The Texas A&M University System Health Science Center Office of Homeland Security Paul K. Carlton,...

The Texas A&M University System Health Science CenterOffice of Homeland Security

Paul K. Carlton, Jr., MD, FACS Lt. Gen, USAF, Ret

Director, Homeland Security The Texas A&M University System

Health Science Center

August 11, 2005

Marty Silverstein Lecture Change is Hard

11 August - USUHS


You may obtain a copy of this presentation at:

www.tamhsc.edu/homeland/

11 August - USUHS


Danger Always Present, Just Beneath the Surface


None of usWant to Face

What Lies Ahead of Us

We Must!

Facing Reality is Difficult


“In times of change the learners will inherit the

world…while the learned will find themselves beautifully

equipped to deal with a world that no longer exists”

Eric Hoffer

11 August - USUHS


Threat We Now Face

COMPLACENCY

We have done a great job with casualty management

in this war!

We cannot get complacent!

11 August - USUHS


Change Is Hard

1.You’re nuts!

2.It would work, but no reason to change!

3.You like it? – It was MY idea!

“Every revolutionary idea evokes three stages of reaction”


Evolution of an Idea

Evolution of a person's reaction to a new idea:– Indignant rejection – Reasoned objection – Qualified opposition– Tentative acceptance– Qualified endorsement– Judicious modification– Cautious adoption– Impassioned espousal– Proud parenthood– Dogmatic propagation

HK Silver, 1965


Evolution of a person's reaction to a new idea:– Indignant rejection

– Reasoned objection

– Qualified opposition

– Tentative acceptance

– Qualified endorsement

– Judicious modification

– Cautious adoption

– Impassioned espousal

– Proud parenthood

– Dogmatic propagation

HK Silver, 1965

Battlefield Medicine- Results Today


Threat We Now Face

COMPLACENCY

We have done a great job with casualty management

in this war!

We cannot get complacent!

11 August - USUHS


Measure of Merit for Military Medicine

Soldiers, sailors, airmen and marines at work doing their jobs- protected against environmental hazards and if injured, receiving the very best possible care!

1. Public Health

2. Casualty Management

11 August - USUHS


Public Health

Best job we have ever done in the history of war

Major improvement over GW I in water, food,

sanitation, etc…


Casualty Management

Focus of the talk

11 August - USUHS


“Unprecedented” Survival Rates

• Soldier survival rates in Iraq highest in U.S. war history

– 1/9 soldiers injured died from wounds

– Wounds critical as past wars

• Several advances

– Improved body armor technology (kevlar helmets and vests)

– On-site treatment by mobile surgical units

• “The average time from battlefield to arrival in the United States is now less than four days. In Vietnam, it was 45 days.” -- Dr. Atul Gawande

Navy Times, Jan 05


Addressed All Areas as Joint Team 2004

Led to highest survival in history of war –

WWII Vietnam/GWI OIF

70% 76% 90%

Result of “Heretical” ThinkingNEJM 9 Dec 04


What does 90% Mean?

11,000+ Injured in Iraq

GW2 90% 9,900

Vietnam/GW1 76% 8,360 1,540

Extra alive because of new thinking!Source: New England Journal of Medicine 9 Dec 2004


Combat Casualty StatisticsFrom Stansbury, Holcomb, Champion, Bellamy, 2005

%KIA = KIA / KIA + (WIA - RTD)%DOW = DOW / WIA – RTD%CFR = KIA +DOW / KIA + WIA

0

5

10

15

20

25

%KIA %DOW %CFR

WWII

Vietnam

OIF/OEF

WIA = Wounded in Action (WIA =RTD+ Evacuated+ DOW)RTD = Returned to Duty in 72 hrsEvacuated = Not RTD in 72 hrsDOW = Died of WoundsKIA = Killed in ActionCFR = Case Fatality Rate

Best we

have ever

done!


Major Variables

•Better body armor that protects vital area

•Stabilization of injury with far forward surgery

•Critical care in the air

•Family support - No One “gives up!”


