the texas a&m university system health science center office of homeland security paul k....
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The Texas A&M University System Health Science CenterOffice of Homeland Security
Paul K. Carlton, Jr., MD, FACS Lt. Gen, USAF, Ret
Director, Homeland Security The Texas A&M University System
Health Science Center
August 11, 2005
Marty Silverstein Lecture Change is Hard
11 August - USUHS
The Texas A&M University System Health Science CenterOffice of Homeland Security
You may obtain a copy of this presentation at:
www.tamhsc.edu/homeland/
11 August - USUHS
The Texas A&M University System Health Science CenterOffice of Homeland Security
Danger Always Present, Just Beneath the Surface
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None of usWant to Face
What Lies Ahead of Us
We Must!
Facing Reality is Difficult
The Texas A&M University System Health Science CenterOffice of Homeland Security
“In times of change the learners will inherit the
world…while the learned will find themselves beautifully
equipped to deal with a world that no longer exists”
Eric Hoffer
11 August - USUHS
The Texas A&M University System Health Science CenterOffice of Homeland Security
Threat We Now Face
COMPLACENCY
We have done a great job with casualty management
in this war!
We cannot get complacent!
11 August - USUHS
The Texas A&M University System Health Science CenterOffice of Homeland Security
Change Is Hard
1.You’re nuts!
2.It would work, but no reason to change!
3.You like it? – It was MY idea!
“Every revolutionary idea evokes three stages of reaction”
The Texas A&M University System Health Science CenterOffice of Homeland Security
Evolution of an Idea
Evolution of a person's reaction to a new idea:– Indignant rejection – Reasoned objection – Qualified opposition– Tentative acceptance– Qualified endorsement– Judicious modification– Cautious adoption– Impassioned espousal– Proud parenthood– Dogmatic propagation
HK Silver, 1965
The Texas A&M University System Health Science CenterOffice of Homeland Security
Evolution of a person's reaction to a new idea:– Indignant rejection
– Reasoned objection
– Qualified opposition
– Tentative acceptance
– Qualified endorsement
– Judicious modification
– Cautious adoption
– Impassioned espousal
– Proud parenthood
– Dogmatic propagation
HK Silver, 1965
Battlefield Medicine- Results Today
The Texas A&M University System Health Science CenterOffice of Homeland Security
Threat We Now Face
COMPLACENCY
We have done a great job with casualty management
in this war!
We cannot get complacent!
11 August - USUHS
The Texas A&M University System Health Science CenterOffice of Homeland Security
Measure of Merit for Military Medicine
Soldiers, sailors, airmen and marines at work doing their jobs- protected against environmental hazards and if injured, receiving the very best possible care!
1. Public Health
2. Casualty Management
11 August - USUHS
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Public Health
Best job we have ever done in the history of war
Major improvement over GW I in water, food,
sanitation, etc…
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Casualty Management
Focus of the talk
11 August - USUHS
The Texas A&M University System Health Science CenterOffice of Homeland Security
“Unprecedented” Survival Rates
• Soldier survival rates in Iraq highest in U.S. war history
– 1/9 soldiers injured died from wounds
– Wounds critical as past wars
• Several advances
– Improved body armor technology (kevlar helmets and vests)
– On-site treatment by mobile surgical units
• “The average time from battlefield to arrival in the United States is now less than four days. In Vietnam, it was 45 days.” -- Dr. Atul Gawande
Navy Times, Jan 05
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Addressed All Areas as Joint Team 2004
Led to highest survival in history of war –
WWII Vietnam/GWI OIF
70% 76% 90%
Result of “Heretical” ThinkingNEJM 9 Dec 04
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What does 90% Mean?
11,000+ Injured in Iraq
GW2 90% 9,900
Vietnam/GW1 76% 8,360 1,540
Extra alive because of new thinking!Source: New England Journal of Medicine 9 Dec 2004
The Texas A&M University System Health Science CenterOffice of Homeland Security
Combat Casualty StatisticsFrom Stansbury, Holcomb, Champion, Bellamy, 2005
%KIA = KIA / KIA + (WIA - RTD)%DOW = DOW / WIA – RTD%CFR = KIA +DOW / KIA + WIA
0
5
10
15
20
25
%KIA %DOW %CFR
WWII
Vietnam
OIF/OEF
WIA = Wounded in Action (WIA =RTD+ Evacuated+ DOW)RTD = Returned to Duty in 72 hrsEvacuated = Not RTD in 72 hrsDOW = Died of WoundsKIA = Killed in ActionCFR = Case Fatality Rate
Best we
have ever
done!
