vibration
„
Altitude
„
Duration
CCATT Mission Reports
In flight care (OEF/OIF)
„
„
„
„
„
Mechanical Ventilation 58 - 85%
Vasoactive or sedative drips
54%
Neuromuscular blockade 4%
Arterial pressure monitor 27%
Intracranial monitor 4 - 25%
LSA Anaconda/Balad Air Base
Time 0
„
„
„
Sgt. J.B. HMMV is
struck and disabled
Sgt J.B. lifts the hood
to investigate smoke
He is struck in the mid
back by sniper round
Time 45 minutes
„
„
„
Taken to Level II
Army FAST Kirkuk
Arrival B/P 80
systolic
Undergoes
exploratory
laparotomy„
„
„
„
„
Left Nephrectomy
Splenectomy
Packing of
abdomen
8 units PRBC’s
B/P 90’s systolic
Time 3 hours
„
Arrives at 332 EMDG
AFTH
„
„
„
„
Cold
Coagulopathic
Acidotic
Taken straight to OR
Time 3-6 hours
„
„
„
„
„
Re-explored
Packed, surgical
control gained
Urgent blood drive for
AB+ blood
Factor VII
administered
Patient warmed to 38
Time 6 hours
„
„
„
„
Transported to ICU
CT scan of spine
Completion of
resuscitation
“Urgent” evacuation
request placed to
JPMRC
Time 10 hours
„
„
„
„
C-141 “Reach” arrives
from Germany
Cargo unloaded
CCATT team alerted
Patient prepared for
transport
Time 10 hours
„
„
„
CCATT arrives
at ICU
CCATT moves
patient to
AMBUS to flight
line
Patient loaded
for flight
Time 12 Hours
„
„
„
Patient loaded for
flight and takeoff
6 hour mission to
Germany
AMBUS transfer
to LRMC
Time 18 Hours
Time 24 hours
„
„
„
„
Taken to OR PI day 2
packing is removed
Colon continuity
restored
Washed out PI day 5
Definitive
decompression and
stabilization of L-2
completed PI day 9
Post-Injury Day 14
„
Patient transferred to
WRMC s/p lumbar
decompression with
CCATT team.
Current and Future Challenges
„
„
„
„
Armed conflict provides generational leaps
in knowledge of the care of the injured
patient
CCATT is of proven value and saves lives
The application of CCATT across all
scenarios is still evolving
The practice of damage control surgery has
evolved with a success that few would have
dared dream
„
„
„
„
‘stabilized but not stable’
Post-surgical patients moved increasingly early in course
Has created a unique critical care transport need
Where To Next ?
Military/Civilian Training Centers
Background
„
„
„
„
Recognition of skill deficits
following Desert Storm
Military Medical Centers do not
routinely participate in high
volume trauma care delivery in
CONUS
The necessity of maintaining a
skilled medic force capable of
caring for the injured is obvious
Recommendation:
“Train military medical personnel
in civilian institutions with a high
volume of trauma and critical
care”
Cincinnati, C-STARS
Center
for
Sustainment of
Trauma
And
Readiness
Skills
Structure
„ 14
Day course aimed at sustaining CCATT
skills for the Active Duty, Reserve and
Guard Component
Clinicals
„
„
„
SICU/BSCU/NSICU
„ Over 3000 patients
treated in ’01
„ Multidisciplinary rounds
Nurses and 4H’s:
„ Shift work with preceptor
„ Hands on patient care,
including transporting,
procedures, etc.
MD’s:
„ Active in rounds, patient
care, procedures, etc
Lt Col William Vananzi and
SSgt Mary Rebholtz
Didactics
„
„
Approximately 30 hours of
lectures covering
„ CCATT
„ AE
„ Trauma
„ Critical Care
Lectures given by
„ University Professors
„ Visiting Professors
„
„
„
Including Cincinnati
Children’s Trauma Staff
Visiting military experts
C-STARS staff
Dedicated USAF Classroom
Flying Tasks
„
„
„
„
Static airframe training and
live CCATT mission in
collaboration with the
445th Airlift Wing at
Wright-Patterson AFB
Targeting 4 hours of flying
time per course
Emphasis on team building
and AE interaction
Patient mission will be
assigned second week
USAF CSTARS Simulation Center
Realistic Environment
CSTARS - Future
„
„
„
Much to be gained on each side of the equation
Continued BRAC will eliminate military clinical
training platforms
Flexibility and collegiality remain keys to
successful development of joint training centers
Current Equipment Suite
„
Good news
„
„
„
It works well enough
All services have
settled on the same
equipment
Bad News
„
„
„
„
It’s old
It’s heavy
It’s clumsy
The pieces are not
meant to work together
The
Imperative
The Challenge
Communication
Add-on Modules
Wireless
Powered by fire wire
Pt.-caregiver
USB port
Pt.-receiving facility
Communicate with/coordinated by central CPU
Pt.-Regional Control
Autonomous oxygen control
„
„
In the deployed setting
Oxygen is a critical
resource
Assumptionit is desirable to decrease
FiO2 as long as SaO2 is
maintained
„
„
Input controller- SaO2
Output controller- FiO2
Closed Loop Clinical Trial
„
„
„
„
„
Clinical trial of up to 50 patients
Four hours of manual and four hours of automatic
FIO2 control in randomized fashion
Both sexes, 18-55 years of age
Multiple trauma patients
Current FIO2 > 35%
Enrollment
„
Patient #1
„
„
„
„
„
„
31 year old following MVC
vs. garbage truck
Bilateral hemopneumothorax
Grade III liver laceration
Coagulopathy
Multiple transfusion
Left femur and tib/fib
fractures
„
Patient #2
„
„
„
„
„
„
„
„
55 year old following MVC vs.
