SCCM Resource Library-Little People in a Big World: Preparation and Planning for U.S. Military Transcontinental Pediatric Critical Care Air Transports

Video Transcription

Hello, my name is Lieutenant Colonel Renee Matos, and I'm a pediatric intensivist in the Air Force, currently at Brooke Army Medical Center in San Antonio.  Today I'm excited to be talking to you about little people in a big world, preparation and planning for U.S. military transcontinental pediatric critical care air transports.  Unfortunately, I have nothing to disclose, and the views presented today are mine and do not represent those of the U.S. Air Force, Army, or Department of Defense.  After hearing quite a bit about what it is like for our transport teams, I wanted to take a step back and talk about the most common airframes we use to transport our patients.  Some of this may be a refresher from the historical video shown in the first lecture. The United States Air Force's Air Mobility Command, or AMC, is responsible for medical  transports in the Air Force. Air Medical Evacuation, or AE, are the aircrew responsible for providing medical support and care during these transports.  Although other aircraft can be used, the three aircraft pictured here are most commonly utilized for en route medical care.  Each has different strengths and weaknesses, and as you've already heard, an aircraft in flight is not an ideal environment to deliver care.  Medical crew members learn how to treat patients aboard an aircraft with limited resources and support, which is very different from a fully staffed and stocked hospital.  I would also say that this is an incredibly different experience than doing rotary wing transports given the duration of flight and inability to land when you are traveling across  an ocean. In this slide are some examples of what each of these aircraft look like when they are set up for the evacuation of a critically ill patient, which then requires use of en  route critical care teams. These particular pictures happen to all be of pediatric critical care patients.  While these airframes are typically used for cargo or mid-air refueling, they can quickly be turned into mobile ICUs with the addition of stanchions that can be secured to hold  various numbers of litters for patients. The C-130, pictured on the left, is a large propeller plane that is most often used for distances across a continent.  The C-17, pictured in the middle, is a jet with the largest capacity of the three, and what medical aircrew frequently refer to as the Cadillac of aircraft, since there is typically  more patient access and airline-type bathrooms. These aircraft are commonly used for flights between continents or across the ocean because of their speed and fuel capacity.  Finally, the KC-135 on the right, which is a mid-air refueler, can be adapted to hold a few litter patients as well.  These aircraft are also faster and can travel long distances, but sometimes have temperature issues where you are cold below the waist and sweating above.  The picture on the right was from a patient moved from Europe to Washington State, a flight that was 11 hours long over the North Pole.  En route critical care is very different across the age continuum. On the far left, you have neonatal transport, which is established for infants less than  30 days or less than 5 kilos, as this is the age group and size that will typically fit inside the neonatal transport system, also called the NTS.  Neonatal teams are supported by staff from the neonatal ICU, including a NICU physician, NICU nurse, and respiratory therapist with neonatal experience and training.  These teams are frequently used outside the continental U.S. and are needed when our military families are stationed and there are obstetric capabilities.  Neonatal emergencies or the need for pediatric subspecialty medical or surgical care generally  requires aeromedical evacuation across the ocean for things like prematurity, respiratory failure, congenital heart disease, or genetic concerns.  These teams complete a neonatal transport course to understand some of the unique needs of babies in flight.  On the far right, on the other end of the spectrum, are what critical care air transport teams, or CCAT, were designed for.  Our adult CCAT teams are pre-positioned across the globe to facilitate rapid transport for critical injuries and illness.  These teams go through four weeks of training in Ohio and have standardized sets of equipment and supplies stocked identically all over the world.  They are required to maintain clinical knowledge and skills with recertification training requirements every few years.  There are deployment slots for these three-person teams, and collectively the five speakers today have over 15 deployments with significant transport experience.  As a pediatric intensivist, I still deploy as part of the adult CCAT team since the overwhelming  majority of military patients that need deployment or transport are in the adolescent range of 18 to 26 years old. In the middle of this slide is the focus of this talk.  