SCCM Resource Library-Global Extracorporeal Life Support Transport: How and Who Gets Moved by the U.S. Military

Video Transcription

Hello, my name is John Huntinghockey. I'm going to be presenting a presentation in the session entitled, When Disaster Strikes,  Lessons Learned from the Critical Care Transport Teams. Specifically, I'm a pulmonary and critical care physician based out of San Antonio, Texas,  and my specific presentation is going to be Global Extracorporeal Life Support, How and Who Gets Moved by the U.S. Military.  I am an active duty member of the United States military and my views do not reflect those of the Department of Defense. I have no other relevant financial disclosures.  Today I'm going to review the history of transport of extracorporeal life support, or ECLS, patients by the United States military.  I will also discuss strategies for successful transport and how we implemented those strategies in the U.S. military during the COVID-19 pandemic.  First I will talk about the history of ECLS in the military. Wilford Hall, one of the United States Air Force military hospitals in San Antonio, Texas,  stood up the first ECLS center in Texas in 1985. It was only one of a handful in the country. It was specifically designed as a program to support neonates, but it also supported  pediatrics. Because of this support, it did a number of transports as far away as Spain and Japan to pick up these young patients.  Fast forwarding about 25 years, Dr. Feng and others published a seminal article called Closing the Care in the Air Gap, which reviewed the experience of the acute lung rescue team,  which is a specially designed team that transported patients on extracorporeal lung support, specifically for severe lung injury.  This article reviewed the role of the acute lung rescue team within the overall military levels of care and levels of evacuation that were required for patients in combat zones  versus getting them to a higher level of care out of the combat zone. During that aeromedical evacuation, sometimes the distance from a theater of operations  or the combat zone was pretty significant, and therefore required a specialized team and specialized preparation in order to safely transport these patients.  This article reviewed the 40 alert activations, and specifically ALERT standing for Acute Lung Rescue Team, and the diagnosis for the patients.  Of note, over two-thirds of those 40 activations occurred in trauma patients that were generally related to injuries that were sustained in a combat theater of operations.  But it is notable to highlight the non-traumatic injuries that occurred in patients that were evacuated also.  Out of those 40 alert activations, only 24 actual evacuations occurred for a variety of reasons, as listed here.  A different article by Bain et al. in the Journal of Trauma and Acute Care Surgery in 2012 reviewed a case series of about 10 patients.  It highlighted a number of different aspects that really changed the paradigm in terms of trauma patients receiving ECLS.  Four out of these 10 patients were cannulated in a war zone. There was a 90% survival in these patients, and the management included the transport  of these very acutely ill patients to a center of expertise in Germany. They concluded that patients with lung injury acquiring ECLS could safely be cannulated  in a war zone, and subsequently be transported to an ECLS center of expertise that provided that higher level of care.  It also highlighted the need to have that specialized team that was able to transport these extremely sick patients.  I will provide a disclaimer for the next slide that is a little bit graphic, where we're  demonstrating and showing one of these trauma patients and how sick they could be. Here's a picture of a patient who suffered an IED blast and ended up becoming a triple  amputee, and at this point had the open abdomen that was placed on ECLS for trauma-related ARDS to his lungs.  You can see the double lumen single cannula in the right IJ and the trach, and how this  patient was able to be managed in a resource-limited environment until transported out to the higher level of care.  In a retrospective review by Reed et al. in Critical Care Medicine in 2013, they reviewed the care and outcomes of over 50 patients on ECLS that spanned over 10 years.  This occurred at a trauma center in Regensburg, Germany. The typical time to support was about five days.  The overall duration of ECLS support ended up being about a week plus or minus a few days.  A little under half of them were transported, and about 79% of them had good survival outcomes, which is better than predicted.  They concluded that ECLS was a good treatment option for trauma patients who had an acute lung injury, but they did show the importance of interdisciplinary teams.  So is there any difference in the outcomes of patients who are transported and then managed at another facility?  Well, in this study of over 200 patients out of Columbia, they showed that in the 80% of patients that were successfully cannulated at an outside hospital, there was no significant  difference in their survival to discharge. When they did a univariate analysis to see what predicted survival, they found that age  and Apache 2 score were the only statistically significant predictors. So what has been the more recent experience for us in the military in transporting ECMO patients?  This descriptive analysis by Reid and many of my colleagues under the guidance of Phil  Mason made a lot of significant findings and descriptions about how our program has specifically grown and evolved, especially over the past 10 years and even five years.  The article does a great job describing our experience of how many air transports and ground transports we did year in and year out.  Really since we started tracking as part of our registry in 2013, it highlighted how each year it grew, especially into 2016 and 2017 when it really took off in our total number  of transports. We started doing more local ground transports within a couple of hours distance from our home base in San Antonio.  We also had a steady amount of air transports during that time frame. In figure two, I want to highlight the total number of inpatients that we managed in addition  to transports and highlight how, as we did more transports, we were able to manage more patients.  This is due to an arrangement that we've made in order to care for patients who are not technically beneficiaries of military medical care.  Through this program, we've been allowed to go and help out the civilian community when patients are needed, when patients have an indication for ECLS, which has helped to  grow our program, also growing our ability as a program to transport these patients, to be ready for whether a patient is a military member or not.  In the article, it also describes the type of patients and their demographics that we transported. The average age was about 43 years old, with about two-thirds of them being male.  The majority were on venovenous ECLS, specifically for respiratory failure, and the average duration of cannulation was a little under three weeks.  In regards to outcomes and complications, I'll highlight that they were separated between patients who were transported locally and those who were transported at a farther distance.  Statistically, it came out that patients who were transported locally tended to have a higher incidence of acute renal failure.  And for overall survival, we found that there was a lower survival to discharge in patients who were transported at a distance, albeit at 65% compared to almost 70% with the local  transports, which are both in line overall in regards to survival with national standards. So now I'll move into strategies and best practices that we've learned not only for  long but also short-range transports of patients on ECLS. So what are the key strategies for a successful transport?  