En Route Critical Care Evacuations From Rarely Utilized Partner Medical Treatment Facilities: A Case Series With Lessons Learned Free

ABSTRACT

Retaining lessons learned from Critical Care Air Transport (CCAT) missions is essential given the recent decrease in operational currency among CCAT personnel. The objective of this case series was to identify and analyze logistical lessons learned from recent critical care transports involving foreign medical treatment facilities with sufficient detail for the CCAT community to incorporate these lessons into future readiness and sustainment training. The provider from each mission submitted a mission narrative with lessons learned. A qualitative analysis of lessons learned described themes from the lessons, as well as similarities and differences from included missions. Three missions were reviewed and four distinct mission stages were identified: (1) pre-mission, (2) at U.S. aircraft, (3) away from U.S. aircraft, and (4) post-mission. Pre-mission lessons learned included the need for professional civilian attire for deployed CCAT teams and the limited availability of pre-mission clinical information. Lessons learned at the aircraft included the following: the need for flexible mission timelines, coordinate and pre-plan transitions with foreign medical teams when possible, and plan for difficult environmental conditions if flight line transfer is required. Lessons learned away from the aircraft included communication challenges between CCAT and the aircraft, contingency planning for narcotic transports, and equipment interoperability issues. Post-mission lessons learned included the need for written communication to disseminate information to the CCAT community. This case series described logistical challenges that present during transport missions involving foreign hospitals. This published series will enable dissemination to the en route care community for possible incorporation into future training.

INTRODUCTION

The collective experience of the Critical Care Air Transport (CCAT) community is decreasing and their readiness is at risk from the “peacetime” effect: a well-documented phenomenon that involves an insidious erosion of the skills needed to manage the first casualties of the next war.¹ Retaining lessons learned from CCAT missions is critical to preparing for future operations.^2,3 While other medical and surgical lessons learned from this era have been captured within the Joint Trauma System (JTS), the logistical and unique challenges overcome by CCAT members to sustain safe transport remain largely undocumented.⁴ Collating and teaching lessons learned from actual missions will improve operational knowledge and result in more relevant readiness and sustainment training. This requires a systematic effort to collect these experiences as the number of experienced personnel in active military service has drastically declined due to low transport volumes since 2014.⁵

In this case series, we identified and analyzed logistical lessons learned from recent critical care transports involving foreign hospitals. The intent of this study was to provide sufficient detail from these missions for the CCAT community to incorporate these lessons into future readiness and sustainment training.

METHODS

This is a case series from a rarely encountered subset of en route critical care missions involving foreign partner treatment facilities during evacuation. Each mission described was conducted by one of the authors who provided a narrative summary of the mission and lessons learned after analyzing the experience. All authors reviewed and edited the mission summaries and lessons for clarity. Locations and units were removed as per JTS quality improvement practices for operational security. A qualitative analysis of the lessons learned verbiage produced a description of relevant themes from the lessons, including similarities and differences from these missions, which were categorized by four mission stages: (1) pre-mission, (2) at the U.S. aircraft, (3) away from the U.S. aircraft, and (4) post-Mission. The protocol was reviewed by the U.S. Air Force 59th Medical Wing Institutional Review Board and determined to be non-research.

RESULTS

Case 1

A CCAT team was alerted to evacuate an active duty male with hypoxic brain injury following a drowning incident that would require transport to a Role IV military treatment facility (MTF) for continued critical care. Limited clinical information was contained within the patient movement request, and efforts to perform a pre-flight patient handoff were not successful. After landing on a U.S. base in a foreign country, a flight surgeon briefed the CCAT team that the patient was found face down in a swimming pool and received bystander cardiopulmonary resuscitation. After emergency response activation, the patient was transported to a local emergency room where he was intubated, stabilized, and transferred to a foreign hospital’s intensive care unit (ICU).