Pediatric critical care air transports are the most commonly staffed by pediatric ICU  physicians with adult ICU nurses and respiratory techs who have pediatric experience or training.  However, unlike the adult teams, for pediatrics there is no standardized set of equipment or supplies, which makes mission planning more timely and complicated.  In emergencies, adult CCAT teams will transport these children in extremis. However, in situations of international disasters or scheduled family moves for military members  with complex medical needs, such as vent dependence, there is time to utilize a pediatric-specific team with equipment and supplies tailored to the mission.  Today I will give you several examples of these missions. I want to spend another minute distinguishing these teams since people may not be familiar with the equipment required.  Neonatal en route critical care uses an isolette known as the neonatal transport system, or NTS, which is pictured here.  The specialized flight-tested isolette has a ventilator and monitor built into it. In a recent review of 10 years of military transport in the Pacific Command Region, or  PACON, it was found that neonates less than 30 days represent approximately 5% of these transports, which translates to approximately 1 to 2 neonates per month, or 21 per year.  These patients are also flown by NICU teams based out of a U.S. military base in Japan, who provide transport for the region.  In the past, military neonatologists stationed in San Antonio actually led the way for ECMO,  or extracorporeal membrane oxygenation support, transport, which is pictured on the top left  and will be discussed a little bit more extensively by Dr. Honey Hopke following this talk.  Non-disaster pediatric air transport in the military typically occurs either in the Pacific region, as I mentioned in the last slide, for medical or surgical emergencies, or in  the continental United States as part of the scheduled military moves involving a medically complex child.  If we focus again on Ashley Sam's paper looking at 10 years of military pediatric transports  in the Pacific, pediatric patients less than 18 represented over 16% of these transports, which can have flight times that exceed 10 hours, as you can see in the map on the right.  Of these patients, approximately one pediatric patient per month is mechanically ventilated during the transport.  If you exclude infants less than 30 days, and you're just looking at the 31 days to 17 years, that still represents 11% of transports for that region, at which equals 50  pediatric transports annually. However, once again, pediatric patients do not have a specific transport system or means  to safely secure them to our standard NATO litters, since they are too large for the neonatal isolate and too small for the standard litter straps.  The picture on the left illustrates one adult pulmonologist's creativity in safely transporting these children and infants.  In this slide, you can see some unique adaptations teams have utilized to safely transport pediatric patients in the military.  Once again, CCAT teams need to be able to secure our patients to a standard NATO litter that can fit into these designated stanchions on the aircraft.  For pediatric patients, this can be more challenging for those infants and kids too large for isolate and too small for the standard NATO litter straps.  You might also notice that the ventilator in the picture on the left is off, since it can sometimes be difficult for children under a certain weight to maintain reliable tidal  volumes in flight with the ventilators that have passed the rigorous flight testing required by the Air Force.  As I move on to talk about pediatric disasters, it's important to consider where children are located.  As most of you know, children are located almost everywhere across the globe and are almost always affected when there are disasters, regardless of whether those disasters are  due to war or weather. I want to also spend a minute to talk about the unique needs of children.  And finally, I will give examples of how pediatric critical care teams in the military are involved during these various disasters.  Across the world, 29% of the population are under 18 years, which represents over 2.2 billion people. In the United States, we have over 73 million children.  Almost 1 million of those belong to our active duty military men and women. Families are currently stationed with an active duty member in many of our overseas assignments,  which means that disasters away from the United States can also impact our military families.  In addition, the United States frequently provides aid and support to children and families  from other countries when disasters occur, and our military transport system may be utilized for these situations.  Another reminder for those less familiar with caring for children is that children have unique needs.  Pediatric patients have anatomical differences, including their airway, shape, and size. The overall size of the patient obviously affects everything in them, from their vessel  size to their organs. Their body composition also varies with age, as infants have disproportionately larger heads and smaller legs than adults.  