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Major Variables
•Better body armor that protects vital area
•Stabilization of injury with far forward surgery
•Critical care in the air
•Family support - No One “gives up!”
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Apples to Apples Comparison
Data from ISR--Case Fatality Rates
8.8% IF/EF
16.5% VN/GWI
22.8% WWII
Stansbury, Holcomb, Champion, BellamyJuly 2005
The Texas A&M University System Health Science CenterOffice of Homeland Security
Combat Casualty StatisticsFrom Stansbury, Holcomb, Champion, Bellamy, 2005
%KIA = KIA / KIA + (WIA - RTD)%DOW = DOW / WIA – RTD%CFR = KIA +DOW / KIA + WIA
0
5
10
15
20
25
%KIA %DOW %CFR
WWII
Vietnam
OIF/OEF
WIA = Wounded in Action (WIA =RTD+ Evacuated+ DOW)RTD = Returned to Duty in 72 hrsEvacuated = Not RTD in 72 hrsDOW = Died of WoundsKIA = Killed in ActionCFR = Case Fatality Rate
Focus on
medical care
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This talk will focus on how we got where we are today
and look to the future
11 August - USUHS
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1983- After Action report from Marine Barracks Bombing
Examined how we dealt with injured globally:
Vietnam
•Comprehensive care in country
•Close by referral to Japan or Philipines
•45 days to reach USA
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1983- After Action report from Grenada
•Grenada invasion
•LtGen Jim Peake, Ret. did much the same thing after Grenada 1983
•Parallel development that intertwined repeatedly USAF-USA-USN-USMC
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Is that correct?
Is there a better way?
Is that what you want for your son or
daughter?
1983- After Action report from Marine Barracks Bombing
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Post Injury Phases of Illness 1983
Injury
Blood Loss
Respiratory Failure
Infection
Recovery
Rehabilitation
Days Weeks Months
Salvageable Mortality From:
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Injury
Blood Loss
Respiratory Failure
Infection
Recovery
Rehabilitation
Days Weeks Months
Salvage Surgery in 1st hour
Secondary Surgery
Definitive Care
Critical Care in the Air
Critical Care in the Air
Salvageable Mortality From
Post Injury Phases of Illness 1983
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This thinking and planning paid dividends in 1st hour of
deployment in October 2001
11 August - USUHS
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*Times and locations are estimated
Injury Scenario: Military and Civilian Care Comparison
1
2
3
4
Elapsed Time Post Injury
Care Received
Military Setting
Civilian Setting
25 min
6* hours
24* hours
48*+ hours
Emergency Surgery Damage Control
MFST personnel
Level 1 Trauma Center
Emergency Surgery Further Stabilization
CCATT enroute /surgical team at AmSurg Center
Level 1 Trauma Center
Level 1 Trauma Center
Level 1 Trauma Center/ Tertiary Hospital
CCATT enroute /surgical team in Military Hospital Setting
Stateside Military Medical Center
Definitive Surgical Care
Definitive Surgical Care
Recent Support of War Effort: Operation Enduring Freedom--Oct 2001
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This has now become the norm according to surgeons at
Landstuhl, Germany
Team work has never been better!
11 August - USUHS
Warren Dorlac 5 August 2005
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Advantage
•Smaller footprints in theater
•Address needs as a threat become apparent
•“Meet Golden Hour”
•Home quickly with full resources
•Family present!
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Lacking to Achieve Vision - 1983
•Critical care in the air
•Modular teams
•Team training
•Joint cooperation
Mired in 60’s
MIND SET ISSUE!
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Casualty Care -Prior to Larrey
•Casualties lay in the field
•If won – care given
•If lost – executed or left to die on the battlefield and looted as spoils of war
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Dominique-Jean Larrey
•1786 – Completed medical studies
•1792 – War breaks out
•1797 – designed first “flying ambulances” for evacuation - “flying ambulances” were horse drawn wagons to collect and carry wounded from battlefield to hospital - consisted of transport, medical supplies and support personnel
•1815- spared by the Duke of Wellington because he took care of all casualties at Battle of Waterloo
Napolean’s Surgeon
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Hence the name of the first modular team was “Flying
Ambulance Surgical Trauma Team” 1984- USAFE
Same concept
“Flying Ambulance”
The Texas A&M University System Health Science CenterOffice of Homeland Security
“In times of change the learners will inherit the
world…while the learned will find themselves beautifully
equipped to deal with a world that no longer exists”
Eric Hoffer
11 August - USUHS
The Texas A&M University System Health Science CenterOffice of Homeland Security
“Change is Hard”
11 August - USUHS
The Texas A&M University System Health Science CenterOffice of Homeland Security
Three Minds
Political Rational Emotional
Must understand interplay
Each person addresses this in various proportion
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Principles for Change
•Never question motivation
•Many see world differently
•Not wrong
•Must sell your points
•Be recognized expert
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Those that disagree are not wrong
They just see the world differently!