Just like my colleagues have highlighted, preparation is so important. Having the right personnel with the right training and the right equipment that actually  works and backup, just in case, is so key. You also have to be able to plan for A, B, and C as much as possible with the contingencies  that could come up, knowing that what you do is meant to mitigate the risk because you'll be in a position of limited resources when you're up at altitude and you might be flying  over the Pacific Ocean with no place to land. It's just the resources you have in front of you and the team to be able to help manage the patient.  Coordinating all the details of the mission behind the scenes is quite challenging because of the different levels of approval that are required and the different agencies that are  involved. But it is plausible and using checklists or other documents to remind ourselves of what  needs to occur and when makes a big difference to some of the cognitive offloading that's required in order to be able to focus on the mission.  Within the actual transport itself, there are lots of precautions in terms of how patients are loaded and unloaded and how to reduce risk during these transitions that something  bad could happen. You have to always be thinking about how the patient's positioned, not only on the actual  litter, which is the transport gurney, but also how accessible they'll be once they've been put into the ambulance or the aircraft and where they're loaded and making sure that  somebody, if not all of us, have a good line of sight for the patient, their vital signs, their pumps and monitors, but then also their ECMO pump and cannulas and ensuring that all  the different tubes, lines, and drains are secured as best as possible because some of the individuals that might be assisting with these transports and the physical labor of  lifting might not realize that the big tube with all the red stuff going through it is actually pretty important and can't really be dislodged at all.  And then knowing that we have all the backup medications, blood products if needed, and and then doing our oxygen calculations to ensure that we have appropriate supplemental  oxygen. I'm not going to go into too much detail, but this document is an example of an algorithm  for us in order to get the appropriate administrative approvals so that we can travel to the site  where we would do the cannulation procedure and subsequently be met by the aircraft. So now I'm going to get into a few of the pictures of different emissions and here highlighting  the fact that when we transport patients, we actually will transport them by ambulance and if we're doing a transport that requires an aircraft, we'll actually back the ambulance  up to the aircraft and you can see the number of hands that are required to move these patients onto the aircraft.  These pictures highlight some of the stressors that can occur in regards to transporting patients.  In the picture to the left, you can see that we're up near the mountains and it can get quite cold, whereas we also will be transporting patients into the San Antonio heat in the  top right-hand picture. And also in the bottom right picture, it can occur in the middle of the night.  So these can be very long transports that can stress us in very different ways. This picture highlights a more local transport, but how even with those transports that might  occur within an hour or two hours of our home base, we still have a fair bit of equipment that have to be utilized for these patients and it pains me to see the chest tube atrium  hanging out over the edge there as we're going in the door, but it just highlights the importance  of being able to track all the different lines and devices to ensure that they're secured. So now I'm going to move into discussing about how our transport team did during the  COVID-19 pandemic. So as an ECMO program, we've had over 80 patients now in the past 18 plus months, a total of  over 60 of them had to be transported into our facility for us to be able to manage them. And about nine of those transports were by air from all kind of coasts of the U.S. and  then also outside of the U.S. too. Over half of those air transports required portable biocontainment unit that was discussed in a prior session.  We also, in patients that were transported by ambulance, would just use a airborne precautions posture.  We experienced no immediate complications during transport or immediately after transport upon arrival to our home hospital.  And our overall outcomes, our survival has been about 56% of decannulation and still  over 50% discharge, which, albeit lower than prior before COVID, is still in line with national standards for COVID patients.  So here's a picture of myself going through on the left the training for the transport isolation system, which was our first portable biocontainment unit.  But I want to highlight the importance on the picture on the right of the team that really contributes towards managing these critically ill patients.  It's really a team of over 15 individuals here in the pandemic, and it really took a lot of training in order to learn how we were going to adjust, adapt, and overcome to the  situation. I also want to highlight that when that transport isolation system, which we have not used more  recently, was on, it really had quite the internal suctioning that occurred, which you could actually tell.  Here are a few pictures of patients that were transported through the negative pressurized container, the NPC, which kind of highlights the amount of equipment and how we stored  the equipment or secured the equipment. But these patients had multiple IV pumps, the vent suction, suction canisters, chest  tubes, the Foley's, and then the ECMO pump too, and how we would place it in order to ensure that they were all secured well within that system.  In the top right corner, you can see there are a number of individuals in the NPC at any one time being able to manage the patient, but it was a logistical challenge to always  kind of keep line of sight if you're outside and need to get in quickly. We have contingency plans for that.  And finally, in the bottom right picture, we kind of got to create it in terms of how we secured the equipment in order to ensure that we could have good visualization of it and  adjust if needed for all the different pumps that patients were on. So what would we have done if an emergency had arose or a potential complication?  Well, we're always prepared with a point of care ultrasound, albeit, as you can see in the picture on the left, it was very small.  We could use that to help diagnose patients getting hypotensive or having worsening hypoxia. Also, in case of emergency, there's a sign on the NPC that I'll highlight here in the  next slide. It read, property of the U.S. Air Force, return to the nearest Air Force base. So if you found this big, giant Connex box somewhere and no one was around it and you  needed to return it, just return it to the nearest Air Force base. But this is kind of how the box actually looked within the back of a C-17 plane.  So in conclusion, our ECLS transport team in the military has increased rapidly in utilization  over the past five years with outcomes that are consistent with the national standards. Our ability to cannulate at outside locations, whether locally or distantly, by our specially  trained critical care teams and ECMO physicians and specialists, and then the subsequent transport  by either ground or air really has allowed us in the military to care for patients while also developing and maintaining this clinical readiness of a very critical asset for medical  patients and trauma patients. Ultimately, as I've reviewed, the successful transport for these missions really requires important preparation, coordination, and training.  Thank you again for your time and attention. I integrated my references into the presentation, and I look forward to answering questions in the live Q&A coming up shortly.

