1

MEDICAL SUPPORT TO THE WARFIGHTER:

FROM BATTLEFIELD TO TERTIARY CARE

LtGen (Dr.) Douglas J. Robb, DO, MPH

CCOM Class of ‘84

April 2015

2

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 is to maintain equal or greater level/ quality of care with

each level of movement

• Destination: World Class NATO/Military/VA Healthcare System

AGENDA

TODAY’S AGENDA

We’ve Got to Be Ready

6

Combatant Commanders’

Areas Of Responsibility

Northern

Command

European

Command

Central

Command

Pacific

Command

Southern

Command

Special Operations

Command

Joint Forces

Command

Strategic

Command

Transportation

Command

Africa

Command

7

• 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/VA Healthcare System

Full Spectrum Healthcare

8

• 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%

Translates To…

AIR & SEA DISTANCES

AIR

7,000 MI

24 HOURS

SEA

8,600 MI

20+ DAYS

SEA

12,000 MI

26+ DAYS

10

Battalion Aid

Station

“Level 1”

In Theater

Hospital

“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”

Continuous En-route Care

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Overseas Medical Center

ASF

INTRA-THEATER INTER-THEATER

Definitive

Care

Theater Hospital

CASF

EMEDS

MASF Theater

Hospital Care

Forward

Resuscitative

Care

MASF

RCCET

& CCATT minus

Battalion

Aid StationFirst

Responder

Care

US Medical Center

Tactical AE Strategic AE

AE Crews

& CCATT

AE Crews

& CCATT

Continuous En-route Care:Stabilized… Stabilizing

CASEVAC/MEDEVAC

1 Hour

TACTICAL MEDEVAC/AE

1-24 Hours

TACTICAL/STRATEGIC AE

24-72 Hours

12

Force Health ProtectionBegins BEFORE You Step to the Jet!

• Deployment Medical Guidance

• Deployment Health Assessments• Pre and Post

• PDHRA after 90 and before 180 days

• Immunizations

• Chemoprophylaxis• CBRNE and Vector

• Occupational Environmental Health Surveillance

• Air, Water, Soil

• Food

• Occupational and Industrial Hygiene

• CBRNE

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• HMMV is struck and

disabled

T+ 00:00

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• Care Under Fire• Combat Application Tourniquet (CAT)

• Hemostatic Dressing

• Tactical Field Care• Hypothermia Prevention

• Combat Pill Pack

• Antibiotics

• Pain Control

• Combat Casualty Evac Care

“Correct Intervention At The Correct Time In The Continuum Of Combat Care!”

• Rapid Casualty Assessment (ABCs)

• Control Hemorrhage (CABs)

• Treat penetrating chest trauma

• Maintain airway

• Package casualty for transport

First Responder Care:

Tactical Combat Causality Care

15

• Taken to Forward

Surgical Care/Level II

• Arrival B/P 80

systolic

• Undergoes

exploratory

laparotomy: • Left Nephrectomy

• Splenectomy

• Packing of abdomen

• 8 units PRBC’s

• B/P 90’s systolic

T+ 00:25

16

MEDEVACMission

• Army

• Navy/AF/Coalition

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Forward Surgical Teams Shock Trauma Platoons

Level II: Forward Surgical/

Resuscitative Care

18

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

13

-No

v-07

13

-Feb

-08

13

-May-0

8

13

-Au

g-08

13

-No

v-08

13

-Feb

-09

13

-May-0

9

13

-Au

g-09

13

-No

v-09

13

-Feb

-10

13

-May-1

0

13

-Au

g-10

13

-No

v-10

13

-Feb

-11

13

-May-1

1

13

-Au

g-11

13

-No

v-11

13

-Feb

-12

13

-May-1

2

13

-Au

g-12

AV

ERA

GE

AG

E (I

n D

ays)

SHIPMENT ARRIVAL DATE (in Weeks)

Shipments: N= 92

Highest Average Age: 10.6 Days (03 Nov 2012)

Lowest Average Age: 3.7 Days (19 Apr 2012)

Average Age past 12 Months: 7.5 Days

Most Recent Shipments: 7 Nov 2012 - 8.2 Days

10 Nov 2012 - 6.4 Days

GOAL IS FOR RBCS TO ARRIVE AT

THE BTC WITHIN 7 DAYS OF

COLLECTION

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Fresher Blood is Better

Start of second

weekly flight to

theater and improved

efficiencies

2001: 30-42 Day RBCs, Saline 2013: < 21 day RBCs, plasma, platelets

19

ASWBPL-E

McGuire AFB

Ramstein

AFB

DoD Donor

Centers

Bagram AB

BSD

EMF

Kuwait

Kandahar

AB

BSD

Al Udeid AB

CENTCOM

379th

EBTC

Blood Lifeline

2001: 14 days

2013: 7.5 days

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• Arrives LV III Theater Hosp

• Cold

• Coagulopathic

• Acidotic

• Taken straight to OR

T+ 03:00

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Level II/III: Theater Expeditionary Hospitals

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Medical Support:Afghanistan

• Combat Casuality Care

• Forward Resuscitative

Surgical Care

• Coalition/Theater Hospitals

• MEDEVAC

• Tactical AE Hubs

• Strategic AE Hubs

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Injury Cause Trends:

Percentage of Total by Cause

51.1%

25.0%

8.7%

15.1%

EXPLOSIVE DEVICE

GSW

MVC

OTHER

THE “POWER” OF COALITION MEDICAL!

