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Eating Soup with a Knife - Evolving En Route Care Clinical Practice Tamara Averett-Brauer, MN, RN, DR-III, Civ, USAF Colonel (Ret), USAF, NC, CFN Core Research Competency Lead -- En Route Care/Expeditionary Medicine USAFSAM Deborah L. Willis, MS, RN, Major, USAF, NC, FN FN/AET Instructor, USAFSAM HQ AMC/SGK: Colonel Andrea K. Gooden Lieutenant Colonel James S. Speight, III Ms Lisa D. DeDecker Disclosures • The presenter has no financial relationships to disclose. • This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with AMSUS. • Neither PESG, AMSUS, nor any accrediting organization support or endorse any product or service mentioned in this activity. • PESG and AMSUS staff has no financial interest to disclose. • Commercial support was not received for this activity. Learning Objectives: At the conclusion of this activity, the participant will be able to: a. Recognize the research continuum and how it contributes to the clinical policy. b.Identify specific translational research put into practice today. c. Discuss future research projects targeting clinical gaps. How do we know what needs research? • Strategic Guidance • Requirements • AFMS Research Thrust Areas • Clinical Inquiry Process • AF Research Execution Wings • Doing the hard work Strategic Guidance U.S. Defense 3rd Offset Strategy Line • DoD • AF Service Core Functions Medical AF Future Operating Concepts • MHS / Joint Joint Concept for Health Services • DHA, Joint Staff Surgeon • AF: SG; SG5 • MEFPAKs/MAJCOMs • Rapid Global Mobility • Command and Control • Agile Combat Support • ACC, AMC, AFSOC • AETC, PACAF, USAFE • MAJCOMs • AMC, ACC, AFSOC, AETC • AFRL AF Service Core Functions AFMS Trusted Care CONOPS Requirements • Gaps (Integrated Capabilities List) • 2015 Air Force Medical Service (AFMS) Capabilities Based Assessment (CBA) • MAJCOMS, MEFPAKS • Portfolio Managers / Research Area Managers • Time Sensitive Operational Needs Optimal Time to Transport / Effects of Flight Research Capabilities Assessment (RCA) En Route Care Research Research Development Document (RDD) Patient Safety Research Research Development Document (RDD) AF SG Modernization/Research Thrust Areas 1. Force Health Protection (FHP) • Prevention of injury/illness and the early detection of emerging threats. 2. En Route Care (ERC/EC) • Continuum of care during transport of patients from point of injury to point of definitive care. 3. Operational Medicine (OM) /In-Garrison Care • Providing definitive patient care/treatment in-garrison. 4. Human Performance (HP) • Enhancing performance of Airmen in challenging environments. 5. Innovations (rolled into Operational Medicine) • Identify, evaluate, and develop novel concepts, new processes, or disruptive technologies. 6. Expeditionary Medicine (EM) • Improving care during contingency operations; and medical countermeasures against combat/operational stressors. Clinical Inquiry Process YES Apply Evidence EBP Project Evidence in Literature Clinical Question (Gap) Evaluate Quality of Practice Change NO Create Evidence Research Project Translate Evidence to Practice AFMS Research Execution • Validated Need (Gap) • Proposed Solutions • Impact, Cost, Priority/Relevance, Transition/Translation Plan • Implementation – Research Programs/Projects • Proposal, Scientific/Technical Methods, Data Collection, Analysis • Deliver Results – Capability, Device, Practice Guidelines, Evidence • Research Execution Wings • 59 MDW • 711 HPW • Corporate Oversight – • HQ AF/SG5, MRAWG, RTAB, Portfolio Managers 59th Medical Wing, Texas • Office of the Chief Scientist / Science & Technology • • • • • • • Vision: Grow Medical Leaders, Drive Innovations in Patient Care and Readiness Clinical Investigations & Research Support Diagnostics & Therapeutics Program Center for Advanced Molecular Detection Nursing Research Dental Research Trauma & Clinical Care Research Program • • • • • • En Route Care Research Center Extracorporeal Life Support Vascular Injury and Forward Damage Control Surgery Restorative and Reconstruction Research Trauma, Hemostasis & Resuscitation Research Immune Modulation