11 August - USUHS
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My focus
Rational mind– also called blunt!
•Improve survival of the wounded
•No other agenda
•No credit needed
Political Rational Emotional
11 August - USUHS
The Texas A&M University System Health Science CenterOffice of Homeland Security
Lacking to Achieve Vision - 1983
•Critical care in the air
•Modular teams
•Team training
•Joint cooperation
Mired in 60’s
MIND SET ISSUE!
The Texas A&M University System Health Science CenterOffice of Homeland Security
Critical Care in the Air
CCATT
“Their Story”
Heretical Thinking!
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CCATT
11 August - USUHS
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Continuous En Route Care
Battalion Aid Station
“Level 1”
In TheaterHospital“Level 3”
Definitive Care“Level 4”
Historical Route From Injury to Definitive Care
CASUALTY EVAC- Evac Policy -
1 Day
TACTICAL EVAC
- Evac Policy -7 Days
STRATEGIC EVAC- Evac Policy -
15 Days
Field Hospital“Level 2”
Vietnam 45 days
OIF 4 days
Out of ME and into WEJOINT TEAM
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Continuous En Route Care
BASLevel 1
Forward Surgical teamsLevel 2
Combat Support Hospital, EMEDS, Fleet
HospitalLevel 3
Definitive CareLevel 4
Current Route from Injury to Definitive Care
Surgical Capability
CASEVAC1 Hour TACTICAL
EVAC24 Hours
STRATEGIC EVAC48-72 Hours
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CCATT History
•Conceptualized 1983- rejected by AE- “Like trying to catheterize a running race horse!”
•Specifics in 1988
•1988 – 1999 developed concept, equipment, training
•2001-2004 proven effective
Against Heavy Opposition
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Evolution of Critical Care in the Air
• Aeromedical Evacuation (AE) system– Stable casualties only - GW1 and prior- “They
might die on our airplanes!”• Critically ill patients could be transferred but the
team had to be assembled ad hoc • Mogadishu, Somalia 1993• Concept of Critical Care Air Transport Team
developed and tested– Lt Gen Paul K. Carlton (ret.), MD, FACS– Col Christopher Farmer (ret.), MD, FACP– Col Jay Johannigman MD, FACS– Lt Col Bill Beninati, MD, FACP Critical Care Physicians
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Critical Care Air Transport Team (CCATT)
• Teams provide critical care expertise to manage patients in transit
• Augment normal AE crew • Personnel
– Active Duty– Guard and Reserve
• Goal of 210 teams– Currently 140– 12-15 teams in theater– 4 special operations teams
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CCATT
• Teams are multidisciplinary
– Physician– Nurse– Respiratory
Therapist • CCATT Course
– 2 weeks• 3 ventilated patients
– 6 patients maximum
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CCATT Equipment
Propaq
MonitorIVAC IV
Pump
Impact VentilatorAC, SIMV, CPAP
modes
PEEP
I-STAT Lab device
Equipment Bags
Total Weight: 585 lbs
Three equipment sets:
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AE AIRFRAMES
Opportune-- not dedicated
Maximizes flexibility
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How does this soldier get home?
Photo from 1st Lt Robert M. Barnhart
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CASEVAC
This job is done by the
Army and Navy
By ground or by air
1 2
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Injury
Blood Loss
Respiratory Failure
Infection
Recovery
Rehabilitation
Days Weeks Months
Salvage Surgery in 1st hour
Secondary Surgery
Definitive Care
Critical Care in the Air
Critical Care in the Air
Salvageable Mortality From
Surgical Care in First Hour
•Life saving only at BAS/CCP
•Meatball/ damage control surgery
•Stabilize fractures
•Never more than 2 hours
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Tactical Evacuation
23
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Injury
Blood Loss
Respiratory Failure
Infection
Recovery
Rehabilitation
Days Weeks Months
Salvage Surgery in 1st hour
Secondary Surgery
Definitive Care
Critical Care in the Air
Critical Care in the Air
Salvageable Mortality From
CCATT if needed
Continuous enroute care
Tactical Evacuation
The Texas A&M University System Health Science CenterOffice of Homeland Security
Injury
Blood Loss
Respiratory Failure
Infection
Recovery
Rehabilitation
Days Weeks Months
Salvage Surgery in 1st hour
Secondary Surgery
Definitive Care
Critical Care in the Air
Critical Care in the Air
Salvageable Mortality FromSecondary Surgery
•Re-stabilization- CSH/AFTH/FST+
•Stop bleeding
•Re-stabilize fractures
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Strategic Evacuation
Patient Movement Request generated
CCATT team requested
Team comes to location and assesses the patient, or is on scene and already taking care of patients which is much better for continuity!