The hospital was approximately a 45-minute drive from the U.S. base. The first challenge encountered was that the host nation customs did not permit CCAT to enter the country with their controlled substances; CCAT was therefore unable to carry any sedation or pain medications. After arriving at the hospital, the second challenge was discovering that the patient was 8 hours into a 24-hour therapeutic hypothermia protocol; due to an ambient outside temperature of 118°F, the team’s clinical judgment was that this protocol could not be maintained en route. After consultation with the Role IV intensivist, neurosurgeon, and the foreign hospital intensivist, it was decided to delay the evacuation by 24 hours. The third challenge was imposed by the foreign emergency medical service (EMS) when they insisted on using their own equipment to transfer the patient from the hospital to the aircraft. This created a complex “tail-to-tail” transfer from the EMS platform to the standard military litter with associated patient movement items (PMIs) in an outdoor environment with extreme wind and heat conditions. In addition, many items that were used by the EMS team were incompatible with CCAT’s equipment and required replacement. Finally, CCAT had to rely on narcotic and sedation medications that were supplied by the sending hospital. After the mission, CCAT coordinated with the base aeromedical evacuation liaison team who traveled to the foreign country to improve conditions and relationships for future missions to this region. Notably, the patient showed purposeful brain function in-flight and later had a good neurologic outcome enabling him to return to duty.

Case 1—Lessons learned

1. Limited pre-flight clinical information will hinder mission planning.

2. CCAT-controlled substances may not be permitted through customs. In such cases, CCAT teams need to know the required amounts of narcotic and sedation that will be required for the patient transport, with an appropriate margin for safety.

3. At the beginning of their deployment, CCAT teams should inquire regarding the process for transporting controlled substances through customs for countries within their area of responsibility. In areas where CCAT is not allowed to transport these medications, teams should seek early discussions with U.S. liaisons to determine whether standing agreements can be created to exempt CCAT operations from these requirements.

4. Role IV MTFs serve a critical function as synchronous telemedicine resources to help make complex medical decisions.

5. Foreign health systems may require the use of their own equipment when engaged in patient care resulting in equipment incompatibilities and complicated patient transfers. Consideration should be given in advance to formalize agreements with foreign EMS on this logistical process.

Case 2

A Tactical Critical Care Evacuation Team (TCCET) was alerted that an adult active duty male fell from a truck sustaining a traumatic brain injury with loss of consciousness. The evacuation team decided to transport the patient to a foreign hospital to obtain CT imaging and assess for the need of neurosurgical intervention.

The patient was airlifted from a U.S. forward MTF to a foreign airport. Next, the foreign emergency medical system (EMS) was engaged to assist in transport to the hospital. The first challenge noted was that the military stretcher was not compatible with the foreign EMS litter. Second, the TCCET needed to be split, and only one member was permitted on the civilian ambulance. Combined, these two challenges would have posed significant safety concerns if the patient were critically ill. The accompanying TCCET member wore civilian clothes based on the strong recommendation from the embassy liaison. Additionally, TCCET members were not permitted possession of their weapons off the aircraft. Naïve estimates predicted a travel time of 30 minutes. However, EMS later stated that airport transports sometimes require 2 hours depending on the time of day and traffic. Therefore, oxygen requirement estimates could have been insufficient.

On arrival, the member provided a verbal handoff to the accepting care team at the foreign hospital. This conversation enabled clarifications of the mechanism of injury and desired plan of care. A diplomatic passport was needed to process through customs. The single TCCET member accompanying the patient had no means of communication with personnel at the aircraft throughout the transport, thus lacking proper mitigation for the security of an isolated personnel in a foreign country.

Following this mission, an after-action review (AAR) was sent to the TCCET’s command surgeon cell who helped recognize the communication gap and facilitate additional communication equipment to close this gap for future missions. TCCET members were told of near-identical issues from prior missions to this foreign hospital, to include delays from patients being sent to the wrong hospital. The AAR process from prior experiences was insufficient to alert future teams to these issues.