This is very important because when disasters occur, children are typically closer to the ground, so more of them is affected.  Children also tend to present in shock differently than adults because of their physiology, which may require different medications.  It is also important to think about the psychological response following a disaster and the potential  that children and families could get separated, making reunification difficult, especially when children are nonverbal.  Children also may congregate in terrorist locations or can unfortunately be targeted by terrorism.  As a result of all of these factors, children are frequently victims of disasters and must be considered in disaster planning.  As a warning in the next several slides, I do have some graphic pictures that may be disturbing to some.  In these slides, I have some examples of pediatric war-related disasters, which can involve severe burns, trauma, and other organ involvement.  These pictures are from patients during the height of the wars in Iraq and Afghanistan. However, during these wars, our war-related pediatric patients were most commonly not  American, which means our medical team's responsibility was to treat in-country, stabilize, and subsequently  transfer these patients to civilian medical care in their country once that was possible. That being said, should these patients be remote, our medical teams may have transferred  them via rotary or fixed wing to our nearest Rule 3 coalition medical facility, which would have more medical and surgical capabilities and capacity to hold the patients in an ICU  for further treatment. We do know that during the peak of these wars, approximately 10% of bed days were taken up by pediatric patients.  There are some exceptions to this strategy, which I will discuss in our first case. Case one is a seven-year-old girl who sustained massive penetrating head trauma by coalition  forces in Afghanistan. US forces have an obligation to provide a level of care commensurate to what we do for  our troops when this occurs, so the patient was transferred to our nearest Rule 2 facility.  The patient was initially deemed neurologically devastated by our adult providers, given her imaging, which you can see here, and the initial neurologic presentation.  However, there happened to be a deployed pediatric ICU physician at this facility who provided  pediatric expertise, including that children often have improved outcomes following these types of injuries when compared to adults.  They were able to convince the Secretary of Defense and Secretary of State to allow transfer to a US military treatment facility for further care and eventual rehabilitation.  This patient was transported to the US for this medical care and then eventually back to Afghanistan once her rehab was complete.  The picture on the left is when she had a tracheostomy and was still recovering and receiving care in the United States, and the picture on the right is at a follow-up appointment  one year later back in Afghanistan. So the next case that occurred happened as a result of the Brussels airport bombing by ISIS in 2016.  During this attack, 35 people died and over 300 were wounded, causing the airport to close and with significant heightened security as NATO forces searched the responsible parties.  This was my first true international CCAT mission. It involves one adult and four children. This military family was on their way to a planned vacation when the bomb exploded  next to them in the airport. The youngest child was being held by her mother, who unfortunately did not survive the explosion.  The children and their father were then transferred to a Belgium burn center where they received their initial care.  With ongoing threats of further terrorist attacks, a combined pediatric CCAT team and a US Army Institute of Surgical Research burn flight team was sent to Belgium to transport  this family back to the US. This mission required joint planning and preparation with packing our supplies from scratch and  in anticipation of all the medications and supplies we might need for this trans-oceanic flight.  On the left shows a five patients lined up during the flight receiving care by our teams and on the right is a picture from CNN that was taken nine months later after significant  rehab that eventually took place at the Center for the Intrepid in San Antonio, Texas, which is at Brook Army Medical Center.  The next case I'll talk about is from 2018 and involved a volcanic eruption in Guatemala that buried towns and killed over 150 people.  Volcan de Fuego covers cities in ash and even still is responsible for hundreds of injuries and over 250 missing persons to this day.  Case three once again involves combining teams using a pediatric CCAT team, an adult CCAT team, and the US Army ISR burn flight team to transport six critically injured burned  children ranging in age from 18 months to 16 years. This mission was unique because the volcano overwhelmed their hospitals.  Many of which have a very difficult medical capabilities than we were used to and when we heard about the mission, the number of children was actually still unclear and until  we arrived, so was their status, the weights, ages, all the medications they were estimated to be on, and any other pertinent information.  