Level 3 to Level 4
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Injury
Blood Loss
Respiratory Failure
Infection
Recovery
Rehabilitation
Days Weeks Months
Salvage Surgery in 1st hour
Secondary Surgery
Definitive Care
Critical Care in the Air
Critical Care in the Air
Salvageable Mortality From
Provide definitive care in Germany or USA
Strategic Evacuation
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Strategic Evacuation
The Texas A&M University System Health Science CenterOffice of Homeland Security
Injury
Blood Loss
Respiratory Failure
Infection
Recovery
Rehabilitation
Days Weeks Months
Salvage Surgery in 1st hour
Secondary Surgery
Definitive Care
Critical Care in the Air
Critical Care in the Air
Salvageable Mortality From
Provide definitive care in Germany or USA
Strategic Evacuation
The Texas A&M University System Health Science CenterOffice of Homeland Security
Patient ExampleBalad, Iraq 11 Sep 04 Washington D.C.
13 Sep 04
6500 miles
2 CCATT teams
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Patient Example
Washington, DC
30 Sept 04
Washington D.C.
Jan ‘05
Now married
Has taken first steps with new limbs
Excited to start his new life
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Patient Example
Source: Air Force Times 28 March 05
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Seamless Continuum of Care
Team Work is Key
Continuous En Route Care
JOINT TEAM
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Lacking to Achieve Vision - 1983
•Critical care in the air
•Modular teams
•Team training
•Joint cooperation
Mired in 60’s
MIND SET ISSUE!
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Traditional Response: Whole Blood
O-Blood
• Multi-Purpose (Shotgun Approach)
• Effective Treatment for Acute Blood Loss
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Current Approach:Component Therapy
• Problem Specific Treatment
• Increased Efficacy • Extends Limited ResourcesFFP
O-
Platelets
O-RBCs
O-
Saline
Plasma
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Medical Building Blocks: Modular Response
• Problem Specific Treatment
• Increased Efficacy • Extends Limited
Resources• Maximizes Options for
Commanders• Flexible Force ModulesCCATT
ECCT
PAMMFST
SPEARR
EMEDS
The Texas A&M University System Health Science CenterOffice of Homeland Security
Medical Building Blocks: Modular Response
• Problem Specific Treatment
• Increased Efficacy • Extends Limited
Resources• Maximizes Options
for Commanders• Flexible Force
Modules EMEDS
PAM
SPEARRMFST
CCATT ECCT
BATDisaster,
MOOTW
CBRNE
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Expeditionary Packages
• Prevention and Aerospace Medicine (PAM) Team
– Designed to prevent disease and non-battle injuries
• Mobile Field Surgical Team (MFST)
– Rapidly deployable, easily transportable, small surgical team
• Small Portable Expeditionary Aeromedical Rapid Response Team (SPEARR)
– Deployable within two hours
– Flexible, broad scope of care
• Critical Care Air Transport Team (CCATT)
– For rapid aeromedical evacuation (AE) worldwide
• Expeditionary Medical Support (EMEDS)
– New version of traditional Air Transportable Clinic / Hospital
• Biological Augmentation Team (BAT)
– Field identification of pathogens of operational concern
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Modular Units of Capability: Providing What’s needed, When needed
• The Crisis Defines the Response• Optimizes Resources• Maximizes Options for Commanders
CRITICAL CARE
Surgical TEAMS
SPEAR
PAM Teams
Staging/CrewsComm
Expanded Beds+10 and +25
Staging Aug+20 Bed
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Prevention and Aerospace Medicine Team (PAM)
• Designed to prevent disease and non-battle injuries• Missions/Tasks
– Health threat/risk assessment– Health hazard surveillance, control, and
mitigation of effects– Primary/emergency care, flight medicine
• Population at risk; 2-10,000• 9 personnel in 3 modules
– Module 1 (Advon) - Aerospace medicine physician, public health officer
– Module 2 - Bioenvironmental engineer (BEE), independent duty medical technician
– Module 3- 2 public health technicians, 2 BEE technicians, aerospace physiologist
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• For Aeromedical Evacuation Patients• Capability: Provides in-flight critical care
transport of 3 ICU patients; with 2nd critical care nurse, 5 stabilized patients
• Personnel: 3 - 1 Physician, 1 Nurse, • 1 Respiratory Tech• Equipment: Light weight, compact, advanced • and sophisticated patient management
equipment and supplies• Operating Conditions: Work with 5• member AE crews to care for stabilized
casualties; for tactical and strategic evacuation
Critical Care Air Transport Team (CCATT)
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Mobile Field Surgical Team (MFST)