Apples to Apples Comparison

Data from ISR--Case Fatality Rates

8.8% IF/EF

16.5% VN/GWI

22.8% WWII

Stansbury, Holcomb, Champion, BellamyJuly 2005




0

5

10

15

20

25

%KIA %DOW %CFR

WWII

Vietnam

OIF/OEF


Focus on

medical care


This talk will focus on how we got where we are today

and look to the future

11 August - USUHS


1983- After Action report from Marine Barracks Bombing

Examined how we dealt with injured globally:

Vietnam

•Comprehensive care in country

•Close by referral to Japan or Philipines

•45 days to reach USA


1983- After Action report from Grenada

•Grenada invasion

•LtGen Jim Peake, Ret. did much the same thing after Grenada 1983

•Parallel development that intertwined repeatedly USAF-USA-USN-USMC


Is that correct?

Is there a better way?

Is that what you want for your son or

daughter?

1983- After Action report from Marine Barracks Bombing


Post Injury Phases of Illness 1983

Injury

Blood Loss

Respiratory Failure

Infection

Recovery

Rehabilitation

Days Weeks Months

Salvageable Mortality From:


Injury

Blood Loss

Respiratory Failure

Infection

Recovery

Rehabilitation

Days Weeks Months

Salvage Surgery in 1st hour

Secondary Surgery

Definitive Care

Critical Care in the Air


Salvageable Mortality From

Post Injury Phases of Illness 1983


This thinking and planning paid dividends in 1st hour of

deployment in October 2001

11 August - USUHS


*Times and locations are estimated

Injury Scenario: Military and Civilian Care Comparison

1

2

3

4

Elapsed Time Post Injury

Care Received

Military Setting

Civilian Setting

25 min

6* hours

24* hours

48*+ hours

Emergency Surgery Damage Control

MFST personnel

Level 1 Trauma Center

Emergency Surgery Further Stabilization

CCATT enroute /surgical team at AmSurg Center



Level 1 Trauma Center/ Tertiary Hospital

CCATT enroute /surgical team in Military Hospital Setting

Stateside Military Medical Center

Definitive Surgical Care

Definitive Surgical Care

Recent Support of War Effort: Operation Enduring Freedom--Oct 2001


This has now become the norm according to surgeons at

Landstuhl, Germany

Team work has never been better!

11 August - USUHS

Warren Dorlac 5 August 2005


Advantage

•Smaller footprints in theater

•Address needs as a threat become apparent

•“Meet Golden Hour”

•Home quickly with full resources

•Family present!


Lacking to Achieve Vision - 1983


•Modular teams

•Team training

•Joint cooperation

Mired in 60’s

MIND SET ISSUE!


Casualty Care -Prior to Larrey

•Casualties lay in the field

•If won – care given

•If lost – executed or left to die on the battlefield and looted as spoils of war


Dominique-Jean Larrey

•1786 – Completed medical studies

•1792 – War breaks out

•1797 – designed first “flying ambulances” for evacuation - “flying ambulances” were horse drawn wagons to collect and carry wounded from battlefield to hospital - consisted of transport, medical supplies and support personnel

•1815- spared by the Duke of Wellington because he took care of all casualties at Battle of Waterloo

Napolean’s Surgeon


Hence the name of the first modular team was “Flying

Ambulance Surgical Trauma Team” 1984- USAFE

Same concept

“Flying Ambulance”


“In times of change the learners will inherit the

world…while the learned will find themselves beautifully

equipped to deal with a world that no longer exists”

Eric Hoffer

11 August - USUHS


“Change is Hard”

11 August - USUHS


Three Minds

Political Rational Emotional

Must understand interplay

Each person addresses this in various proportion


Principles for Change

•Never question motivation

•Many see world differently

•Not wrong

•Must sell your points

•Be recognized expert


Those that disagree are not wrong

They just see the world differently!

11 August - USUHS


My focus

Rational mind– also called blunt!

•Improve survival of the wounded

•No other agenda

•No credit needed


11 August - USUHS




•Modular teams

•Team training


Mired in 60’s

MIND SET ISSUE!



CCATT

“Their Story”

Heretical Thinking!


