Gina R. Dorlac

Air transport of patients with severe lung injury: Development and utilization of the acute lung rescue team

BACKGROUND Critical Care Air Transport Teams (CCATTs) are an integral component of modern casualty care, allowing early transport of critically ill and injured patients. Aeromedical evacuation of patients with significant pulmonary impairment is sometimes beyond the scope of CCATT because of limitations of the transport ventilator and potential for further respiratory deterioration in flight. The Acute Lung Rescue Team (ALRT) was developed to facilitate transport of these patients out of the combat theater. METHODS The United States TRANSCOM Regulation and Command/Control Evacuation System and the United States Army Institute of Surgical Research Joint Theater Trauma Registry databases were reviewed for all critical patients transported out of theater between November 2005 and March 2007. Patient demographics, diagnosis, and clinical history were abstracted and ALRT patients were compared with CCATT patients. RESULTS The ALRT was activated for 11 patients during the study period. Five patients were transported as a result of these activations. Trauma-related diagnoses were responsible for 82% of these requests. ALRT missions comprised 0.6% of all critical patient movements out of the combat theater and 1% of ventilator transports. Average FIO2 was 0.92 +/- 0.11 for ALRT patients and 0.53 +/- 0.14 for CCATT patients (p = 0.005). ALRT patients required a mean positive end expiratory pressure of 19.0 cm H2O +/- 2.2 cm H2O compared with 6.5 cm H2O +/- 2.4 cm H2O in the CCATT group (p = 0.002). CONCLUSIONS Lung injury in the combat theater severe enough to exceed the capability of CCATT transport is uncommon. Patients for whom ALRT was activated had significantly higher positive end expiratory pressure and FIO2 than those transported by CCATT. One-fourth of patients for whom ALRT was considered died before the team could be launched; transport may have been a futile consideration in these patients. Patients with even severe acute respiratory distress syndrome can be successfully transported by experienced, equipped specialty teams.

Intercontinental aeromedical evacuation of patients with traumatic brain injuries during operations Iraqi Freedom and Enduring Freedom

Traumatic brain injury contributes significantly to military combat morbidity and mortality. No longer maintaining comprehensive medical care facilities throughout the world, the US military developed a worldwide trauma care system making the patient the moving part of the system. Life-saving interventions are performed early, and essential care is delivered at forward locations. Patients then proceed successively through increasingly capable levels of care culminating with arrival in the US. Proper patient selection and thorough mission preparation are crucial to the safe and successful intercontinental aeromedical evacuation of critical brain-injured patients during Operations Iraqi Freedom and Enduring Freedom.

Critical care at Landstuhl Regional Medical Center.

BACKGROUND Landstuhl Regional Medical Center is the largest U.S. medical facility outside the United States, and it is the first permanently positioned hospital outside the combat zone providing care to the wartime sick and wounded. As of November 2007, Landstuhl Regional Medical Center personnel have treated over 45,000 patients from Operations Enduring Freedom and Iraqi Freedom. The current trauma/critical care service is a multidisciplinary, intensivist-directed team caring for a diverse range of clinical diagnoses to include battle injuries, diseases, and nonbattle injuries. Admissions arise from an at-risk population of 500,000 widely distributed over a geographic area encompassing three continents. DISCUSSION When compared with 2001, the average daily intensive care unit census has tripled and the patient acuity level has doubled. Combat casualties account for 85% of service admissions. The clinical practice at this critical care hub continues to evolve as a result of wartime damage control trauma care, robust critical care air transport capabilities, length of stay, and other unique factors. The services focus is to optimize patients for an uneventful evacuation to the United States for definitive care and family support. SUMMARY Successful verification in 2007 as an American College of Surgeons level II trauma center reflects a continuing institutional commitment to providing the best possible care to the men and women serving our nation in the global war on terror.

Effects of Simulated Altitude on Ventilator Performance

BACKGROUND Aeromedical transport of critically ill casualties requires continued safe operation of medical equipment at altitude. We evaluated performance of two ventilators in an altitude chamber. METHODS Two ventilators used by the United States Air Force (USAF) Critical Care Air Transport Teams were operated in an altitude chamber at barometric pressure of 754 mm Hg, 657 mm Hg, 563 mm Hg, and 428 mm Hg simulating altitudes of sea level, 4,000, 8,000, and 15,000 feet. At each altitude ventilators were set to deliver three tidal volumes (VT) from 0.25 L to 1.0 L. Airway pressure, timing, flow, and volumes were measured every breath. Measured parameters included VT, positive end-expiratory pressure (PEEP), inspiratory time, expiratory time, inspiratory flow, peak inspiratory pressure, expiratory flow, and respiratory rate. RESULTS The Impact 754 compensated for changes in altitude maintaining the set VT within 10% of the sea level VT. Tidal volume delivery of the 754 was less precise during operation of the compressor at an inspired oxygen concentration of 0.21. With each increase in altitude, the LTV VT increased. At 8,000 feet VT increased by 10% and at 15,000 feet VT increased by 30% (p<0.001). Respiratory rate was not affected by altitude with either device. CONCLUSIONS The Impact 754 compensates ventilator output to deliver the desired tidal volume regardless of changes in altitude and barometric pressure. The LTV-1000 does not compensate for changes in altitude resulting in delivery of increasing tidal volumes with falling barometric pressure. Clinicians should be aware of ventilator performance and ventilator limitations to provide safe and effective ventilation during transport.

Assessment of emergency general surgery care based on formally developed quality indicators

Background. Emergency general surgery outcomes vary widely across the United States. The utilization of quality indicators can reduce variation and assist providers in administering care aligned with established recommendations. Previous quality indicators have not focused on emergency general surgery patients. We identified indicators of high‐quality emergency general surgery care and assessed patient‐ and hospital‐level compliance with these indicators. Methods. We utilized a modified Delphi technique (RAND Appropriateness Methodology) to develop quality indicators. Through 2 rankings, an expert panel ranked potential quality indicators for validity. We then examined historic compliance with select quality indicators after 4 nonelective procedures (cholecystectomy, appendectomy, colectomy, small bowel resection) at 4 academic centers. Results. Of 25 indicators rated as valid, 13 addressed patient‐level quality and 12 addressed hospital‐level quality. Adherence with 18 indicators was assessed. Compliance with performing a cholecystectomy for acute cholecystitis within 72 hours of symptom onset ranged from 45% to 76%. Compliance with surgery start times within 3 hours from the decision to operate for uncontained perforated viscus ranged from 20% to 100%. Compliance with exploration of patients with small bowel obstructions with ischemia/impending perforation within 3 hours of the decision to operate was 0% to 88%. For 3 quality indicators (auditing 30‐day unplanned readmissions/operations for patients previously managed nonoperatively, monitoring time to source control for intra‐abdominal infections, and having protocols for bypass/transfer), none of the hospitals were compliant. Conclusion. Developing indicators for providers to assess their performance provides a foundation for specific initiatives. Adherence to quality indicators may improve the quality of emergency general surgery care provided for which current outcomes are potentially modifiable.