Transcript Deployed Medical Decisions - Alliance of Air National Guard Flight

Deployed Medicine and
Clinical Decision-Making –
Experiences at Manas AB, Kyrgyzstan
Sep 2005 – Jan 2006
Col Kevin “Schweaty” Bohnsack
110 MDG/CC
Battle Creek ANGB, MI
ANGMS – Pulse of the Guard
Kyrgyzstan
It’s like Up North, eh?!
Overview
• Manas Air Base Mission and Medical Support
• Host Nation Background/Capabilities
• Air Evacuation and Coordination
• Case Presentations x 3
Kyrgyzstan
Manas Air Base
Manas Air Base Mission
376 AEW - Project expeditionary air power in support of
Operation Enduring Freedom



Strategic Airlift Hub
Air Refueling
Tactical Airlift

Move People, Cargo, and Fuel
376 EMDG - Provide 24/7 medical care and
preventive medicine to optimize warrior
performance
Moving People, Cargo and Fuel
People…
…and more people and cargo…
…and cargo…
…and cargo…
…and more cargo...
…and more cargo (low-level)...
…and more cargo (at night)…
…and fuel for the fight.
“EMEDS Plus/Minus”

29 person EMDG
 EMEDS (Expeditionary Medical Support) Basic/Tailored
ANGMS – Pulse of the Guard
EMDG Organizational Chart
Commander
1st Sergeant
Surgeon
Dental
Life Skills
Logistics
Life Skills
Tech
Chief Nurse
SGP
Admin
CRNA
Nurse
Administrator
BMET
NCOIC
Technician
Lab
Technician
Dental
Tech.
tech
Shift
Leader
Shift
Leader
tech
tech
tech
tech
tech
tech
tech
Provider
Public
Health
IDMT
BEE
tech
ANGMS – Pulse of the Guard
376 EMDG Responsibilities

Clinical and administrative services to forces at Manas AB.
 acute medical care
 flight medicine
 dental
 public health
 industrial health services

Coordinate consultations with referral Military Treatment
Facilities in the AOR - primarily Al Udeid and Bagram.

Coordinate aeromedical evacuation as appropriate with primary
referral to Al Udeid and Landstuhl GE.
Great Base
Great Mission
Great Deployment
Host Nation Factoids
•
Former Soviet Socialist Republic
•
Largest contributor to country’s Gross National Product is a Canadianowned and operated gold mine
•
The second largest contributor is the U.S.-operated Manas Air Base.
•
Ethnicity is still 20-40% Russians. The north is primarily of Asian descent
and the south has more nomadic tribes similar to Afghanistan.
•
Capital city is Bishkek, approximately 30 minutes away by shuttle bus along
the main highway
•
Physicians are trained in Kyrgyz or Russian hospitals along European
system.
•
Salary for a General Surgeon is $40 per month, supplemented by postoperative “favors” given to them by grateful families.
Downtown
Mountains
Host Nation Capabilities
•
National Surgical Center – Best for emergency surgery (appendicitis that
can’t wait for AE)
•
National Trauma Hospital – Best for mass casualty due to trauma and
orthopedics
•
National Cardiology Hospital – Good for diagnostic medical evaluations
including work-up of acute MI and pulmonary embolus
•
Kumtor Clinic (Private) – More “Western-oriented” diagnostic approach with
equipment. Insight re: best surgeons in Bishkek – to have on “retainer” to
use as needed
Kyrgyz Republic
National Surgical Center

Teaching hospital with 250 beds (90%
occupancy rate), 98 staff surgeons,
12 ICU beds, and 5 OR’s primarily for
abdominal and thoracic surgeries.

Commonly performed procedures
include appendectomy,
cholecystectomy, pancreas and
stomach operations and
thoracoabdominal trauma repair
procedures.

Diagnostic equipment includes
laboratory blood and urine testing,
plain x-rays, ultrasounds,
esophagogastroduodenoscopy and
colonoscopy.
KEY: Visits to each facility at
beginning of each rotation.
Kyrgyz Republic
National Surgical Center



Spartan facilities, but generally clean
Minimal modern equipment in ICUs and ORs
Good surgical experience in terms of
numbers of cases treated
KEY: Build relationships.
Kyrgyz Republic
National Surgical Center

Overhead light in OR
with ambient light
through windows.

OR suite is on the
same floor as the
inpatient wards.

