Interfacility Transfer Teams: A Pilot Study to Assess Viability as a Skill Sustainment Platform.

INTRODUCTION: A US Naval hospital in the remote Pacific region has developed interfacility transfer (IFT) teams staffed by active duty personnel out of necessity due to a large percentage of critically ill patients requiring IFT and a lack of local resources. The IFT program underwent significant improvements in training and quality assurance in 2017. We sought to assess patient safety when transport was performed by our locally sourced and trained IFT teams. En route care (ERC) is a recognized critical capability gap in the US Navy requiring clinicians with current knowledge and skills to maintain competency. IFT programs may be a viable skill sustainment program for ERC clinicians. MATERIALS AND METHODS: A database was created as part of the quality assurance program to collate information on patient demographics, level of care provided, reason for transport, and interventions provided by the transporting team. A retrospective review of these data was conducted with emphasis on the appropriateness of patient management and skill sustainment for active duty personnel. The project was deemed institutional review board exempt. RESULTS: Of the 1,193 patient care reports reviewed, interventions were required in 128 (10.7%) of patients and 58 (4.9%) required ventilator management. Medical deterioration occurred during 22 (1.8%) of the transports, with 20 (90.9%) of the deterioration episodes managed appropriately. No patient harm occurred. CONCLUSIONS: IFT teams with local training were able to safely transport critically ill patients with no adverse outcomes, defined as direct harm to the patients as a result of transport. Patient care during transports included routine interventions, ventilator management, and troubleshooting of patient deteriorations. Our data further suggest IFT programs may be a viable skill sustainment platform for ERC clinicians.

A Conceptual Framework for Non-Military Investigators to Understand the Joint Roles of Medical Care in the Setting of Future Large Scale Combat Operations.

As the wars in Iraq and Afghanistan end, the US military has begun to transition to the multi-domain operations concept with preparation for large scale combat operations against a near-peer adversary. In large scale combat operations, the deployed trauma system will likely see challenges not experienced during the Global War on Terrorism. The development of science and technology will be critical to close existing capability gaps and optimize casualty survival. This review comprises a framework of deployed trauma care to provide nonmilitary investigators a general understanding of our deployed trauma care system. Trauma care begins at the Role 1 which encompasses all care from the point of injury and the battalion aid station, through transport to the Role 2 or forward staged mobile surgical team such as a Forward Resuscitative Surgical Detachment. Role 1 point of injury care approximates the care delivered by Emergency Medical Services (EMS) personnel. The Battalion Aid Station approximates the care available at a freestanding emergency center with significant differences in training level of the providers, number of beds, and diagnostic capabilities. Role 2 medical care is part of an area support medical company with surgical capabilities. The Role 2 represents the first role of care which provides damage control surgery. This capability approximates a small community hospital with the primary difference being limited patient holding capacity and reduced diagnostic equipment. The Role 3 field hospital is the largest military treatment facility in the deployed setting. The Role 3 approximates a civilian level 2 trauma center with smaller holding capabilities and diagnostic abilities limited to that of a computed tomography (CT) scanner and less.

Regionalization of EMS Medical Direction for Naval Medical Forces Pacific.

INTRODUCTION: Medical direction has been the cornerstone to safe and effective prehospital and enroute care since the establishment of emergency medical services (EMS). Medical oversight by a physician has been shown to improve clinical outcomes in both settings. When the Navy Regional Office of the EMS Medical Director was established in 2016, it brought additional resources, including the addition of a paramedic and nurse EMS analyst and recruitment of additional local medical directors (LMDs). This, combined with the engagement of military leadership, allowed for expansion and improvement of medical direction in our prehospital and enroute care system and the establishment of a continuous quality improvement (CQI) program. MATERIALS AND METHODS: In 2017, a database was created to collect total run volume, acuity of calls, number of certain time-sensitive conditions, and CQI performance. A retrospective review of this database was conducted. This project was deemed institutional review board exempt. RESULTS: LMD reports that submission went from 17% for 2017 to 64% for 2018, 91% for 2019, and 79% for 2020. In 2019, 67% of the sites had verifiable CQI programs and, in 2020, this improved to 80% of sites. The review also revealed insight into levels of acuity seen by prehospital and enroute care providers. CONCLUSION: Our results demonstrate that improvement in medical oversight in a large regional prehospital system can be achieved through persistence and engagement of nonmedical leadership.

Navy En-Route Care in Future Distributed Maritime Operations: A Review of Clinician Capabilities and Roles of Care.

OBJECTIVE: As the United States Navy transitions from Operation Iraqi Freedom/Operation Enduring Freedom to preparing for a near-peer competition, an increasing focus of wartime strategy relies upon a network of distributed naval assets for total sea control, known as Distributed Maritime Operations (DMO). Historically, embedded medical personnel have provided care at sea in times of war. Recent reviews of shipboard and evacuated mass casualty incidents have alluded to weaknesses in the existing Navy Medicine approach that will require advances in care provision to sustain high-quality care that would benefit from industry and civilian academic collaboration. To gain input from civilian prehospital expertise and insight, the current DMO and Navy En-Route Care (ERC) systems must be plainly described for non-Navy military and civilian leaders, clinicians, and researchers to understand. METHODS: N/A. RESULTS: In this review, we translate US Navy structure and vernacular into common civilian and non-Navy language, describe the maritime role-tiered ERC system, elucidate the medical assets on each naval warship, and discuss clinician levels and capabilities while deployed to help communicate the inherent challenges of US Navy maritime medical care during routine operations, casualty treatment, stabilization, and evacuation. CONCLUSIONS: We describe the roles of care, clinician levels, and medical assets within the Navy ERC system for researchers and military leaders who aim to mitigate the inherent challenges of future maritime trauma care in the age of Distributed Maritime Operations. This paper lays the framework of the Navy deployed medical system to enable research in maritime en-route care, and prompt inclusion of identified solutions into common use in the US Navy.