Case 2—Lessons learned

1. Be prepared to split the en route care team for ground transport.

2. Communication equipment and plan for the members leaving the aircraft should be in place before the mission.

3. Military litter systems are often not compatible with EMS stretchers.

4. TCCET and CCAT teams secure PMI to the military litter. If litter non-compatibility is encountered, moving the patient to the foreign EMS stretcher will pose a significant patient safety and logistical challenge. EMS regulations may not allow for floor loading of a military litter. Consideration should be given to formalize an agreement in advance with the foreign EMS on this logistical process.

5. Medical teams need to know local weapon regulations. A time out before departing an aircraft may help avoid a diplomatic incident from U.S. non-compliance with foreign weapon restrictions.

6. The best practice is to have a U.S. medical provider accompany the patient to the foreign hospital to (1) ensure the patient goes to the right hospital, (2) ensure an adequate medical capability en route is available, and (3) provide a complete and accurate verbal handoff.

7. Rugged and professional civilian attire is a necessary deployment item to reduce the visibility of U.S. military personnel at foreign hospitals while enabling professional interactions with receiving foreign hospital personnel.

8. An official passport is necessary for CCAT teams using foreign airports.

9. AAR with local medical command elements can help close capability gaps for future missions.

10. Medical providers should recognize that the AAR process may be insufficient in retaining and disseminating lessons learned. Therefore, medical providers should take ownership of retaining, documenting, and conveying these to future teams. It would also be of value to communicate these lessons to CCAT training platforms to maintain operational relevance of readiness training.

Case 3

A CCAT team was activated to transport a patient with a severe traumatic brain injury that required mechanical ventilation support at an ally foreign hospital. It was not possible to contact the sending facility to perform a remote patient handoff. Members were instructed to wear civilian attire; however, only non-professional civilian clothing was available. Upon arrival at the airport, the first challenge encountered by the CCAT team was being informed by the aeromedical evacuation (AE) crew that there was a strict departure deadline in effect and the aircraft would depart without the CCAT team if that timeline was not met. En route to the hospital, the driver used evasive driving techniques to reduce transit time and posed a safety risk to the members in the vehicle. The second challenge occurred after arrival at the hospital, when non-medical U.S. personnel were utilized to help transport the CCAT equipment to the patient’s bedside; these members became lost with the equipment, which delayed patient packaging. The next challenge occurred when the foreign hospital staff did not recognize CCAT team members as medical professionals because their civilian attire was too casual. This caused difficulty in interactions with foreign medical personnel and delays as initially CCAT personnel were not even allowed to touch the patient. In addition, the CCAT ventilator was not compatible with Middle Eastern local oxygen systems and a low-flow adapter was used. The driver’s evasive driving techniques on the return trip needed to be dissuaded by the CCAT team, given threats to safety for a critically injured patient.

Case 3—Lessons learned

1. Limited pre-flight clinical information will hinder mission planning.

2. Professional civilian attire is necessary during deployment, as casual civilian attire may impair interactions with foreign staff.

3. CCAT equipment should always remain with CCAT.

4. Medical equipment in non-U.S. healthcare systems is frequently not compatible with U.S. equipment, in this case the IMPACT 731 ventilator to local Middle East local oxygen systems.

5. Low-flow adapters should always be brought when evacuating from a foreign hospital.

6. Transport timeline restrictions should be realistic.

7. Evasive driving techniques during rushed patient transport may be counterproductive and should be discouraged when possible.

Qualitative Analysis

The analysis and categorization yielded four distinct mission stages that CCAT teams should consider. These mission stages included (1) pre-mission, (2) at U.S. aircraft, (3) away from U.S. aircraft, and (4) post-mission. A summary of the lessons learned from these three cases is found in Table I. These results illustrate a template for how the en route care (ERC) community can retain successful strategies between current and future CCAT teams.