CCATT

11 August - USUHS


Continuous En Route Care

Battalion Aid Station

“Level 1”

In TheaterHospital“Level 3”

Definitive Care“Level 4”

Historical Route From Injury to Definitive Care

CASUALTY EVAC- Evac Policy -

1 Day

TACTICAL EVAC

- Evac Policy -7 Days

STRATEGIC EVAC- Evac Policy -

15 Days

Field Hospital“Level 2”

Vietnam 45 days

OIF 4 days

Out of ME and into WEJOINT TEAM



BASLevel 1

Forward Surgical teamsLevel 2

Combat Support Hospital, EMEDS, Fleet

HospitalLevel 3

Definitive CareLevel 4

Current Route from Injury to Definitive Care

Surgical Capability

CASEVAC1 Hour TACTICAL

EVAC24 Hours

STRATEGIC EVAC48-72 Hours


CCATT History

•Conceptualized 1983- rejected by AE- “Like trying to catheterize a running race horse!”

•Specifics in 1988

•1988 – 1999 developed concept, equipment, training

•2001-2004 proven effective

Against Heavy Opposition


Evolution of Critical Care in the Air

• Aeromedical Evacuation (AE) system– Stable casualties only - GW1 and prior- “They

might die on our airplanes!”• Critically ill patients could be transferred but the

team had to be assembled ad hoc • Mogadishu, Somalia 1993• Concept of Critical Care Air Transport Team

developed and tested– Lt Gen Paul K. Carlton (ret.), MD, FACS– Col Christopher Farmer (ret.), MD, FACP– Col Jay Johannigman MD, FACS– Lt Col Bill Beninati, MD, FACP Critical Care Physicians


Critical Care Air Transport Team (CCATT)

• Teams provide critical care expertise to manage patients in transit

• Augment normal AE crew • Personnel

– Active Duty– Guard and Reserve

• Goal of 210 teams– Currently 140– 12-15 teams in theater– 4 special operations teams


CCATT

• Teams are multidisciplinary

– Physician– Nurse– Respiratory

Therapist • CCATT Course

– 2 weeks• 3 ventilated patients

– 6 patients maximum


CCATT Equipment

Propaq

MonitorIVAC IV

Pump

Impact VentilatorAC, SIMV, CPAP

modes

PEEP

I-STAT Lab device

Equipment Bags

Total Weight: 585 lbs

Three equipment sets:


AE AIRFRAMES

Opportune-- not dedicated

Maximizes flexibility


How does this soldier get home?

Photo from 1st Lt Robert M. Barnhart


CASEVAC

This job is done by the

Army and Navy

By ground or by air

1 2


Injury

Blood Loss

Respiratory Failure

Infection

Recovery

Rehabilitation

Days Weeks Months


Secondary Surgery

Definitive Care




Surgical Care in First Hour

•Life saving only at BAS/CCP

•Meatball/ damage control surgery

•Stabilize fractures

•Never more than 2 hours


Tactical Evacuation

23


Injury

Blood Loss

Respiratory Failure

Infection

Recovery

Rehabilitation

Days Weeks Months


Secondary Surgery

Definitive Care




CCATT if needed

Continuous enroute care

Tactical Evacuation


Injury

Blood Loss

Respiratory Failure

Infection

Recovery

Rehabilitation

Days Weeks Months


Secondary Surgery

Definitive Care



Salvageable Mortality FromSecondary Surgery

•Re-stabilization- CSH/AFTH/FST+

•Stop bleeding

•Re-stabilize fractures


Strategic Evacuation

Patient Movement Request generated

CCATT team requested

Team comes to location and assesses the patient, or is on scene and already taking care of patients which is much better for continuity!

Level 3 to Level 4


Injury

Blood Loss

Respiratory Failure

Infection

Recovery

Rehabilitation

Days Weeks Months


Secondary Surgery

Definitive Care




Provide definitive care in Germany or USA



Patient ExampleBalad, Iraq 11 Sep 04 Washington D.C.

13 Sep 04

6500 miles

2 CCATT teams


Patient Example

Washington, DC

30 Sept 04

Washington D.C.

Jan ‘05

Now married

Has taken first steps with new limbs

Excited to start his new life


Patient Example

Source: Air Force Times 28 March 05


Seamless Continuum of Care

Team Work is Key


JOINT TEAM




•Modular teams

•Team training


Mired in 60’s

MIND SET ISSUE!