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• Re-explored

• Packed, surgical control

gained

• Urgent blood drive for

AB+ blood

• Patient warmed to 38

degrees

T+ 03:00 to T + 06:00

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• Transported to ICU

• CT scan of spine

• Completion of

resuscitation

• “Urgent” evacuation

request placed

T+ 06:00

NAVY

MEDCENS

SERMC

DDEAMC

GPRMC

BAMC

PRMC

TAMC

Air Force

MEDCENS

WRMC

MAMC

NARMC

WAMC

WRAMC

ERMC

LRMC Germany

Iraq

Kuwait

Afghanistan

Overflow Exams/Medevac

Workflow/workloads

Radiologist

LEGEND

18th MEDCOM

121st General Hospital

-

JOINT THEATER SUPPORT:

TELEMEDICINE & TELERADIOLOGY

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T+ 10:00

• CCATT team alerted

• Patient prepared for transport

• C-17 arrives from Germany

• Cargo unloaded

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Aeromedical Evacuation

Cargo In…

…Patients Out!

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MASF/CASF

• Mobile Aeromedical

Staging Facility (MASF)• Mobile 24hr staging at tactical

airheads

• Rapid response staging

• Contingency Aeromedical

Staging Facility (CASF)

• 24hr staging at strategic

airheads

• Support to Theater Hospital

• Transport to AE aircraft

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Tactical AE: Intra-theater

Hub & Spoke• C-130/NATO

• Opportune A/C

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Garmabak

Chaghcharan

Qal’eh-ye Now

Meymaneh

Keleft

Jeyretan

Sar-e PolSamangan

Pol-e Khomri

Taloqan

Feyzabad

Eshkashem

Charikar

Farah

Delaram

Lashkar

Gah

Herat

Bamian

Shindand

Zaranj

Baghlan

Spin Boldak

Baghran

Balkh

JacobabadShamsi

Mazar-e-Sharif

Baraki

Ghazni

Gardez

Jalalabad

Khowst

Konduz

Shir Khan

Shkin

Orgun-eDeh Rawod

Geresk

Qalat

Bagram

Kandahar

Kabul

Karshi Khanabad

Miram Shah

Tarin Kowt

Termez

Strategic AE: Inter-theater

GE

GE

UK/GE

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Global Patient Movement

16613145 47 56 52 48 56 48 4740

643 703 745 812 752827

271242257 318261 303 238 320 251297276303313

3135 31

41

721 779698

653

686728614

896977

802865

881865

884843

877

946

720

878804

0

500

1000

1500

2000

2500

3000

Pa

tie

nt

Mo

ve

me

nt

Re

qu

es

ts

CCATT TMS

CCATT PTS#

CENTCOM

EUCOM

NORTHCOM

SOUTHCOM*

PACOM

Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

49 36 44 49 52 51 64 54 77 34 53 76 64

71 55 76 91 83 84 117 87 113 53 87 115 103

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AE:

Lifeline Home

CENTCOMScottAndrews

Ramstein

EUCOMTravis

Kadena

PACOMHickam

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• CCATT arrives at

ICU

• CCATT moves

patient to AMBUS

to flight line

• Patient loaded for

flight

T+ 10:00

36

“FLYING ICUs”

Critical Care Air Transport

37

Transforming

Combat Casualty Care

Body Armor/Tactical Combat Casualty Care/

Damage Control Surgery & Resuscitation/CCATT

05

1015202530354045

Rev

War

War

of 18

12

Civil W

ar

WW

I

WW

II

Kore

a

Viet Nam

Gulf W

ar I

OEF/O

IF

Wartime US Lethality Rate (%)

38

Impact of DoD Trauma System: 2005 – 2013

Data from US Joint Trauma System (JTS)

39

• Patient loaded for flight

• 7 hour mission to Germany

• AMBUS transfer to Landstuhl

Regional Medical Center, Germany

T+ 12:00

40

• Taken to OR

• Re-explored/wash outs

T+ 24:00

41

• Patient transferred to

Walter Reed National

Capital Region with

CCATT team

T + 48:00

42

“TEAM MEDICS”

VA DoD

COMMUNITY

43

Aw

es

om

e (

z)

Time (t)

“Great Ideas” as a Function of TimeWorld War I

• IV fluids

• Blood transfusions

• Motorized ambulances

• Topical antisepsisWorld War II

• Whole blood/plasma available

• Specialty-specific surgical

groups

• Antibiotics

• Fixed wing aeromedical

evacuationKorean Conflict

• Improved fluid resuscitation

• Forward availability of definitive

surgery

• Helicopters for patient

evac/transport

• Primary repair/grafts for vascular

injuryVietnam

• Improved use of helicopters

• Improved laboratory support

• Portable radiology equipment

• Mechanical ventilators in theater

Desert Shield/Storm

• Burn team augmentation of

evacuation hospitals to provide

theater-wide burn care

• Intercontinental aeromedical

transport of burn patients

GWOT/OCO

• Military trauma system (JTTS/JTTR)

• Improved tourniquets

• Hemostatic agents

• Common use of external fixators

• “Damage control” resuscitation

• “Damage control” surgery

SUMMARY: CONTINUUM OF CARE INTEGRATED “JOINT/COALITION” SYSTEM of SYSTEMS

The “why”…

…we do what we do!

…the “Why Not”

There’s No Coming Home….

…Without you!

Study hard…focus on the patient...

and we’ll see you on the High Ground!