Residents follow
patients at night.
KEY: Different Setting =
Different Standards
Kyrgyz Republic
National Surgical Center

Good surgical
sterilization techniques
 Apparently good
infection control
practices
 Doesn’t appear as
“clean” as US facility, but
none of the hospitals in
this region meet that
standard
 Probably no worse than
risk of contamination in
field hospital with limited
case load
KEY: If you have equipment to
bring with you, bring it.
Kyrgyz Republic
National Surgical Center
Department of Surgery

10 beds with private
suites and a separate OR

Private room with one
bed a little nicer than the
normal rooms that are
shared.

Welcomes our staff to
supplement theirs in any
way we desired.
KEY: People can be very good
but they may not have the
same resources as you.
Cardiology Hospital

Major Internal Medicine Referral
Hospital
 All Internal Medicine
Subspecialties Available
 2 ICUs with 12 cardiac beds and
10 medicine beds
 Renal dialysis available.
KEY: Get to know the
healthcare system in your
host nation.
Cardiology Hospital

Laboratory is able to run PTTequivalent for continuous
heparin drip.

No ability to check for protime
(PT) and does not carry warfarin
(Coumadin) in-house.

Echocardiography and
ultrasound also available.
KEY: Augment diagnostic
capabilities even if you
won’t necessarily treat at
that facility.
Cardiology Hospital

ICU step-down beds consist of the patient being directly
observed by a clinician. No direct monitoring equipment
available after initial stay in ICU.
KEY: Develop a level of
comfort and familiarity with
their rules of engagement.
National Trauma Hospital

Typical hallway in any
downtown hospital.

Some facilities do not have
overhead lighting for hallways.

No creature comforts such as
cafeteria, linen service, etc.
KEY: Realize that you as a
healthcare provider can
develop familiarity but
Airman Snuffy will be very
surprised.
Pharmacy ROE

Patients must purchase their own
medications provided in the hospital from inhouse pharmacies located in the hallways.

Some more specialized medications may be
carried by only one pharmacy in the entire
city. (eg. Plavix)
KEY: Do not make any assumptions about standards or
reimbursement and bring cash (or finance who has the cash.)
Iridiocyclitis Case
KEY: Reinforce host nation
practices and plans with
back-up from reachback
resources.
Kumtor Clinic

Canadian-Kyrgyz Mining Company –
Medical Operations

Primary mission: Occupational Medicine
and coordinating care of company ex-pats

Excellent contacts with local surgeons who
are “best in their field”

Clinical capability similar to that of EMDG
although they have some increased
diagnostic capabilities.
KEY: Explore other options
and use more familiar
resources if required.
Kumtor Clinic

Diagnostic laboratory with
ability to perform
chemistries including
TSH.