Four of the six children were intubated and mechanically ventilated with up to 40 total body surface area burns.  The mission for us was to transport the patients from a consolidated hospital in Guatemala  where they had been moved to, to the United States for their burn care, which was to happen in Galveston, Texas.  To this day, I still don't know why these children were selected or how the Department of State decided to move them, but this was our mission and we moved in as there were  still ongoing eruptions in Guatemala. So this shows kind of the hospital logistics that we saw and they were complicated since  although the patients were consolidated to this one hospital, they were located in three places throughout the hospital.  The youngest three children were in a pediatric ICU, that is shown in the picture on the left,  and the oldest was 16 years old in an adult ICU who was also the mother of the youngest, and the two that were not intubated were in the emergency department kind of holding area.  The picture on the left again is one of our nurses and RTs that was preparing to move the 18-month-old patient, and on the right is where we initially centrally staged our  equipment and supplies since our teams had to disperse to these three locations and come back for things as needed.  The mission planning was complicated and we only had a couple of hours to prepare and package six patients and determine which team members would travel with each of the patients  in the six ambulances during rush hour traffic to get back to the airfield. Some of the patients needed additional lines placed and some stabilization.  We had to get gases on all the patients and move them to all our equipment and medications.  I'll focus briefly on the 18-month-old as an example case during this mission to highlight some of the challenges we experienced with planning and preparation.  The patient's weight was estimated to be 15 kilos and she had an estimated 41% total body surface area burn.  We were told she was on norepinephrine and dobutamine drips for hypotension in addition to a fentanyl drip for sedation.  We had to bring all of our own medications, including those the patients might be on and those we might anticipate needing in various scenarios.  We had a central line and arterial line of Foley and NG tube and her only labs were from three days prior since their capabilities were severely limited in this overstressed  community hospital. Unfortunately, we had some circuit and ventilator issues resulting in increased dead space and  hypercarbia so we ended up having to bag the patient for the mission. The patient was transported safely and survived to hospital discharge.  The final example I will provide is more recent and involved the Afghanistan refugee evacuation last year.  In the midst of efforts to evacuate large numbers of refugees, a suicide bomber outside the Kabul airport gate resulted in the death of 183 people and at least 150 more who were  wounded. As most people know, sitting outside those gates were families attempting to evacuate the country. So not unexpectedly, children were included in those impacted.  I was able to identify three critically injured children from this attack who were transported by one CCAT team from Kabul to Qatar following the IED attack.  The estimated ages of these patients who were transported in that single mission were 9, 12, and 14 years.  All were intubated and had undergone damage control resuscitative surgery by our medical teams in place prior to evacuation.  Example injuries from these children beyond their burns included femur fractures, liver  lacerations, intraperitoneal hematoma, sigmoid colectomy, and all received massive transfusions.  Of note, supplies for pediatric patients were scarce and the teams evacuating were all adult teams as were the teams that were operating on the patients and treating and triaging  the wounded. The medical areas set up in the Kabul airport obviously had no availability for CT scans or advanced imaging.  They had minimal diagnostic and treatment capabilities and minimal pediatric experience amongst the medical team members.  These teams had moved from the Bagram hospital that was in Afghanistan to the airport as they were trying to evacuate.  As I mentioned the minimal pediatric supplies, I want to take a minute to focus briefly on examples of the pediatric supplies that are not in our Adult C-Cut Allowance Standard  Bag Sets. This is especially important for our teams to know so that they understand the limitations they might have for transporting smaller pediatric patients.  We do not have most pediatric sizes of masks, bags, airways, blades, or airway adjuncts. We also lack diapers, wipes, and baby blankets.  Smaller syringes to measure lower doses of medications and especially smaller eneral syringes are also not included.  Not surprisingly, we do not carry formula bottles or pacifiers, which we often need when we transport PEDS patients.  