Traditional Response: Whole Blood

O-Blood

• Multi-Purpose (Shotgun Approach)

• Effective Treatment for Acute Blood Loss


Current Approach:Component Therapy

• Problem Specific Treatment

• Increased Efficacy • Extends Limited ResourcesFFP

O-

Platelets

O-RBCs

O-

Saline

Plasma


Medical Building Blocks: Modular Response


• Increased Efficacy • Extends Limited

Resources• Maximizes Options for

Commanders• Flexible Force ModulesCCATT

ECCT

PAMMFST

SPEARR

EMEDS


Medical Building Blocks: Modular Response


• Increased Efficacy • Extends Limited

Resources• Maximizes Options

for Commanders• Flexible Force

Modules EMEDS

PAM

SPEARRMFST

CCATT ECCT

BATDisaster,

MOOTW

CBRNE


Expeditionary Packages

• Prevention and Aerospace Medicine (PAM) Team

– Designed to prevent disease and non-battle injuries

• Mobile Field Surgical Team (MFST)

– Rapidly deployable, easily transportable, small surgical team

• Small Portable Expeditionary Aeromedical Rapid Response Team (SPEARR)

– Deployable within two hours

– Flexible, broad scope of care

• Critical Care Air Transport Team (CCATT)

– For rapid aeromedical evacuation (AE) worldwide

• Expeditionary Medical Support (EMEDS)

– New version of traditional Air Transportable Clinic / Hospital

• Biological Augmentation Team (BAT)

– Field identification of pathogens of operational concern


Modular Units of Capability: Providing What’s needed, When needed

• The Crisis Defines the Response• Optimizes Resources• Maximizes Options for Commanders

CRITICAL CARE

Surgical TEAMS

SPEAR

PAM Teams

Staging/CrewsComm

Expanded Beds+10 and +25

Staging Aug+20 Bed


Prevention and Aerospace Medicine Team (PAM)

• Designed to prevent disease and non-battle injuries• Missions/Tasks

– Health threat/risk assessment– Health hazard surveillance, control, and

mitigation of effects– Primary/emergency care, flight medicine

• Population at risk; 2-10,000• 9 personnel in 3 modules

– Module 1 (Advon) - Aerospace medicine physician, public health officer

– Module 2 - Bioenvironmental engineer (BEE), independent duty medical technician

– Module 3- 2 public health technicians, 2 BEE technicians, aerospace physiologist


• For Aeromedical Evacuation Patients• Capability: Provides in-flight critical care

transport of 3 ICU patients; with 2nd critical care nurse, 5 stabilized patients

• Personnel: 3 - 1 Physician, 1 Nurse, • 1 Respiratory Tech• Equipment: Light weight, compact, advanced • and sophisticated patient management

equipment and supplies• Operating Conditions: Work with 5• member AE crews to care for stabilized

casualties; for tactical and strategic evacuation

Critical Care Air Transport Team (CCATT)


Mobile Field Surgical Team (MFST)

• Rapidly deployable, easily transportable, small

• surgical team

• Provide lifesaving trauma care within one hour

• of injury

• Personnel: 1-General Surgeon, 1-Orthopedic Surgeon,

• 1-Emergency Physician, 1-Anesthesiologist, 1-OR Nurse/Tech

• Equipment: Manportable 300 lbs of medical equipment and supplies in 5 backpacks, 60lb generator, 1 folding litter

• Capability: Care for up to 20 patients in 48 hrs; perform up to 10 life or limb saving/stabilization procedures

• Operating conditions: Intended for specialized surgery tasks as stand alone for short periods or as medical augmentation unit; transportable by any means; uses shelter of opportunity; no patient holding capability


Similar Thinking

All interchangeable as needed

Service Name Number Time

USA FFST 50 1943

USAF FAST 20 1984

USA FST 24 1985

USAF MFST 5 1994

USN FSRT 8 2000


Change Is Hard

Ft. Polk, Louisiana

Joint Readiness Training Center

USA light units train there

In conjunction with USAF/USN/USMC


LEVELS of medical care

I II III IV

Buddy/Self aid

BAS See a doc – no operation

Surgical Care limited ICU care

Definitive care

Change Is Hard

Medical Report Card is DOW Rate


1st Day- Oct ‘95


I II III IV

Played at JRTC

12 hours in – card pulled Stinger/SA 7/16 are present AE denied via chopper




I II III

DOW rate 39%- 12 hr evac time COL Lester Martinez (now retired MajGen)

pushed surgical care forward to BAS with 5 member AF Surgical team (led by Ty Putnam)