Small ultrasound machine
available for “quick-look”
diagnostic capability.
KEY: Anticipate what your
population may need.
Host Nation Capabilities
•
National Surgical Center – Best for emergency surgery (appendicitis that
can’t wait for AE)
•
National Trauma Hospital – Best for mass casualty due to trauma and
orthopedics
•
National Cardiology Hospital – Good for diagnostic medical evaluations
including work-up of acute MI and pulmonary embolus
•
Kumtor Clinic (Private) – More “Western-oriented” diagnostic approach with
equipment. Insight re: best surgeons in Bishkek – to have on “retainer” to
use as needed
Host Nation Capabilities
KEY: Know your transport options.
Bottom Line for EMEDS
•
On-site stabilization for surgical and other ill military and eligible
contractors that require hospitalization until AE arrives.
•
Unstable patients are brought downtown with additional medical
supplies, drugs, and blood as available.
•
For mass casualty scenarios, rely on local transportation to
supplement our own, taking patients downtown followed by AE ASAP.
•
376 EMDG will continue to offer acute medical and dental care on an
urgent need basis to US Embassy State Department and DoD
personnel and families, but routine medical and dental care should be
obtained locally.
Questions/Principals
•
•
•
•
•
Administrative
•
Memorandums of Understanding – are they in the SOFA?
•
Payment - cash
Surgical Concerns
•
Anesthesia
•
Sterilization Equipment
Medical Issues
•
Medications
•
EMEDS supply
•
Downtown - country of origin and cost
•
Supplies – Have a “go bag”
•
Monitoring equipment
•
Standard of Care/Philosophy differences
“Creature Comforts”
•
Linen
•
Food
Communication
•
Availability of translator
•
Physician to physician communications
Spirit Award
Aeromedical Evacuation
Battlefield
CSH/ATH
AELT
MASF
Fixed Facility/ASF
Main Operating Base
FINAL
DESTINATION
AE Alphabet Soup
Medical Treatment Facility (MTF)
AELT (Air Evacuation Liaison Team)
TRAC2ES (TRANSCOM Regulating and Command and Control
Evacuation System) – web-based system to input a…
PMR – Patient Movement Request
ASF (Aeromedical Staging Facility)
Qatar/Germany
TPMRC (Theatre Patient Movement Requirements Center) –
validate requirement
AECT (Air Evacuation Control Team) – find the airlift
Obligate picture of an AF Form
TRAC2ES
• Online tool
• Interface between MTF requesting air
evacuation and TPMRC
• Includes everything on the 3899 and more…
so the admin team should develop an extra
questionnaire for other information such as
home address, home phone, etc.
• Contractors require Passport number and
insurance information.
Patient Movement Precedents
URGENT: Immediate movement to save life,
limb or eyesight; normally within 12 hours
(Psychiatric cases and terminal cases are not eligible!)
PRIORITY: Patient should move within 24 hours for
medical care not locally available
ROUTINE: Patient can move on the next regularly
scheduled mission
Aeromedical Staging Facility
• Fixed facility - 50 bed increments
• Capacity 50-250 patients every 6
hours
• Provides continuing in-transit
patient care during AE from AOR
to CONUS.
• Patient stay can be extended up
to 24 – 72 hours.
C-130, C-17, or opportune airlift
Mountains
Medical Logistics
Requisition and Shipment
USAMM
C-E
Mosul
Manas
Kirkuk
Balad
Bagram
Bagdad
Tallil
Kandahar
Kuwait
USAMM
C-SWA
Materiel Shipment Only
Requisition and Shipment Route
Djibouti
SOURCE: CENTCOM Brief – 3 Apr 2006
Issues
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•
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Telemedicine
• Teleradiology
• Teledermatology
• E-mail services (formal and informal)
Safe transport
• No such thing as “medical passengers” or “medpax”
• Level of care decision
Closest destination of care
• Sister Service
• Coalition Forces
• Downtown
Return to Duty (RTD) Issues
• Al Udeid – destination of choice for members likely to be RTD
• 30 day cutoff
• Maximize capability for the line commander
Stethoscope, medications,
digital camera, thumb drive…
Army Telemedicine
Issues
•
•
•
•
Telemedicine
• Teleradiology
• Teledermatology
• E-mail services (formal and informal)
Safe transport
• No such thing as “medical passengers” or “medpax”
• Level of care decision
Closest destination of care
• Sister Service
• Coalition Forces
• Downtown
Return to Duty (RTD) Issues
• Al Udeid – destination of choice for members likely to be RTD
• 30 day cutoff
• Maximize capability for the line commander
AIR EVAC PROTOCOL FOR MANAS AB
(AEF 7/8, Sep 2005 – Jan 2006)
Patient presents
to Manas EMDG
AIR EVAC PROTOCOL
No
Should the
patient be seen
downtown?
No
Yes
Yes
Will the
patient return
to duty within
30 days?
No
No
No
Yes
Can
Al Udeid
treat?
No
Send patient to
Landstuhl
No
Yes
Send patient to
Al Udeid
Can you
provide follow-up