And pictured on the right is a supply of sugar water labeled by one of our NICU transport teams as the Peacemaker juice, aka liquid love, which they never leave without.  But that is also missing from the adult supply kits. Adult kits also lack small sizes of IV catheters, pediatric sizes for suction catheters or Foley's,  alternative setups for ART lines, appropriate monitoring cables that I will elaborate on a little more in the next slide, and proper ear protection for infants to protect them  from those loud and noisy aircrafts. This slide provides some examples of the additional cables we require to safely monitor and transport  smaller children, which again are not part of our standard equipment. In the top left, you can see how we have used a Y connector and bubble tubing to connect  a single lumen neonatal blood pressure cuff to the normal dual lumen blood pressure cable that we carry.  Also note the pediatric pulse oximeter cables typically have a 5-4 connector that's different  from the connector that attaches to our monitor, which also requires an adapter cable that's not stocked in our equipment.  Pediatric EKG leads are generally three-lead due to the size that fits on the patient, and that cable in the lower right fits into the circle of our EKG port, but again, it's  not included in our standard adult equipment set and would need to be ordered separately.  There are also monitor configurations to consider, including switching to pediatric mode for vital sign parameters and some EKG differences.  The ventilator requires pediatric circuits and accoutrements, and it's important to consider  the proportionately increased dead space that's added from the end tidal and the suction and the filter that we usually put between the ventilator and the patient.  If we need a syringe pump, we need to get pre-approval since it's not part of our standard equipment, and it is important to remember sizing for suction catheters, maybe a scale  for diaper weights, or appropriately-sized Foley catheters so that you can monitor I's and O's.  And we also do not typically use pressure bags for arterial line setups in infants and young children.  And finally, blood draws and flushes can cause significant swings in their blood volume and contribute to anemia or fluid overload if too much blood is withdrawn or too many flushes  are given to the patient. All of these things are really important when you're considering long-term or long flights because this isn't just a quick 30-minute or two-hour flight.  Some of these are overseas and can last over 10 hours, as I mentioned before. In summary, pediatric critical care transport has a role in the military aeromedical evacuation,  and its availability is part of what allows families to be stationed with service members overseas.  These teams are utilized for disaster responses, both terrorist and natural, for both US and foreign children.  Although civilian teams frequently care for military families in the continental United  States, this can reduce the skills maintenance for CCAT team members, who are the only resource available during more dangerous missions when the threat of ongoing attacks persists.  Unfortunately, during high-risk scenarios, there may not be civilian alternatives to our military aeromedical evacuation system, which means it is important to maintain this  capability for the benefit of the United States and the world. This means maintaining pediatric skills and appropriately resourcing these specialty transport  teams with supplies for these missions, since in crisis situations across the globe, our military medical teams are who we rely on to safely transport all ages and sizes of  patients. Thank you so much for your attention. I'll be available for questions at the designated time.

Video Summary

Lieutenant Colonel Renee Matos, a pediatric intensivist in the Air Force, discusses the preparation and planning for U.S. military transcontinental pediatric critical care air transports. She explains that the United States Air Force's Air Mobility Command is responsible for medical transports in the Air Force, and the Air Medical Evacuation (AE) are the aircrew responsible for providing medical support during these transports. The three most commonly used aircraft for en route medical care are the C-130, C-17, and KC-135. Lieutenant Colonel Matos highlights the challenges of providing pediatric critical care during air transports, as there is no standardized set of equipment and supplies for pediatric patients. She also shares examples of pediatric air transports during disasters, such as war-related injuries, terrorist attacks, volcanic eruptions, and refugee evacuations. She emphasizes the importance of maintaining pediatric skills and properly resourcing specialty transport teams with supplies for these missions.

Asset Subtitle

Crisis Management, Pediatrics, 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 Pediatrics

Knowledge Area Crisis Management

Knowledge Level Advanced

Membership Level Select

Tag Evacuation

Tag Pediatrics

Year 2022

Keywords

pediatric intensivist

Air Force

transcontinental pediatric critical care air transports

C-130

C-17

KC-135

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