• Rapidly deployable, easily transportable, small
• surgical team
• Provide lifesaving trauma care within one hour
• of injury
• Personnel: 1-General Surgeon, 1-Orthopedic Surgeon,
• 1-Emergency Physician, 1-Anesthesiologist, 1-OR Nurse/Tech
• Equipment: Manportable 300 lbs of medical equipment and supplies in 5 backpacks, 60lb generator, 1 folding litter
• Capability: Care for up to 20 patients in 48 hrs; perform up to 10 life or limb saving/stabilization procedures
• Operating conditions: Intended for specialized surgery tasks as stand alone for short periods or as medical augmentation unit; transportable by any means; uses shelter of opportunity; no patient holding capability
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Similar Thinking
All interchangeable as needed
Service Name Number Time
USA FFST 50 1943
USAF FAST 20 1984
USA FST 24 1985
USAF MFST 5 1994
USN FSRT 8 2000
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Change Is Hard
Ft. Polk, Louisiana
Joint Readiness Training Center
USA light units train there
In conjunction with USAF/USN/USMC
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LEVELS of medical care
I II III IV
Buddy/Self aid
BAS See a doc – no operation
Surgical Care limited ICU care
Definitive care
Change Is Hard
Medical Report Card is DOW Rate
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1st Day- Oct ‘95
LEVELS of medical care
I II III IV
Played at JRTC
12 hours in – card pulled Stinger/SA 7/16 are present AE denied via chopper
Medical Report Card is DOW Rate
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LEVELS of medical care
I II III
DOW rate 39%- 12 hr evac time COL Lester Martinez (now retired MajGen)
pushed surgical care forward to BAS with 5 member AF Surgical team (led by Ty Putnam)
DOW rate dropped to 13%
2nd Day- Oct ‘95
Medical Report Card is DOW Rate
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DOW stayed at 13%
Led to push surgical care forward
FST (USA) Forward Surgical Team FSRT (USN) Forward Surgical Resuscitation Team MFST (USAF) Mobil Field Surgical Team
3rd Day- Oct ‘95
Medical Report Card is DOW Rate
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“Change is Hard”
11 August - USUHS
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Ft. Polk, Louisiana
•Not doctrinal
•Will not do
•Required appeal
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Ft. Polk, Louisiana
•Appealed by line BrigGen to 18th AB Corp Commander – LtGen Hugh Shelton
•Asked USA to review its doctrine
•They did
•Changed doctrine to do salvage surgery and meet “Golden Hour”
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Evolution of Thinking – US Military
Idea meet
logic test
NO (stop)
YES
YES - Set up scenarios-realistic exercise
Scenarios at JRTC
proven effective- not effective – implemented (38% to 13%) discarded Forward Surgical Care Pushed Far Forward
The Texas A&M University System Health Science CenterOffice of Homeland Security
Lacking to Achieve Vision - 1983
•Critical care in the air
•Modular teams
•Team training
•Joint cooperation
Mired in 60’s
MIND SET ISSUE!
The Texas A&M University System Health Science CenterOffice of Homeland Security
Team Training
Ken Mattox, Don Trunkey and others have advocated for military teams to do “trauma training” programs in preparation for war since 1975
The Texas A&M University System Health Science CenterOffice of Homeland Security
Change Is Hard
1.You’re nuts!
2.It would work, but no reason to change!
3.You like it? – It was MY idea!
“Every revolutionary idea evokes three stages of reaction”
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1998
Push hard to establish “Ft. Ben Taub” in Houston
Did in 1999 with joint team of 13
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2000 - 2001Training Spread
•USAF Center for Sustainment Training and Readiness Skills (CSTARS)
-Baltimore Shock Trauma -Cincinnati for CCATT
-St. Louis for National Guard and reserves
•USA – Miami
•USN - LA
The Texas A&M University System Health Science CenterOffice of Homeland Security
Lacking to Achieve Vision - 1983
•Critical care in the air
•Modular teams
•Team training
•Joint cooperation
Mired in 60’s
MIND SET ISSUE!
The Texas A&M University System Health Science CenterOffice of Homeland Security
Standards Established
11 August - USUHS
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RSVP
Readiness
Skills
Verification
Program
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RSVP-Dance Card
•What are requirements to go to war?
•Consultants answered those program questions.
•RSVP criteria established for each deployable person
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For Example
General surgery
-50 open laps every 2 years
-50 ventilated patient days
-etc…
If not met then go to CSTARS for 4 week update prior to deployment
Certified for deployment!