tree
Hypotensive and tachycardic
at the scene
ED ABG 7.15/44/297 – FIO2
= 1.0
Open tib/fib fracture, pelvic
fracture, femur fracture, crush
injury right foot
Free fluid in the abdomen –
dead bowel – Hartman’s
procedure
Massive transfusion
Bilateral rib fractures 3-6
Thoracic spine fractures T1T5
Autonomous controller
Subject #1
Manual Control
Patient #3 Manual ⇒ Automatic Control
Results- closed loop control of FiO2
6
Control
5
Closed Loop
4
3
2
1
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15
Control Period
<88%
89-91%
92-96%
97100%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15
Closed Loop Group
< 88%
89-91%
92-96%
97-100%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15
CCATT Monitoring Project
„
Project undertaken to
monitor CCATT
transports from Balad
Air Base to LRMC
Pt #1
120
100
80
60
40
20
0
1 49 97 145 193 241 289 337 385 433 481 529 577 625 673 721 769 817
HR
SpO2
FIO2
AM
AM
AM
AM
AM
AM
AM
AM
AM
AM
AM
AM
AM
AM
AM
PM
PM
PM
PM
PM
PM
PM
PM
PM
PM
PM
PM
100
90
80
70
60
50
40
30
20
10
0
5 :0 3
5 :2 8
5 :4 0
6 :1 6
6 :2 0
6 :4 4
6 :5 2
7 :1 4
7 :2 4
8 :0 8
8 :5 5
9 :3 3
9 :5 0
1 0 :3 2
1 1 :1 9
1 2 :0 6
1 2 :5 2
1 :2 1
1 :3 1
1 :5 4
2 :1 6
2 :3 7
2 :4 4
3 :1 4
3 :1 9
3 :3 2
3 :5 2
SpO2
FIO2
6-Aug-2006
Autonomous Controllers
„
„
„
„
Increase Safety?
Improve Outcomes?
Compensate for the
austere/difficult
environment
Increase Capabilities
of provider ?
„
„
„
„
Prompts
Feedback
Suggested treatment(s)
Algorithms of care
So What ?
Force Multiplier
Eyes, Ears and Hands
and Minds
The Autonomous Care Collaborative
Future Areas of Autonomous Control
„
Mechanical Ventilation
„
„
„
„
IV Fluid Control
„
„
„
„
PEEP
Rate/ventilation
Weaning
Battlefield prior to hemorrhage
control
Post-Op resuscitation
Burn patients
Target Controlled infusion
„
„
„
Analgesia
Sedation
Anesthesia
Closed Loop Fluid Resuscitation of
Hemorrhagic Shock
8 algorithms compared w/ LR
Target Blood Pressures equally achieved all algorithms
Fluid Requirements were different
125
Mean Arterial Pressure
Total Fluid in
100
mm Hg
75
DT
50
PID
Fuzzy
25
5
25
baseline
-30
0
5
closed loop resuscitaton
30
60
90
120
150
180
minutes
Titrated Resuscitation of Shock 2001-05
ONR Grant # N00014-00-1-0362 PI: GC Kramer
Interface Research
„
Context Sensitive
„
„
„
Provide cues based on
monitored parameters
Access to levels of
sophistication
Variable levels of
autonomous control
En-Route Care System
I am a ….
Medic
Nurse
Flight Surgeon
CCATT doc
Master Caution Light!
F-16 paneltells you
that
something
is wrong!
TAKE
ACTION
QUICKLY!
Master Caution for Shock
This could be
our
Master Caution
light for a
patient in
trouble
Master Caution for Shock
„
„
Monitor is
actually a
Multi-Function
Display
intuitive and
directive to fix
problem!
Senior Visiting Surgeon Program
„
„
„
Initially conceived as a
means of sharing
information and
mentorship
Presented to the
Executive Committee of
the ACS COT in 2005
Jointly sponsored by…
„ ACS
„ ACS COT
„ AAST
SVS Overview
„
„
„
Two to four week
rotation
Clinical involvement in
the ICU, OR and all
aspects of care
Mentorship of military
surgeons with end
goal of peer reviewed
publications
SVS participants
„
„
„
C. William Schwabb
Gene Moore
Donald Trunkey
Scheduled to participate
„
„
„
„
„
„
„
LD Britt
David Feliciano
Margaret Knudson
Larry Roberts
Norm McSwain
Ron Maier
Frederick Moore
The (very near) future
„
„
The warfighter deserves
the very best
Improvements in
technical capabilities
offer a significant
opportunity to enhance
the care of the injured
soldier but also point the
way to a solution for our
Homeland Defense
If we are able to see great distances it
is because we rise on the shoulders of
the giants who came before us