Research 711th Human Performance Wing, Ohio Part of the Air Force Research Laboratory (AFRL) • Airman Systems Directorate (RH) • Human Systems Integration Directorate (HP) • USAF School of Aerospace Medicine (USAFSAM) • • • • • • Office of the Dean (ED) International & Expeditionary Education & Training (ET) Aerospace Medicine (FE) Occupational & Environmental Health (OE) Preventive Medicine & Public Health (PH) Aeromedical Research Department (FH) • En Route Care Research Division (FHE) • Operational Medicine Research Division (FHO) • Human Performance (HP) and Force Health Protection (FHP) Research • Applied Technology and Genetics Center (FHT) • Research Support Division (FHS) Doing the Hard Work • Work with Stakeholders / Champions • JPC, SG Portfolio Managers, MEFPAKS (AMC) • Proposal Writing • Abstract; Background; Military Relevance; Technical Program Summary/Methods; References; Milestones/Deliverables; Facilities/Equipment/Experience; Subcontracts; Cost Proposal; Biosketches of Investigators; Letters of Support; Quad Chart • Scientific/Technical Reviews • Methods, Sample Sizes, Statistics, Data Analysis • Resource Requirements • Funding, Personnel, Equipment, Aircraft/Chamber Test Plans • Research Protection Program • Institutional Review Board (IRB) / Institutional Animal Care & Use Committee (IACUC) • Get Funded • Do the work! • Tell the story -- Disseminate findings Finding Funding – DHP Sources • Joint RDT&E • Defense Medical Research and Development Program (DMRDP) • Joint Program Committees (JPC) 1 – Medical Simulation Training & Informatics 2 – Military Infectious Disease 5 – Military Operational Medicine 6 – Combat Casualty Care 7– Medical Radiological Defense 8– Clinical & Rehabilitative Medicine 9 – Advanced Development • Joint DHP Small Business Innovation Research (6.1-6.3a) • Air Force • RDT&E (Research, Development, Test & Evaluation) • O&M (Operations & Maintenance) • 59 MDW Clinical Investigations • 711 HPW Studies & Analysis • Other • Congressionally Directed Medical Research Program (CDMRP) • Joint Warfighter Medical Research Program (JWMRP) Types of DHP RDT&E Funding 1. Basic Research • Attaining greater knowledge and understanding of fundamental principles of science and medicine. 2. 3. Applied Biomedical Research Technology • Refinement of concepts and ideas into potential solutions with a view toward evaluating technical feasibility. Medical Technology Development • Development of candidate solutions and components of early prototype systems for test and evaluation, including support of early stage clinical trials. • 6.3a Advanced Technology Development / 6.3b Demonstration & Validation 4. Advanced Component Development • Clinical trials for FDA licensed products and accelerated transition of FDA regulated and non-regulated products and medical practice guidelines to operational users through clinical and field validation studies. 5. 6. Medical Systems Development • Development of demonstration of medical commodities prior to initial full-rate production and fielding, including initial operational test and evaluation and clinical trials. Management Support • Infrastructure and civilian salary support. 7. Medical Systems Sustainment Activities • Pre-planned product improvement of fielded medical products and evaluation of the effectiveness of fielded products, therapies, treatments, or medical guidelines. So….What does this mean for En Route Care? Where have we been? Where are we going? • History – Advances in En Route Clinical Care • Here we are … 2016 • What has changed? • What’s the next step? Advances in En Route Clinical Care • Where it all began?? • The 1st part of the 20th Century, as the concept of fixed wing aircraft flight became a reality, so did moving wounded by air. • Prior to WWI – little to no advancements • WWI – began to see the need for moving patients by air and realized the need for specially designed aircraft • By the end of WWI (1918), the Curtis JN-4 “Jenny” was modified for air transport of wounded • In 1922, the US converted a Fokker F-IV into an “Air Ambulance” • In 1928, the USMC in Nicaragua developed what we now call “retrograde