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For Example
CCATT Nurses
•50 ventilator patient days
•Readiness training
•Etc…
If not met then go to CSTARS for 2 week update prior to deployment
Certified for Deployment
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Result
•Military teams well prepared for conflict that started after 11 September 2001
•Patients more challenging in war, but principles are real and applicable
The Texas A&M University System Health Science CenterOffice of Homeland Security
Combat Casualty StatisticsFrom Stansbury, Holcomb, Champion, Bellamy, 2005
%KIA = KIA / KIA + (WIA - RTD)%DOW = DOW / WIA – RTD%CFR = KIA +DOW / KIA + WIA
0
5
10
15
20
25
%KIA %DOW %CFR
WWII
Vietnam
OIF/OEF
WIA = Wounded in Action (WIA =RTD+ Evacuated+ DOW)RTD = Returned to Duty in 72 hrsEvacuated = Not RTD in 72 hrsDOW = Died of WoundsKIA = Killed in ActionCFR = Case Fatality Rate
The Texas A&M University System Health Science CenterOffice of Homeland Security
Lacking to Achieve Vision - 1983
•Critical care in the air
•Modular teams
•Team training
•Joint cooperation
Mired in 60’s
MIND SET ISSUE!
The Texas A&M University System Health Science CenterOffice of Homeland Security
Joint Cooperation
•Casualty does not care who takes care of them – Army, Navy, Air Force, Marine Corp
•They care that they get taken care of
•Has required many years to get into “WE” mindset of Jointness!
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Team
Military
US Army
US Air Force
US Navy
US Marine Corp
All now closely integrated team members
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Now moved to coalition operation
We have not gone to war by ourselves as a country
since 1898!
11 August - USUHS
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Coalition Cooperation
•Many nationalities involved
•Doing well together
•Heard Australian Neurosurgeon debrief his SG after Balad assignment – Feb 05
•Praised coalition cooperation
•Given a leadership position!
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“Change is Hard”
11 August - USUHS
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Overview
•Heresy
•Appeal
•Imperatives
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Heretics Defined
Someone who sees a truth that contradicts the conventional wisdom of an organization, remains loyal to that truth... AND at the same time, remains loyal to the organization
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Heretics Won’t Shut Up
… Not because they are being
difficult, but
… Because they see a truth that is
difficult to deal with
The Texas A&M University System Health Science CenterOffice of Homeland Security
Appeal--A Heretic’s Tool
• Chains of Authority
• When to Appeal
• When to Take a Stand
• Seven Steps to Keep You Safe
The Texas A&M University System Health Science CenterOffice of Homeland Security
Use Established Chain of Command
• Wiring diagram that explains who’s in charge• Learn it• Know it• Understand it• Use it
The Texas A&M University System Health Science CenterOffice of Homeland Security
Chain of Influence
• Extends beyond chain of command
• Affects assignments, working conditions, promotion, etc
The Texas A&M University System Health Science CenterOffice of Homeland Security
Authority
• Basic functions• Punish those who do evil• Praise those who do well
• Why we need to be under it• For character training• For conscience’ sake• For credibility and influence
The Texas A&M University System Health Science CenterOffice of Homeland Security
When to Appeal to Authority
• When they fail in their duty
• When they go beyond their duty
• When they ask you to do wrong
• When damage to life or property might occur
The Texas A&M University System Health Science CenterOffice of Homeland Security
How to Appeal
• Check your own attitude
• Have the spirit of a learner and servant…be humble
• Do your homework and find out why you disagree
• 99% of problems will be yours, not your boss’s
The Texas A&M University System Health Science CenterOffice of Homeland Security
Is There an Alternative?
• First, discover basic intentions of the one who gave the command being appealed• Different views of work are healthy• Different levels of understanding are basis of most
disagreements• Design a creative alternative
• Don’t complain without offering a solution to the problem
• Ensure all details are addressed• Prepare to quickly follow through on proposed
alternative
The Texas A&M University System Health Science CenterOffice of Homeland Security
Complaints without
Solutions = Whining
11 August - USUHS
The Texas A&M University System Health Science CenterOffice of Homeland Security
Whining
11 August - USUHS
The Texas A&M University System Health Science CenterOffice of Homeland Security
Contact the Proper Authority
• Talk to the person in charge who can make the decisions
• Inform your boss of your intent to appeal
• Invite him / her to your appeal
• Establish your position under his / her jurisdiction
• It is their problem!
The Texas A&M University System Health Science CenterOffice of Homeland Security
When Your Appeal is Rejected...