Video Summary

Dr. John Huntinghockey presents on the topic of extracorporeal life support (ECLS) patient transport by the United States military. He discusses the history of ECLS in the military and reviews articles that highlight the successful transport of trauma patients with acute lung injury. Dr. Huntinghockey emphasizes the importance of interdisciplinary teams and the need for specialized preparation and equipment during transport. He also shares his team's recent experience in transporting ECLS patients during the COVID-19 pandemic, highlighting the use of portable biocontainment units and the challenges faced. The presentation concludes with an overview of strategies and best practices for successful ECLS transport, including the importance of preparation, coordination, and training. Overall, Dr. Huntinghockey's presentation demonstrates the military's ability to care for critically ill patients and maintain clinical readiness during transport missions.

Asset Subtitle

Crisis Management, Cardiovascular, 2022

Asset Caption

Military medical teams uniquely need to be able to manage the transport of critically ill patients, regardless of the nature of their illness, over great distances to receive definitive care. These teams must be able to deploy at a moment's notice and care for patients with complex polytrauma, acute respiratory failure, highly infectious diseases, and possibly children as well as adults. This session will review the capabilities and experiences of the U.S. military's critical care air transport (CCAT) teams, as well as lessons from their work that may be broadly applicable to "earthbound" critical care.

Meta Tag

Content Type Presentation

Knowledge Area Cardiovascular

Knowledge Area Crisis Management

Knowledge Level Advanced

Learning Pathway Cardiothoracic Critical Care

Membership Level Select

Tag Evacuation

Tag Extracorporeal Life Support

Tag Cardiothoracic Critical Care

Year 2022

Keywords

extracorporeal life support

ECLS

patient transport

United States military

trauma patients

	Society of Critical Care Medicine 500 Midway Drive Mount Prospect, IL 60056 USA Phone: +1 847 827-6888 Fax: +1 847 439-7226 Email: support@sccm.org	Contact Us About SCCM Newsroom Advertising & Sponsorship DONATE	MySCCM LearnICU Patients & Families Surviving Sepsis Campaign Critical Care Societies Collaborative	GET OUR NEWSLETTER
© Society of Critical Care Medicine. All rights reserved. \| Privacy Statement \| Terms & Conditions The Society of Critical Care Medicine, SCCM, and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.