AE” • But…..the leading nurses in the Red Cross and the Army NC were not interested!! Advances in En Route Clinical Care • At the beginning of WWII, AE was considered dangerous, medically unsound and militarily impossible. • The Army SG did not feel it was a substitute for field ambulances • The 3rd AF (Lt Col Malcolm Grow) was willing but until the Army agreed there would be no progress • War has a way about changing minds…..by 1942 10,000 casualties had been moved on the C-47 from the Pacific Theater to CONUS • In 1942, Lt Col David Grant, advocated for AE and for specially trained personnel • In Feb, 1943, the first class of flight nurses graduated from Bowman Field, KY after a 4 week course in flight physiology, survival and loading procedures • At its peak, the US evacuated almost 100,000 casualties per month; in 1945, the 1-day AE record was set at 4704 patients Advances in En Route Clinical Care • Korea and Vietnam saw increasing dependence on AE as C-54 both field medicine and AE evolved in planning and complexity • The C-54, C-46 and C-47 were used as retrograde AE aircraft in Korea • In the first 6 months of the war over 30,000 were evacuated • AE contributed to a decreased death rate of the wounded which was 50% less than seen in WWII C-54 • Vietnam initially used the C-118 and C-130 Cargo aircraft until the C-141 came on the scene in 1965 • By 1969, MAC evacuated an average of 11,000 casualties per month • The C-9A was brought on board in 1968 and the USAF AE system remained relatively stable until our recent operations Here we are…2016 • Just short of 100 years of AE under our belts • Conflict in CENTCOM began in 2003 • Since 2003 we have had an explosion of changes to the AE system • Operational changes which we will not discuss in this briefing • Clinical changes - both lessons learned and evidence based practice • More evidence is needed in many areas • Let’s look at a few of our clinical changes………. How the World has Changed • From stable to stabilized to stabilizing with the advent of critical care transport teams • For AE, a new way to look at old practices, a better way to care for our patients and an improved way to train for the next war En Route Critical Care TCCET BAS Wounde d Self Aid & Buddy Care First Responder Continuous TCCET Forward Surgical teams Forward Resuscitati ve IncCraepaabsielityin Level Time CSH, EMEDS, Fleet Definitive Care Theater Hospitals of Care Provided What has changed? • Heimlich Valves • Used for 50 yrs. on all chest tubes preventing backflow of drainage into the chest • As we moved from stable to stabilized, what drains from the chest also changed • No longer serous, it became primarily blood products • Blood clots – serous does not • Several patients with tension pneumothorax due to clotted Heimlich valves What we did Selected a chest drainage system with an integral valve, preventing backflow, eliminating the Heimlich Valve What has changed? • Enteral feedings • Continuous enteral feedings not allowed due to the risk of aspiration • All tube feedings were stopped for AE • New research on burn patients showed the earlier you started tube feedings and re-started the GI system, the better the recovery of the patient • What we did • Talked with GI, CC, Burn consultants for the Army and AF • Identified critical steps to allow for safe feedings to the patient • Published a policy letter allowing feedings if criteria were met What has changed? • Pain Control • Prior to this conflict oral and IM used almost exclusively • Poor pain control for our wounded • Standard of care on the ground used IV/PNB/Epidural • What we did • Started a massive training program to train all AECMs on pain control • • • • • • • Use of pain scales and how to apply them IV instead of IM pain medication Peripheral Nerve Blocks and how to care for the patient Epidural catheters for pain control and how to care for the patient Use of pulse oximetry Other adjuncts for pain control High-risk medication requires 2-person validation What has changed? • Position of the head of the litter aft • Configuration guidelines stated the head of the patient is always to the aft of the