• Identify the cause of a rejected appeal
• You
• Your appeal
• Your authority
• Hold up your mirror and look critically at yourself
Political Rational Emotional
The Texas A&M University System Health Science CenterOffice of Homeland Security
When Criticized...
• Look for issue…don’t take it personally• Grain of truth in everything that’s said
• Trace criticism to its real source• Another agenda?• Reaction to me or what’s been said?
• Respond quickly but wisely to your critics • Know that you are under your proper
umbrella of authority
The Texas A&M University System Health Science CenterOffice of Homeland Security
When Criticized… (cont’d)
• Look at fear as an invitation to defeat• Make a conscious effort to improve
with every critique• Understand if you are leading as you
should, you will be subject to frequent criticism• No controversy, no progress
The Texas A&M University System Health Science CenterOffice of Homeland Security
Have Courage of Your Convictions
• Be ready to stand alone for the right if it’s appropriate
• Integrity is KEY
• Understand we ALL see the world differently
The Texas A&M University System Health Science CenterOffice of Homeland Security
Change is Hard
Senior official in ASD/HA 2000
“Dr. Carlton, thank God for bureaucracies! We will prevent you from endangering our patients with these idiotic ideas! We will out bureaucrat you!”
The Texas A&M University System Health Science CenterOffice of Homeland Security
Seven Steps of Actionfor Appeal
1. Check attitudes• Both yours and your boss’s
2. Clear conscience• Make the appeal because it is
“right” 3. Discern basic intentions
• Know your boss’s basis for decision
The Texas A&M University System Health Science CenterOffice of Homeland Security
4. Design creative alternatives• Appeal without a solution is
whining 5. Appeal to your authority
• Explain how it will reach the goal• Leave final decision up to
authority
Seven Steps of Actionfor Appeal (continued)
The Texas A&M University System Health Science CenterOffice of Homeland Security
6. Be patient…let authority mull it over
• Forcing a quick answer usually results in a “no”
7. Be ready to stand alone
Integrity - Service - Excellence
Seven Steps of Actionfor Appeal (continued)
The Texas A&M University System Health Science CenterOffice of Homeland Security
Remember….
• If it’s a good idea it will surface again• FAST EMEDS 16 years• Med Center without walls – still not done• TRICARE – fixes ’95- still not done• Career Option Matrix- enlisted nurses – still not
done• CCATT – 15 years• RSVP – 15 years
The Texas A&M University System Health Science CenterOffice of Homeland Security
Leadership Imperatives
• Core Values
• Attitude
• Competence
• Mentorship
• Self Protection
The Texas A&M University System Health Science CenterOffice of Homeland Security
Today
11 August - USUHS
The Texas A&M University System Health Science CenterOffice of Homeland Security
Unintended Consequences
•Rapid return of casualties puts them
in their family support system
•4 days versus 45 day VN conflict
•Hard to measure but real
The Texas A&M University System Health Science CenterOffice of Homeland Security
Seamless Contingency of Care
Injury Salvage Surgery 1st hour Ventilated AE ride chopper or fixed wing
2nd Salvage Surgery or Definitive surgery Ventilator AE ride for fixed wing
Germany – Definitive Surgery Vent AE ride
USA – Definitive Care Average 4 days for wounds, can be only 24 to 36 hours
The Texas A&M University System Health Science CenterOffice of Homeland Security
Continuous En Route Care
Battalion Aid Station
“Level 1”
In TheaterHospital“Level 3”
Definitive Care“Level 4”
Historical Route From Injury to Definitive Care
CASUALTY EVAC- Evac Policy -
1 Day
TACTICAL EVAC
- Evac Policy -7 Days
STRATEGIC EVAC- Evac Policy -
15 Days
Field Hospital“Level 2”
Vietnam 45 days
OIF 4 days
Out of ME and into WEJOINT TEAM
The Texas A&M University System Health Science CenterOffice of Homeland Security
Today
•Equipment and people were separated so non-functional
•Need light, quicker NBC shelter system
The Texas A&M University System Health Science CenterOffice of Homeland Security
Today
•Need one pallet hospital
•Self erecting
•Self contained for power and HVAC
•NBC hard
•Towable behind a HumVee
•Sling loadable by helo
The Texas A&M University System Health Science CenterOffice of Homeland Security
Today
•Tried to do with SPEARR trailer
•Got left behind when deployed
•Good concept
•Equipment was lacking
The Texas A&M University System Health Science CenterOffice of Homeland Security
Tomorrow
•As retiree I can be more flexible
•Went to shelter manufacturer and told him what was needed
•Drew it out on the back of a napkin
The Texas A&M University System Health Science CenterOffice of Homeland Security
•USA funded development
•Now we have one pallet shelter system
•Self erecting
•Self contained for power and HVAC
•NBC hard
•One person set up in 5 minutes
•Towable behind HumVee
•Sling loadable
Tomorrow
The Texas A&M University System Health Science CenterOffice of Homeland Security
Tomorrow
11 August - USUHS
The Texas A&M University System Health Science CenterOffice of Homeland Security
EMEDS
•Is a concept!