care?
Yes
Can
Bagram
Treat?
Yes
Send patient to
Bagram
Can the patient
be definitively
treated here?
Patient stays at
Manas
Will the patient
return to duty?
Yes
Dyspnea
HISTORY OF PRESENTING ILLNESS
•
38 yo contractor with MMP presented originally on 13 Sep 2005 to the clinic with URI
symptoms. He followed-up three days later on 16 Sep 2005 with worsening dypsnea
on exertion.
PAST MEDICAL HISTORY
•
•
•
morbid obesity s/p gastric bypass (Mar 2005) – weight went from 510 down to 280
pounds
hypothyroidism (2000) – Synthroid 75 mcg PO qd for the past 2 years with no recent
laboratory checks to his knowledge
gout – occasionally takes Indocin for any gouty attacks
SOCIAL HISTORY
•
Food services industry due to stay here for another couple weeks before he returns to
Jordan where he normally resides/works (and has a pregnant girlfriend)
Dyspnea
PHYSICAL EXAMINATION
•
•
Vitals: P 112, BP 130/85, O2 saturation of 92% but 88% with ambulation.
Lungs: clear
ANCILLARY TESTS?
Dyspnea
EKG
•
sinus tachycardia, nonspecific T wave abnormalities
WHAT ARE YOU GOING TO DO?
BACKGROUND INFORMATION
•
Old EKG was not available so the treating physician called back to the States and was
able to get a description of the past EKG read over the phone by the emergency room
physician on-duty in Tennessee.
•
Walkthrough comparison revealed that flipped T waves were a new finding in leads V2
and V3.
Dyspnea
DOWNTOWN EVALUATION
•
•
Echocardiogram – pulmonary hypertension at ~60 mm
Lower extremity doppler – “floating thrombus” in the right femoral vein
DOWNTOWN RECOMMENDATION
•
Do not initiate anti-thrombotic therapy such as heparin until an inferior vena cava filter
has been placed.
Dyspnea
PATIENT – TRANSLATOR – KYRGYZ ATTENDING PHYSICIAN – MILITARY PHYSICIAN
•
•
Kyrygz attending physician explained that they would like to place an IVC filter.
Translator explained situation to patient and the military physician over the phone.
OPTIONS
Transfer patient back to EMEDS and initiate anticoagulants OR press with IVC filter
BACK HOME AT THE EMEDS RANCH
•
Military physician explained to the patient that this course of action was the best
recommendation under the current circumstances.
CENTAF
•
Military physician explained situation to CENTAF/SG who agreed with plan.
Dyspnea
AIR EVACUATION
•
•
•
Request entered through TRAC2ES.
Questionable insurance coverage delayed decision by 48 hours.
Company back in Texas finally agreed that he would be moved by International SOS.
48 hour POST-OP VISIT
•
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•
•
Heart rate in the 80’s, BP 120’s/80’s, and pulse oxygenation level is 91%.
Heparin drip running. Last PTT checked was 24 hours ago.
Nitro drip running at 5 mcg/minute.
Right leg is in pain and Kyrgyz physician has ordered Vishnevsky’s ointment.
No warfarin available but a Russian-made oral anti-coagulant is a possibility.
Dyspnea
VISHNEVSKY’S OINTMENT
•
•
•
Pine tar is main ingredient.
Used to increase venous/arterial circulation in patients with DVT’s or
claudication.
Vishnevsky was a famous Russian general surgeon.
QUESTIONS
•
Keep heparin running when we have low molecular weight heparin (Lovenox)?
•
Keep nitro going?
•
Do we initiate Russian-made oral anticoagulants?
•
Is Vishnevsky’s ointment ok?
Dyspnea
RECOMMENDATIONS
•
•
•
•
Start Lovenox shots 1 mg/kg bid and discontinue continuous heparin drip.
Discontinue nitro drip.
Do not initiate oral anticoagulant.
Hippocratic oath applied to the use of topical pine tar on his leg.
AIR EVACUATION AND THE REST OF THE STORY
•
•
•
International SOS picked up patient directly from the hospital and brought him to
Landstuhl. He was sent back to the States for stabilization on warfarin that was
originally initiated at Landstuhl.
Contractor returned to Jordan within a few months to be with his pregnant girlfriend
and resume his food services job.
EKG technician for the Tennessee hospital received employee of the quarter for her
initiative and resourcefulness.
Chest Pain
HISTORY OF PRESENTING ILLNESS
•
45 yo transient Army full-bird colonel presented on 25 Oct 2005 with the chief
complaint of chest pain for the past hour. Review of systems positive for diaphoresis
and nausea.
PAST MEDICAL HISTORY
•
•
Past history of “abnormal heart rhythm” – takes Beta blocker
gout – occasionally takes Indocin for any gouty attacks
SOCIAL HISTORY
•
Reservist – Activated for a 6 month tour in Kabul. He is not attached to any particular
unit there at Manas.
Chest Pain
PHYSICAL EXAMINATION
•
•
•
Vitals: P 120, BP 110/74, O2 saturation of 96%
Heart: tachycardia, no obvious murmurs
Lungs: clear
ANCILLARY TESTS?
Chest Pain
EKG #1 – initial
•
sinus tachycardia, 1-2 mm elevation of the ST segment
WHAT ARE YOU GOING TO DO?
EKG #2 – 45 minutes later
•