aircraft • What we did • Limited scope research project showed the g-forces of take-off increases intracranial pressure • Identified this can be mitigated by loading the patient with the head of the patient towards the front of the aircraft • The critical care physician decides how the critical care patient should be loaded What has changed? • Balloons of ET tubes and urinary catheters were filled with saline to mitigate the affects of altitude on air • What we did • Research showed that filling ET tubes with fluid did more damage to the trachea than those filled with air. • It is impossible to remove all air bubbles of the fluid and those will expand • By using a cuff pressure monitor, ET balloons are filled with air and the minimal leak technique is used to avoid tissue trauma • Urinary catheters can be filled with saline as they are not associated with tissue damage in the bladder What has changed? • Hemoglobin - Below 8 could not be moved • What we did • Evaluate underlying cause, is it chronic and acute • Blood products for acute plus continuous oxygen ordered • Chronic has likely compensated – PRN oxygen order What has changed? • Myocardial Infarction must wait 10 days before movement • What we did • No research to support this, infuse thrombolytics if indicated • TVFS will decide when it is appropriate to move the patient What has changed? • No standardized call criteria to alert the trauma team at the destination MTF • What we did • Reviewed current civilian call criteria for EMS • Developed a standardized Rapid Response Criteria checklist for AE What has changed? • No standardized hand-off format • What we did • Researched current hand off tools and how they could or could not fit the AE mission • Modified a current hand off tool for AE • Fielded the ISBAR format for use in AE What has changed? • Paper documentation. DoD was directed to go paperless to create a longitudinal medical record • What we did • Launched the AE EHR • The AE EHR is operational at key operational hubs • Yes, it still has a long way to go! What has changed? • No standardized prophylaxis for DVT • Several pulmonary embolisms manifested during AE • Unprecedented in the age group we were moving • What we did • Developed and fielded a CPG for prevention of thromboembolism What has changed? • No contagious patient movement capability • The USAMRIID Airborne Isolation Team was disbanded • USAF CCATTs picked up the mission • What we did • PIU developed and fielded • TIS developed and fielded What has changed? • No standardized guidelines for SAM patients • Difficult to identify who should or should not self administer • No documentation of patient education • No standardized amounts of medication • What we did • Developed and coordinated a policy to allow for self medicating patients • Included patient education • Physician approval required • Re-evaluated at each stop What’s the next step? En Route Care Research at 711HPW En Route Car e Resear ch Division Aeromedical Research Depar tment Cleared, 88PA, Case # 2016-3951, 9 Aug 2016. • Impact of Transport • Patient Safety • En Route Clinical Care • Medical Technologies / Clinical Validation • Training & Simulation Continuum of Care En Route Care (EC) Expeditionary Medicine (EM) Point of Injury (Role I) Far Forward Care (Role II) Theater Level Care (Role III) Definitive Care (Role IV) http://www.defense.gov/DODCMSShare/NewsStoryPhoto/201105/hrs_110506-D-6666M-444.JPG Impact of Transport • Provider Impacts • Moral Distress in CCAT Nurses: Phenomenological Exa mination • Fatigue • Patient Impacts • Assessment of Aeromedical Evacuation Transport Pati ent Outcomes with and without Cabin Altitude Restriction (CAR) • Quantifying C-130 Patient Vibration Patterns • Hypobaric Exposure Timing after TBI: Targeted Modulation to Improve Outcomes • Aeromedical Evacuation (AE) of Military Working Dogs (MWD) • Hypobaria • Effect of Hypobaria during Sepsis on Survival, Encephalopathy, and Energy Metabolism • Hypoxia • Hypoxemia during Aeromedical Transport of the Walking Wounded: Determining the Etiology and Incidence of Hypoxemia Patient Safety • Regulated Aeromedical Evacuation – A Retrospective Database • e.g. Aeromedical Evacuation Registry (AER) • En Route Patient Staging System (ERPSS): Translating Competencies • Evaluation of Handoff Outcomes in a Multi-site Continuum of Care Exercise (I-SBAR) • Risk Factors for Pressure Ulcer Development in CCATT Patients • Assessment of Pain in AE http://www.defense.gov/news/newsarticle.aspx?id=63808 Biomarkers and Decision Support Validation of Prototype Continuous Real Time Vital Signs Video Analytics Monitoring System “CCATT Viewer” Viewer 2.0 (Updated Viewer) En Route Clinical Care • CPGS • Based on Solid Evidence • Pain Management in the AE Environment • ERPSS • Intercostal Liposomal Bupivacaine for the Management of Blunt Chest Trauma http://www.defense.gov/DODCMSShare/NewsStoryPhoto/201105/hrs_110506-D-6666M-444.JPG • Effect of Fluid Resuscitation Strategy during En Route Care on Acute Lung Injury after Hemorrhage and Burn Injury • Development and Usability of a Mobile Pain Assessment Application (App) for En Route Care Medical Technologies / Clinical Validation of Equipment • Closed Loop Control • Oxygen / Ventilation / Fluid Management • Evaluation of Mechanical Ventilator Use w/ Liquid Oxygen Systems • Device Testing -- In hypobaric environment • Evaluating the Usefulness of Noise Immune Stethoscope (NIS) Technology in the Aeromedical Evacuation (AE) and Critical Care Air Transport (CCAT) Simulated High Ambient Noise (C-130) Environment NoiseImmune Stethoscope Photo from Thinklabs website with permission from manufacturer Training & Simulation • How to best train to achieve objectives • Training Gap Analysis of Active Duty AE Techs/Nurses Using Simulation • Features of Simulation • Simulation Practices Assessment for Active Duty AE Sustainment Training • Standardized Debriefing Process for Cadre and Impact on CCAT Advanced Course Student Performance • Learning Styles, Teaching Methods • CCATT Nurse Performance Prediction: Application of a Cognitive Model to Mitigate Skill Decay Using Simulation • Types of simulation • Synthetic/Immersive Environments, Augmented Reality, Serious Medical Games • Aircraft Simulators – Cargo Compartment Trainers, Fuselage Trainers • Building a Program of Research for Simulation in AE/CCAT System There’s so much more….. • Working with others • Army, Navy, Coast Guard • International Partners • University and Industry Partners • What we don’t know….. • Future requirements, operating environments • Distances, platforms, mechanisms of injury/illness • Cellular/molecular impacts of hypobaria, hypoxia • Technologies • • • • • Telemedicine/ Tele-mentoring, Remote Monitoring, Human-Machine Teaming EHR -- Voice to Text, Continuous Monitoring w/Decision Support, Wearable Sensors Nanotechnology, Semi/Autonomous Transport Robotics, Machine Learning Techniques Tricorder….? Suspended Animation….? Clinical Inquiry Process YES Apply Evidence EBP Project Evidence in Literature Clinical Question (Gap) Evaluate Quality of Practice Change NO Create Evidence Research Project Translate Evidence to Practice Learning Objectives: a.Recognize the research continuum and how it contributes to the clinical policy. b.Identify specific translational research put into practice today. c.Discuss future research projects targeting clinical gaps. Obtaining CME/CE Credit If you would like to receive continuing education credit for this activity, please visit: http://amsus.cds.pesgce.com Additional info if time permits • Pressure Ulcers • Our litter patients are at risk for pressure ulcers • The original orange AE mattress did little to mitigate pressure ulcer concerns • What we did • Researched and developed new litter mattress using technology designed for operating room tables • Procured new black mattresses and disposed of old orange mattresses • New medications • Phenergan changed out for Zofran – faster effect with less sedation • Dramamine changed out for Meclizine – • No communication tools to facilitate crew to crew or crew to patient communication • Researched, developed and fielded the AWIS for AECMs • ASF, MASF, CASF – legacy planning factors • ERPSS building block approach to patient staging much like EMEDS