Now, if you were expecting Jay Yellen to speak with you, he's not here. You get me instead. Sorry. We're going to talk about mechanical ventilation, analgesia, and sedation. This will not be a lecture about how to set the ventilator. You know how to do that. This is about the stuff that surrounds whether you should be setting the ventilator. These are my disclosures, none of which are financial in nature. Since I in part work for the government, they will disavow all knowledge or endorsement of anything that I have to say. These are our objectives. We're going to talk about austere and resource-limited environments. You have people who are in this audience who regularly spend their time in those spaces. They are expert. In the context of being in those places, we're going to talk about respiratory failure and distress, how you make decisions about who will receive therapy, what therapy you can provide and how you'll manage that, and then some concerns about evacuation. Austere is resource-limited, and oftentimes people will decide that the military approach to this and the civilian approach, these are two very different things. I submit to you that that is in fact not the case during humanitarian crises, because they both converge on places like this. This is Haiti. This is resource-constrained for sure, but you had both civilian practitioners, military practitioners and military regular service people in support and safety and security roles. This is where the two meet. In order to understand what you can and can't do, there are certain considerations that are important. The first is to define your mission and the team that will be helping you. There are operational considerations that you see grouped in three ways. What is your mission? You must understand that because what you bring has to be mission aligned. Bringing excess is very challenging. The goals must be set in advance. The kind of equipment that you will then deploy should be specifically aligned as well. When will that get there? How will you get more of it? It is not the same as the practice in your tertiary and quaternary care center. And then the staff that you must bring with you, and sometimes you bring them with you in a telecritical care way. If you need to talk about that, see Jeremy Pamplin or Chris Colombo in the back. They are expert. You must have them lined up in a way that meets what people will need that are in the field. And regardless of whether you're there in person or in the unfortunate way that we've been linked over the past three years, there is a very real risk of moral distress and you must plan for that. Sometimes you see things that you did not ever think you would see. Do not read the boxes. The boxes are there to represent that there are three very distinct phases before you go, while you're there, and then afterwards that must be taken into consideration when you think about your people, the environment, their equipment, the socioeconomic space in which you find your self-rendering aid. Think about Haiti and all the people that had limbs amputated where there were not ramps, wheelchairs, or prostheses. And then the ethics. In particular, non-Western ethics and what the rules of engagement happen to be and how engaged they will be with you and where people will go afterwards. All of these considerations are part of the pre-planning. The ethics are big. The goal is different. We have first come, first served almost without limit. Here during a crisis, it is the greatest number of possible people to be saved. And it changes all of the pieces that you see in that green box. Locality effects must be considered. What are the ethics that are involved? It influences how people will view the aid that you render. Understanding the local values and expectations is important. Is it okay to amputate that limb? Is it okay not to rescue the 72-year-old? Is it never okay not to rescue the 5-year-old? Or when is that acceptable in that locality? And you also must understand whether or not you are the only agency that is rendering aid or whether you're just one part of a much larger enterprise. The kinds of decisions that affect the ethical concerns are ones that in general should be made ahead of time rather than making them up as you go. And you need to share those with the agency that is hosting you or with the host nation. This means you need to decide on whose team you're playing. Is it military, a federal disaster response organization, or one of the others? They all have their own separate rules. You may be recruited in very different ways to participate in any of those teams. They all have different considerations for you. But they also prepare you differently. If you look at physical skills, anybody have a hospital that says you have to have certain endurance requirements other than the military people to practice? No? In this space, endurance becomes important. The environment, whether you are cold-weather tolerant or heat intolerant, these things become important. And do you need medications for a sustained deployment if you're going for three weeks or three months? Where will you get your medications? Do you need just-in-time training for your skills or do you already come with them? Are you used to working as a solo individual or do you know how to work in a team? As intensive as you work in a team, it's a matter of course. And are you going to be familiar with the very specific equipment that will be available on site? If not, you need to learn. Dissonance between expectations and reality often drives moral distress. But these are also life events for people. Sometimes they see things that they have no context to place. The first time you see it, it can be quite shocking. But this means that you're positioned in a unique spot. The iceberg model is one that is used to great effect. There's your austere team. They're all the way up top. They see all the things there. Logistics and supply, the mission focus, this is all outside of your immediate purview because you are facing the reality of that austere environment. And of course, the needs and all the specifics for evacuation, well, that's not very evident when you're taking care of lots of patients. This brings you to one of the things that you'll do, which is take care of people with acute respiratory distress or failure. The etiology may drive decisions. Here we try and save every last person that comes in. You may not have the resources to do that. So if it is primarily an airway patency issue, that may be much easier to deal with than the addition of organ failure driven acute respiratory failure because that civilian may show up needing care right alongside the person that has been injured during the humanitarian crisis. You may need to take care of both, especially if the existing hospital is overwhelmed with injury care. We've seen this in the Ukraine. Taking care of