•Not a checklist, equipment or supplies
•Must be constantly examined and intelligently improved
The Texas A&M University System Health Science CenterOffice of Homeland Security
Tomorrow
•8.8% can be improved
•Better out of hospital care
•Improvements are at enlisted first responder level
•All of us should look for them
The Texas A&M University System Health Science CenterOffice of Homeland Security
Tomorrow
•Prevention might be better than treatment to lower wounded rate
•Better body armor
•Ability to stop bleeding
The Texas A&M University System Health Science CenterOffice of Homeland Security
Lacking to Achieve Vision - 1983
•Critical care in the air
•Modular teams
•Team training
•Joint cooperation
Mired in 60’s
MIND SET ISSUE!
How about 2005?
The Texas A&M University System Health Science CenterOffice of Homeland Security
Future
CCATT
•Joint CCATT teams formalized
•Move into CASEVAC/enroute care
The Texas A&M University System Health Science CenterOffice of Homeland Security
CCATT
•Key is ventilator•I have seen programs that adjust vents automatically by pulse oximetry so is computer controlled entirely- we need these!
•Address technical issue of airway management
•MD
•RN
•Enlisted
All could be trained to do
The Texas A&M University System Health Science CenterOffice of Homeland Security
CCATT
•Integrated PorDITs, full imaging system in a PDA, for diagnostic capability
•No more than one back pack or equipment per patient
•Cannot allow it to get big!
•Must make it smaller
•Forward deploy the bag so can rotate
The Texas A&M University System Health Science CenterOffice of Homeland Security
-15
-10
-5
0
5
10
15
0 1 2 3 4 5 6
Spirometry
PorDITS• PC-based Intensive Care Unit
The Texas A&M University System Health Science CenterOffice of Homeland Security
Portable Diagnostic Imaging System
Lap top computer that integrated 8 receptacles for imaging accessoriesEKG with automatic reading done
Spirometry
Pulse oximetry and capnography
Ultrasound
XRay sending unit
Digital camera
Automatic BP reading
Automatic temp recording
PorDits
Fielded in 2001
The Texas A&M University System Health Science CenterOffice of Homeland Security
Portable Diagnostic Imaging System
Prototypes cost $10K each
Production should be much less expensive
Available in PDA size now via SF
Should be part of every full time or part time medical unit
Would be useful for CCATT/AE
PorDits
The Texas A&M University System Health Science CenterOffice of Homeland Security
CCATT
•Integrated PorDITs, full imaging system in a PDA, for diagnostic capability
•No more than one back pack of equipment per patient
•Cannot allow it to get big!
•Must make it smaller
•Forward deploy the back pack so can rotate from home station
The Texas A&M University System Health Science CenterOffice of Homeland Security
Future
Modular Teams
•Trauma specialists – ortho & GS combined on European model
•Standardized equipment and training all services for trauma care
•Get smaller– three persons if we had one combined surgeon as above
The Texas A&M University System Health Science CenterOffice of Homeland Security
Future
Team Training
•Plug deployable teams into university hospital
•Model is University of Colorado
•Fully audited
•Win-win on both sides
The Texas A&M University System Health Science CenterOffice of Homeland Security
Future
University Hospital
•Military gets out of bricks and mortar except for casualty reception hospitals
•University has trained people for state readiness response
•Money earned by people stationed at the University goes to pay TriCare bill
The Texas A&M University System Health Science CenterOffice of Homeland Security
Future
Joint Cooperation
•Integration of inpatient facilities will go a long way toward this
•Each service is unique in its requirements yet has much commonality
•Need to preserve the culture of each service yet look for commonality so we can survive fiscally!
The Texas A&M University System Health Science CenterOffice of Homeland Security
Tomorrow
Made great headway in casualty care management to date
Our job is to continue to improve the system
We cannot be complacent!
The Texas A&M University System Health Science CenterOffice of Homeland Security
Is it the best way?
Is it okay for your son or daughter?
11 August - USUHS
“Military is our family!”
The Texas A&M University System Health Science CenterOffice of Homeland Security
“Change is Hard”
11 August - USUHS
The Texas A&M University System Health Science CenterOffice of Homeland Security
BE PERSISTENT!
Heretics Are Not All Bad!
11 August - USUHS