DOW rate dropped to 13%

2nd Day- Oct ‘95



DOW stayed at 13%

Led to push surgical care forward

FST (USA) Forward Surgical Team FSRT (USN) Forward Surgical Resuscitation Team MFST (USAF) Mobil Field Surgical Team

3rd Day- Oct ‘95




11 August - USUHS


Ft. Polk, Louisiana

•Not doctrinal

•Will not do

•Required appeal


Ft. Polk, Louisiana

•Appealed by line BrigGen to 18th AB Corp Commander – LtGen Hugh Shelton

•Asked USA to review its doctrine

•They did

•Changed doctrine to do salvage surgery and meet “Golden Hour”


Evolution of Thinking – US Military

Idea meet

logic test

NO (stop)

YES

YES - Set up scenarios-realistic exercise

Scenarios at JRTC

proven effective- not effective – implemented (38% to 13%) discarded Forward Surgical Care Pushed Far Forward




•Modular teams

•Team training


Mired in 60’s

MIND SET ISSUE!


Team Training

Ken Mattox, Don Trunkey and others have advocated for military teams to do “trauma training” programs in preparation for war since 1975


Change Is Hard

1.You’re nuts!

2.It would work, but no reason to change!

3.You like it? – It was MY idea!

“Every revolutionary idea evokes three stages of reaction”


1998

Push hard to establish “Ft. Ben Taub” in Houston

Did in 1999 with joint team of 13


2000 - 2001Training Spread

•USAF Center for Sustainment Training and Readiness Skills (CSTARS)

-Baltimore Shock Trauma -Cincinnati for CCATT

-St. Louis for National Guard and reserves

•USA – Miami

•USN - LA




•Modular teams

•Team training


Mired in 60’s

MIND SET ISSUE!


Standards Established

11 August - USUHS


RSVP

Readiness

Skills

Verification

Program


RSVP-Dance Card

•What are requirements to go to war?

•Consultants answered those program questions.

•RSVP criteria established for each deployable person


For Example

General surgery

-50 open laps every 2 years

-50 ventilated patient days

-etc…

If not met then go to CSTARS for 4 week update prior to deployment

Certified for deployment!


For Example

CCATT Nurses

•50 ventilator patient days

•Readiness training

•Etc…

If not met then go to CSTARS for 2 week update prior to deployment

Certified for Deployment


Result

•Military teams well prepared for conflict that started after 11 September 2001

•Patients more challenging in war, but principles are real and applicable




0

5

10

15

20

25

%KIA %DOW %CFR

WWII

Vietnam

OIF/OEF





•Modular teams

•Team training


Mired in 60’s

MIND SET ISSUE!


Joint Cooperation

•Casualty does not care who takes care of them – Army, Navy, Air Force, Marine Corp

•They care that they get taken care of

•Has required many years to get into “WE” mindset of Jointness!


Team

Military

US Army

US Air Force

US Navy

US Marine Corp

All now closely integrated team members


Now moved to coalition operation

We have not gone to war by ourselves as a country

since 1898!

11 August - USUHS


Coalition Cooperation

•Many nationalities involved

•Doing well together

•Heard Australian Neurosurgeon debrief his SG after Balad assignment – Feb 05

•Praised coalition cooperation

•Given a leadership position!