respiratory failure from this injury, including the field expedient tourniquet, which doesn't work all that well, this is multidimensional, and if you don't have resources, this may not be a person that you choose to provide care for. It may be much more difficult than this person that clearly has rib fractures, a bit of a crushed chest, maybe a cardiac injury, but that person is harder than this one that simply has a sternal fracture. This one is much easier than this person that shows up that has respiratory failure from necrotizing soft tissue infection. They all have respiratory failure, but they all have very different needs and very different resource constraints. And therefore, we've been taught to think about respiratory failure and distress as hypoxic or hypercarbic or some combination, and in this kind of a resource limited setting, I submit to you that that is not useful. You should think of conflict and civilian spaces as virtually the same, they have injury or they don't, as the etiology. This creates a very different framework that allows you to deploy resources in a way that makes sense. Because there are all these other concerns, we've heard about some of these here, and we'll hear more about unusual organisms, but there's always the threat that you and your team may be subject to chemical, biologic, radiologic, nuclear, and in particular, explosive attack, which means that where you believe you're going to set up may also need to be mobile, as opposed to the usual anchored spaces in which we currently work. That must also factor into what you're willing to do and for whom. Tools, history, exam, pulse oximetry, very portable, right? You can deploy this virtually any place. Point of care laboratory testing rather than a fixed lab and a portable ultrasound. The butterfly is going every place. These are easily portable tools for you. They don't require a lot of training other than ultrasound, but that seems to be much more ubiquitous at this point than it was five to ten years ago. When you think about how you're now going to manage the person that you've assessed, will you have power? Last week in the Ukraine, one of the hospitals had power for two hours and no power for four. How do you manage respiratory failure then? Going back to the polio epidemic, you're going to bag them, right? But you can't bag them very easily if you're using a very advanced ventilator setting. What devices do you need to run? Will you have them? Will you have flowing oxygen or not? If you're dependent upon an 18-wheeler to bring you oxygen or the routine electrical work of your oxygen farm, you may not have that at all. Will you have enough clinicians to deal with the numbers of patients? If you agree to treat them, how can you get them out of that space? What if it's not just evacuation, but you need extrication? Military is very good at extrication, but if you're not part of the military team, you must also consider that. What you're looking at here is a portable oxygen concentrator, 33 inches tall, 46 pounds. It needs an AC power supply, but it can run on a battery. You get 15 liters per minute of oxygen flow. That's it. You could link them in series. I won't really be excited about carrying this around on my back. This is one of the many portable ventilators that you can use, and it has lots of capabilities. But now if you have to bring in oxygen and the ventilator and all the equipment that goes with it, that may be impractical. Therefore, simple approaches succeed. This is not the British SAS moniker, but this is reasonable. If you don't need invasive mechanical ventilation, conservative O2 targets, 88 to 92%. This is fine. It is all you need. Low flow O2, if you have it. High flow O2 uses a lot of gas. But if you need invasive mechanical ventilation, simple things work. If you like to use pressure regulated volume control, don't do that. I like APRV. That's not happening. AC volume cycles in a lung protective ventilation way. That makes sense. There may be some people that will be able to transition to pressure support and peep. But the majority of your patients, if they need help, they need a lot of help. Part of that help is analgesia and sedation. Pharmacotherapy is a major issue because you may not have medications. Or if you had them, you may not be able to get them. Think about the start of the COVID pandemic when everyone ran out of propofol. You may not be able to have these agents bussed in or flown in or dropped in. Transportation may be in a denied space. If you need refrigeration, if you don't have power, it will not work. And if you have a pallet of medications, who will secure those? That was a major problem in Haiti. Who is going to keep all of your stuff safe so that you could use it? So inventory supply is a big issue. This also means that you should narrow your pharmacopoeia. Analgesia and sedation. Analgesia is great with opioids because opioids also provide some sedation. But there's a very good role and a potent role for ketamine in the field. If you're going to sedate people, if you deliberately wish them to have the respiratory drive impacted, opioids are grand. For others that you're trying to get off of mechanical ventilation, avoiding opioids is ideal. You may use atypical antipsychotics or typical antipsychotics for sedation. Normalization of blockade is not a routine event, but it may be particularly helpful for transport for tube maintenance safety. If you've ever flown in a helicopter with a patient that is thrashing about, it is an occasionally unsettling experience. You say, why do I need to tell you all this? Aren't we already prepared for this? The answer is no. This is a global thermonuclear war simulation by the National Laboratories, and you can find this lots of places. We've war-gamed this. We've war-gamed it for Washington, D.C., in fact, at the granular street level of what is expected to occur. Right? Why don't we have it for this? Where is all the data that can be used to drive predictive analytics? This is part of an ask for industry to make this into one of the games instead of World of Warcraft or Mario Kart. We should be able to work within this space to say, in this location with these teams with this kind of injury set, what do I need and how will this impact outcome? And then you can optimize that. So I'll leave you with these conclusions. You must plan for things that help you and things that hurt you. Preparation is absolutely key, and you must train and train in a team-based fashion for this across different scenarios if you really wish to be effective. And for all of the things that you know how to do in the ICU, it is only one aspect of care. But if you do it well with a team that works well together and has transacted memory, you save lives. So with that, I will thank you.

mechanical ventilation

analgesia

sedation

austere environments

resource-limited environments