DISCUSSION

Operational experience over the past two decades has largely been in the Central Command Area of Operations, a region that had a robust, high footprint U.S. medical system enabling high levels of care with relatively shorter transport times.² Current operations in austere environments utilize foreign hospitals to enable a higher level of care near the point of injury when timely U.S. resources are unavailable.⁸ Use of these facilities introduces novel logistical challenges compared to usual transports between U.S. military destinations based on the authors’ experiences. Specifically, teams frequently travel longer distances to the hospital, and missions require detailed collaboration with foreign medical teams. Collaborating with foreign medical teams raises the need for interoperable medical equipment. Given that these transfers are prevalent across the spectrum of operational medicine, patient transfer between U.S. equipment and foreign EMS should be incorporated into future training. Oxygen system and CCAT ventilator incompatibility also pose a unique challenge. When transporting patients from foreign medical facilities, it is critical that the CCAT team has low-flow oxygen capability in order to be self-sufficient in providing critical care tasks and not rely on foreign equipment.

Communication difficulties were another important challenge within each mission. For example, traffic patterns en route to the hospital are not generally known to the AE crew and can create a discordance between pre-mission travel estimates and the actual transport time needed. CCAT should have the necessary equipment to maintain timely communications with the aircraft; this will mitigate against a false sense of urgency. This series emphasizes the need for planning among CCATT, AE, and aircrew with an understanding that timelines are more difficult to predict in this en route care mission set involving foreign hospitals.

The logistical challenges encountered during the missions presented in this case series were not broadly disseminated to the CCATT community based on the authors’ experience and informal conversations with colleagues. All process improvement (PI) strategies include data collection, analysis, and dissemination of lessons learned, and these principles are central to the aims of the American College of Surgeons Committee on Trauma and the military’s JTS.^6,7 Our case series demonstrates that valuable information can be gleaned from the experiences of CCAT team members to inform future mission preparation. As shown in case 2, the current AAR process sometimes fails to consistently turnover relevant mission information among successive teams and highlights the importance of maintaining continuity documents at deployed locations. The presented mission narratives in a case series format address the dissemination gap and will enable actual mission experiences to inform didactic lectures and simulated missions. Currently, CCAT readiness training platforms are often unaware of these region-specific challenges and the successful strategies that were used for mission success.⁸

The future of en route care will likely involve smaller medical footprints, longer transport times, and more flexible medical operation planning due to lack of air superiority in multi-domain operating environments.³ This change highlights a more forward, dynamic ERC mission that will likely introduce new operational and logistical challenges, as seen with prior unregulated CCAT missions.⁴ Greater dissemination of lessons learned from previous conflicts with sufficient detail for integration into readiness and sustainment training may mitigate against the growing experience gap within the ERC community.⁹ A process to capture the clinical-technical work associated with en route critical care should be considered; it will help readiness and sustainment platforms maintain their relevance and mitigate the “peacetime” effect and decline in operational knowledge of the current workforce.

LIMITATIONS

These lessons learned were collected after substantial time had elapsed since conducting the mission. Reviewing AARs written shortly after mission conclusion would likely provide higher quality data. Analysis of AARs was not feasible as the en route critical care pilot unit lacks sufficient AAR numbers for review. Additionally, multiple attempts by authors of this publication and other researchers over a period of several years have been unsuccessful in receiving permission to review the AARs submitted at the operational unit level.

CONCLUSION

Logistical challenges are frequently present during en route critical care missions utilizing foreign medical treatment facilities. The findings of this case series support the need to capture and disseminate past lessons learned to the broader ERC community with sufficient detail to enable incorporation into readiness and sustainment training.

ACKNOWLEDGMENTS

We thank Maria Castenada, En Route Care Research Center Program Manager, for her supporting efforts.

FUNDING

None declared.

CONFLICT OF INTEREST STATEMENT

None declared.

REFERENCES

Author notes