11 August - USUHS


Overview

•Heresy

•Appeal

•Imperatives


Heretics Defined

Someone who sees a truth that contradicts the conventional wisdom of an organization, remains loyal to that truth... AND at the same time, remains loyal to the organization


Heretics Won’t Shut Up

… Not because they are being

difficult, but

… Because they see a truth that is

difficult to deal with


Appeal--A Heretic’s Tool

• Chains of Authority

• When to Appeal

• When to Take a Stand

• Seven Steps to Keep You Safe


Use Established Chain of Command

• Wiring diagram that explains who’s in charge• Learn it• Know it• Understand it• Use it


Chain of Influence

• Extends beyond chain of command

• Affects assignments, working conditions, promotion, etc


Authority

• Basic functions• Punish those who do evil• Praise those who do well

• Why we need to be under it• For character training• For conscience’ sake• For credibility and influence


When to Appeal to Authority

• When they fail in their duty

• When they go beyond their duty

• When they ask you to do wrong

• When damage to life or property might occur


How to Appeal

• Check your own attitude

• Have the spirit of a learner and servant…be humble

• Do your homework and find out why you disagree

• 99% of problems will be yours, not your boss’s


Is There an Alternative?

• First, discover basic intentions of the one who gave the command being appealed• Different views of work are healthy• Different levels of understanding are basis of most

disagreements• Design a creative alternative

• Don’t complain without offering a solution to the problem

• Ensure all details are addressed• Prepare to quickly follow through on proposed

alternative


Complaints without

Solutions = Whining

11 August - USUHS


Whining

11 August - USUHS


Contact the Proper Authority

• Talk to the person in charge who can make the decisions

• Inform your boss of your intent to appeal

• Invite him / her to your appeal

• Establish your position under his / her jurisdiction

• It is their problem!


When Your Appeal is Rejected...

• Identify the cause of a rejected appeal

• You

• Your appeal

• Your authority

• Hold up your mirror and look critically at yourself



When Criticized...

• Look for issue…don’t take it personally• Grain of truth in everything that’s said

• Trace criticism to its real source• Another agenda?• Reaction to me or what’s been said?

• Respond quickly but wisely to your critics • Know that you are under your proper

umbrella of authority


When Criticized… (cont’d)

• Look at fear as an invitation to defeat• Make a conscious effort to improve

with every critique• Understand if you are leading as you

should, you will be subject to frequent criticism• No controversy, no progress


Have Courage of Your Convictions

• Be ready to stand alone for the right if it’s appropriate

• Integrity is KEY

• Understand we ALL see the world differently


Change is Hard

Senior official in ASD/HA 2000

“Dr. Carlton, thank God for bureaucracies! We will prevent you from endangering our patients with these idiotic ideas! We will out bureaucrat you!”


Seven Steps of Actionfor Appeal

1. Check attitudes• Both yours and your boss’s

2. Clear conscience• Make the appeal because it is

“right” 3. Discern basic intentions

• Know your boss’s basis for decision


4. Design creative alternatives• Appeal without a solution is

whining 5. Appeal to your authority

• Explain how it will reach the goal• Leave final decision up to

authority

Seven Steps of Actionfor Appeal (continued)


6. Be patient…let authority mull it over

• Forcing a quick answer usually results in a “no”

7. Be ready to stand alone

Integrity - Service - Excellence

Seven Steps of Actionfor Appeal (continued)


Remember….

• If it’s a good idea it will surface again• FAST EMEDS 16 years• Med Center without walls – still not done• TRICARE – fixes ’95- still not done• Career Option Matrix- enlisted nurses – still not

done• CCATT – 15 years• RSVP – 15 years


Leadership Imperatives

• Core Values

• Attitude

• Competence

• Mentorship

• Self Protection


Today

11 August - USUHS


Unintended Consequences

•Rapid return of casualties puts them

in their family support system

•4 days versus 45 day VN conflict

•Hard to measure but real


Seamless Contingency of Care

Injury Salvage Surgery 1st hour Ventilated AE ride chopper or fixed wing

2nd Salvage Surgery or Definitive surgery Ventilator AE ride for fixed wing

Germany – Definitive Surgery Vent AE ride

USA – Definitive Care Average 4 days for wounds, can be only 24 to 36 hours



Battalion Aid Station

“Level 1”

In TheaterHospital“Level 3”

Definitive Care“Level 4”

Historical Route From Injury to Definitive Care

CASUALTY EVAC- Evac Policy -

1 Day

TACTICAL EVAC

- Evac Policy -7 Days

STRATEGIC EVAC- Evac Policy -

15 Days

Field Hospital“Level 2”