sinus tachycardia, 4 mm elevation of the ST segment
Chest Pain
DOWNTOWN EVALUATION
•
Echocardiogram – decreased left ventricular wall motion
DOWNTOWN RECOMMENDATION
•
•
•
Initiate thromboplastin (TPA) treatment.
Activase and Lovenox supplied from EMEDS supply.
French-made Plavix and Russian-made Lipitor provided from outside pharmacy.
Chest Pain
PATIENT – TRANSLATOR – KYRGYZ ATTENDING PHYSICIAN – MILITARY PHYSICIAN
•
24 hour observation in ICU
WHAT DO YOU WANT TO DO?
CCATT REQUEST AND EVALUATION
•
•
CCATT (Critical Care Aeromedical Transport Team) arrived within 36 hours and visited
the patient downtown.
Intensivist requested LifePak for monitoring purposes but the battery lost power.
Attempts to establish an alternate power source with a transformer were not
successful.
Chest Pain
EMEDS “ICU”
•
CCATT intensivist picked up patient on hospital day #3 and brought him back to the
EMEDS. CCATT intensive care nurse alternated shifts with intensivist.
AIR EVACUATION
•
Patient was air evacuated out by an aircraft of opportunity, a KC-10, and brought to
Landstuhl.
Chest Pain
THE REST OF THE STORY
•
The patient was sent on to Walter Reed where he underwent cardiac catheterization.
The mid-diagonal had a 90% blockage and there was mild inferobasilar hypokinesis.
•
A stent was placed and he is now on a beta blocker and statin drug.
•
Plan is to retire in June 2006.
Fractured Clavicle
HISTORY OF PRESENTING ILLNESS
•
55 yo contractor (airfield manager) fell while on horseback riding trip. Phone call
received from the OSS commander at 1730 that the patient was at a downtown
hospital.
PAST MEDICAL HISTORY
•
Hypertension – lisinopril and HCTZ. No primary care physician of record. He has
normally received refills from the EMEDS facility.
SOCIAL HISTORY
•
Lives in Kyrgyzstan full-time with local girlfriend
Fractured Clavicle
PHYSICAL EXAMINATION
•
No examination possible because patient is downtown at his own apartment but a
fellow contractor brought the films back to base.
X-RAY FROM DOWNTOWN
Fractured Clavicle
ORTHOPEDICS E-CONSULTATION
•
•
•
Poor film quality is difficult to evaluate. Recommendation was to have a CT of the
shoulder in case there was a “floating shoulder.”
Patient given narcotic pain medications.
Air evacuation to Landstuhl
LANDSTUHL ORTHO CONSULT
•
•
•
Repeat film (no CT)
Non-surgical case.
Conservative treatment with sling x
2-3 months and serial films to
document callous formation.
CAN HE COME BACK TO MANAS?
Fractured Clavicle
POST-CONSULTATION COURSE
•
•
•
Persistent pain requiring frequent narcotic pain refills.
Patient felt that fracture was getting worse with one bone component poking into skin.
Patient sought downtown consultation on his own who recommended surgery.
DOWNTOWN KYRGYZ
•
•
Kyrgyz physicians fixed a plate to his clavicle.
Surgery was repeated three days later because the end of the plate was poking through
his skin and causing irritation.
FOLLOW-UP
•
Patient experienced significant post-operative pain and came into the clinic three more
times for Percocet, once calling on Christmas Day for medication.
Fractured Clavicle
THE REST OF THE STORY
•
Patient counseled that he needs to get subsequent post-operative care from downtown
orthopedic surgeon.
•
No subsequent visits to the EMEDS for narcotic pain medication refills.
Contractor Care Protocol
CONTRACTOR CARE PROTOCOL
Contractor presents
to Manas EMDG
Patients advised that they must either:
• Continue downtown care and obtain
locally-purchased medications, paying
for services on their own.
OR
• Obtain a U.S.-based physician to
manage the specific medical problem.
• Manas EMDG physicians are not
responsible for any routine health
maintenance issues such as cancer,
cholesterol, or heart disease
screening.
AND
• Manas EMDG physicians will
continue to see the patients for any
urgent care or emergent issues IAW
DoDI 3020.41.
Clinical
Ops
PAM
No
Yes Is air evac
Patients also counseled that:
Contractor
Care
Air Evac
Protocol
No
NOTE:
If the patient refuses any
of these steps, he or she
will be considered to be
an Against Medical Advice
(AMA) patient
required to
address medical
problem?
No
No
Should the
patient be seen
downtown?
No
Can patient
be definitively
treated here?
Yes
Yes
Can initial
follow-up be
provided
at EMDG ?
Yes Are there any
chronic medical
problems?
Yes
No
No
Does patient
have a U.S.-based
physician?
Yes
Can patient
receive subsequent
care of chronic medical
problem and/or routine
prescriptions via
U.S.-based
physician?
Yes
Is preventive
maintenance
up-to-date?
Yes
Follow-up
as needed
No
Recommend follow-up
with U.S.-based provider
for maintenance issues.
Overview
• Manas Air Base Mission and Medical Support
• Host Nation Background/Capabilities
• Air Evacuation and Coordination
• Case Presentations x 3
Questions?