A review of the first 10 years of critical care aeromedical transport during operation iraqi freedom and operation enduring freedom: the importance of evacuation timing.

IMPORTANCE: Advances in the care of the injured patient are perhaps the only benefit of military conflict. One of the unique aspects of the military medical care system that emerged during Operation Iraqi Freedom and Operation Enduring Freedom has been the opportunity to apply existing civilian trauma system standards to the provision of combat casualty care across an evolving theater of operations. OBJECTIVES: To identify differences in mortality for soldiers undergoing early and rapid evacuation from the combat theater and to evaluate the capabilities of the Critical Care Air Transport Team (CCATT) and Joint Theater Trauma Registry databases to provide adequate data to support future initiatives for improvement of performance. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of CCATT records and the Joint Theater Trauma Registry from September 11, 2001, to December 31, 2010, for the in-theater military medicine health system, including centers in Iraq, Afghanistan, and Germany. Of 2899 CCATT transport records, those for 975 individuals had all the required data elements. EXPOSURE: Rapid evacuation by the CCATT. MAIN OUTCOMES AND MEASURES: Survival as a function of time from injury to arrival at the role IV facility at Landstuhl Regional Medical Center. RESULTS: The patient cohort demonstrated a mean Injury Severity Score of 23.7 and an overall 30-day mortality of 2.1%. Mortality en route was less than 0.02%. Statistically significant differences between survivors and decedents with respect to the Injury Severity Score (mean [SD], 23.4 [12.4] vs 37.7 [16.5]; P < .001), cumulative volume of blood transfused among the patients in each group who received a transfusion (P < .001), worst base deficit (mean [SD], -3.4 [5.0] vs -7.8 [6.9]; P = .02), and worst international normalized ratio (median [interquartile range], 1.2 [1.0-1.4] vs 1.4 [1.1-2.2]; P = .03) were observed. We found no statistically significant difference between survivors and decedents with respect to time from injury to arrival at definitive care. CONCLUSIONS AND RELEVANCE: Rapid movement of critically injured casualties within hours of wounding appears to be effective, with a minimal mortality incurred during movement and overall 30-day mortality. We found no association between the duration of time from wounding to arrival at Landstuhl Regional Medical Center with respect to mortality.

Business continuity after catastrophic medical events: the Joplin medical business continuity report.

On May 22, 2011, The St Johns Mercy Medical Center in Joplin, MO, was destroyed by an F-5 tornado. There were 183 patients in the building at that time in this 367-bed Medical Center. The preparation and response were superbly done and resulted in many lives saved. This report is focused on the reconstitution phase of this disaster response, which includes how to restore business continuity. As 95 percent of our medical capacity resides in the private sector in the United States, we must have a proper plan for how to restore business continuity or face the reality of the medical business failing and not providing critical medical services to the community. A tornado in 2007 destroyed a medical center in Sumter County, GA, and it took more than 365 days to restore business continuity at a cost of $18M. The plan executed by the Mercy Medical System after the disaster in Joplin restored business continuity in 88 days and cost a total of $6.6M, with all assets being reusable. The recommendation from these lessons learned is that every county, state, and Federal Emergency Management Agency region has a plan on the shelf to restore business continuity and the means to be able to do so. The hard work that the State of Missouri and the Mercy Medical System did after this disaster can serve as a model for the nation in how to quickly recover from any loss of medical capability.

Providing critical care during a disaster: the interface between disaster response agencies and hospitals.

OBJECTIVE: Recent natural disasters have highlighted shortfall areas in current hospital disaster preparedness. These include the following: 1) insufficient coordination between hospitals and civil/governmental response agencies; 2) insufficient on-site critical care capability; 3) a lack of "portability" of acute care processes (i.e., patient transport and/or bringing care to the patient); 4) education shortfalls; and 5) the inability of hospitals to align disaster medical requirements with other competing priorities. CONCLUSIONS: Definition of the roles and responsibilities of a hospital during a disaster requires additional planning precision beyond the prehospital response phase. Planners must also better define plans for circumstances when or if a hospital is rendered unusable. Disaster medical training of hospital personnel has been inadequate. This article details the specifics of these issues and outlines various potential approaches to begin addressing and formulating remedies to these shortfalls.

Hospital disaster medical response: aligning everyday requirements with emergency casualty care.

In this essay, we would like to pragmatically and realistically introduce three topics: (a) Within the hospital, critical care is acknowledged as an enormous cost driver that becomes even less manageable during a disaster response scenario. It is widely recognised that hospital critical care capabilities for large scale disaster response require significant increases, but an overarching plan to accomplish this goal is lacking. This plan necessarily includes equipment, personnel, training, and space expansion. Lesser degrees of illness and injury will likely be cared for in other venues. What is required to provide 'large scale' critical care? (b) During a true large scale disaster with a large casualty stream, the mandate is not to provide 'standard of care,' but rather 'sufficiency of care.' What is that, what does that mean to critical care and the hospital, and how is that determined? (c) Are there other mandated in-hospital requirements that can be appropriately and successfully leveraged for disaster medical response?

Worldwide disaster medical response: an historical perspective.

OBJECTIVE: Disaster medicine and disaster medical response is a complex and evolving field that has existed for millennia. The objective of this article is to provide a brief review of significant milestones in the history of disaster medicine with emphasis on applicability to present and future structures for disaster medical response. RESULTS: Disaster medical response is an historically necessary function in any society. These range from response to natural disasters, to the ravages of warfare, and most recently, to medical response after terrorist acts. Our current disaster response systems are largely predicated on military models derived over the last 200 yrs. Their hallmark is a structured and graded response system based on numbers of casualties. In general, all of these assume that there is an identifiable "ground zero" and then proceed with echelons of casualty retrieval and care that proceeds rearward to a hospital(s). In a civil response setting, most civilian models of disaster medical response similarly follow this military model. This historical approach may not be applicable to some threats such as bioterrorism. A "new" model of disaster medical response for this type of threat is still evolving. Using history to guide our future education and planning efforts is discussed. CONCLUSION: We can learn much from an historical perspective that is still applicable to many current disaster medical threats. However, a new response model may be needed to address the threats of bioterrorism.