Vietnam 45 days

OIF 4 days

Out of ME and into WEJOINT TEAM


Today

•Equipment and people were separated so non-functional

•Need light, quicker NBC shelter system


Today

•Need one pallet hospital

•Self erecting

•Self contained for power and HVAC

•NBC hard

•Towable behind a HumVee

•Sling loadable by helo


Today

•Tried to do with SPEARR trailer

•Got left behind when deployed

•Good concept

•Equipment was lacking


Tomorrow

•As retiree I can be more flexible

•Went to shelter manufacturer and told him what was needed

•Drew it out on the back of a napkin


•USA funded development

•Now we have one pallet shelter system

•Self erecting

•Self contained for power and HVAC

•NBC hard

•One person set up in 5 minutes

•Towable behind HumVee

•Sling loadable

Tomorrow


One Pallet


Tomorrow

11 August - USUHS


EMEDS

•Is a concept!

•Not a checklist, equipment or supplies

•Must be constantly examined and intelligently improved


Tomorrow

•8.8% can be improved

•Better out of hospital care

•Improvements are at enlisted first responder level

•All of us should look for them


Tomorrow

•Prevention might be better than treatment to lower wounded rate

•Better body armor

•Ability to stop bleeding




•Modular teams

•Team training


Mired in 60’s

MIND SET ISSUE!

How about 2005?


Future

CCATT

•Joint CCATT teams formalized

•Move into CASEVAC/enroute care


CCATT

•Key is ventilator•I have seen programs that adjust vents automatically by pulse oximetry so is computer controlled entirely- we need these!

•Address technical issue of airway management

•MD

•RN

•Enlisted

All could be trained to do


CCATT

•Integrated PorDITs, full imaging system in a PDA, for diagnostic capability

•No more than one back pack or equipment per patient

•Cannot allow it to get big!

•Must make it smaller

•Forward deploy the bag so can rotate


-15

-10

-5

0

5

10

15

0 1 2 3 4 5 6

Spirometry

PorDITS• PC-based Intensive Care Unit


Portable Diagnostic Imaging System

Lap top computer that integrated 8 receptacles for imaging accessoriesEKG with automatic reading done

Spirometry

Pulse oximetry and capnography

Ultrasound

XRay sending unit

Digital camera

Automatic BP reading

Automatic temp recording

PorDits

Fielded in 2001


Portable Diagnostic Imaging System

Prototypes cost $10K each

Production should be much less expensive

Available in PDA size now via SF

Should be part of every full time or part time medical unit

Would be useful for CCATT/AE

PorDits


CCATT

•Integrated PorDITs, full imaging system in a PDA, for diagnostic capability

•No more than one back pack of equipment per patient

•Cannot allow it to get big!

•Must make it smaller

•Forward deploy the back pack so can rotate from home station


Future

Modular Teams

•Trauma specialists – ortho & GS combined on European model

•Standardized equipment and training all services for trauma care

•Get smaller– three persons if we had one combined surgeon as above


Future

Team Training

•Plug deployable teams into university hospital

•Model is University of Colorado

•Fully audited

•Win-win on both sides


Future

University Hospital

•Military gets out of bricks and mortar except for casualty reception hospitals

•University has trained people for state readiness response

•Money earned by people stationed at the University goes to pay TriCare bill


Future

Joint Cooperation

•Integration of inpatient facilities will go a long way toward this

•Each service is unique in its requirements yet has much commonality

•Need to preserve the culture of each service yet look for commonality so we can survive fiscally!


Tomorrow

Made great headway in casualty care management to date

Our job is to continue to improve the system

We cannot be complacent!


Is it the best way?

Is it okay for your son or daughter?

11 August - USUHS

“Military is our family!”



11 August - USUHS


BE PERSISTENT!

Heretics Are Not All Bad!

11 August - USUHS


Questions?

Dr Paul K. Carlton, Jr.Lt Gen, USAF, Ret

Director, Homeland Security

The Texas A&M University System Health Science Center

To obtain a copy of this presentation: www.tamhsc.edu/homeland/

The Texas A&M University System Health Science Center Office of Homeland Security Paul K. Carlton,...

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Transcript of The Texas A&M University System Health Science Center Office of Homeland Security Paul K. Carlton,...