Is Prehospital Ketamine Associated With a Change in the Prognosis of PTSD?

INTRODUCTION: Ketamine is an alternative to opioids for prehospital analgesia following serious combat injury. Limited research has examined prehospital ketamine use, associated injuries including traumatic brain injury (TBI) and PTSD outcomes following serious combat injury. MATERIALS AND METHODS: We randomly selected 398 U.S. service members from the Expeditionary Medical Encounter Database who sustained serious combat injuries in Iraq and Afghanistan, 2010-2013. Of these 398 patients, 213 individuals had charted prehospital medications. Clinicians reviewed casualty records to identify injuries and all medications administered. Outcomes were PTSD diagnoses during the first year and during the first 2 years postinjury extracted from military health databases. We compared PTSD outcomes for patients treated with either (a) prehospital ketamine (with or without opioids) or (b) prehospital opioids (without ketamine). RESULTS: Fewer patients received prehospital ketamine (26%, 56 of 213) than only prehospital opioids (69%, 146 of 213) (5%, 11 of 213 received neither ketamine nor opioids). The ketamine group averaged significantly more moderate-to-serious injuries, particularly lower limb amputations and open wounds, compared with the opioid group (Ps < .05). Multivariable regressions showed a significant interaction between prehospital ketamine (versus opioids) and TBI on first-year PTSD (P = .027). In subsequent comparisons, the prehospital ketamine group had significantly lower odds of first-year PTSD (OR = 0.08, 95% CI [0.01, 0.71], P = .023) versus prehospital opioids only among patients who did not sustain TBI. We also report results from separate analyses of PTSD outcomes among patients treated with different prehospital opioids only (without ketamine), either morphine or fentanyl. CONCLUSIONS: The present results showed that patients treated with prehospital ketamine had significantly lower odds of PTSD during the first year postinjury only among patients who did not sustain TBI. These findings can inform combat casualty care guidelines for use of prehospital ketamine and opioid analgesics following serious combat injury.

Annual Cost of Civilian EMS: An Analysis of Navy Expenditures in Southern California.

Objective: Southern California Naval hospitals incur substantial costs through the use of civilian emergency medical services (EMS) as they lack an internal transportation team. This study aimed to quantify the volume and the associated charges for these transports in the Southern California area as these are currently unknown. Methods: This is a retrospective analysis of de-identified billing claims accessed through the Military Health System Management Analysis and Reporting Tool (M2) system. Data collected included the number and type of transports from Naval Hospitals in the Southern California area as well as the resulting charges. Data from Naval Medical Center San Diego (NMCSD) and Naval Hospital Camp Pendleton (NHCP) were collected over the 2018 and 2019 fiscal years. Results: There were 19,886 and 19,014 total ambulance transports in 2018 and 2019, respectively. Of these, about a quarter (8674/38900, 22.3%) were 9-1-1 calls from the patient's home resulting in an admission at a military treatment facility or network hospital. The majority were interfacility transports (20138/38900, 51.8%). These included transports from hospital discharge to home (3900/38900, 10.0%), transfers between hospitals (1648/38900, 4.2%), transfers from an office to a hospital (1818/38900, 4.7%), and transport for medical care (11682/38900, 30.0%). A large portion of these transports were for unclear transport needs (10088/38900, 25.9%). TRICARE paid $3,872,057 in 2018 and $4,004,996 in 2019 for a total of $7,877,053 spent on ambulance transport over the 2 years analyzed. Outside health insurance paid $10,217,016 over the same timeframe for these same claims. Conclusion: The interfacility transport costs incurred between NMCSD and NHCP are substantial, possibly leaving room for cost savings to be determined by further studies.

Joint Trauma System Clinical Practice Guideline (JTS CPG): Prehospital Blood Transfusion. 30 October 2020.

This Clinical Practice Guideline (CPG) provides a brief summary of the scientific literature for prehospital blood use, with an emphasis on the en route care environment. Updates include the importance of calcium administration to counteract the deleterious effects of hypocalcemia, minimal to no use of crystalloid, and stresses the importance of involved and educated en route care medical directors alongside at a competent prehospital and en route care providers (see Table 1). With the paradigm shift to use FDA-approved cold stored low titer group O whole blood (CS-LTOWB) along with the operational need for continued use of walking blood banks (WBB) and point of injury (POI) transfusion, there must be focused, deliberate training incorporating the different whole blood options. Appropriate supervision of autologous blood transfusion training is important for execution of this task in support of deployed combat operations as well as other operations in which traumatic injuries will occur. Command emphasis on the importance of this effort as well as appropriate logistical support are essential elements of a prehospital blood program as part of a prehospital/en route combat casualty care system.

Ketamine Use in Operation Enduring Freedom.

INTRODUCTION: Ketamine is a dissociative anesthetic increasingly used in the prehospital and battlefield environment. As an analgesic, it has been shown to have comparable effects to opioids. In 2012, the Defense Health Board advised the Joint Trauma System to update the Tactical Combat Casualty Care Guidelines to include ketamine as an acceptable first line agent for pain control on the battlefield. The goal of this study was to investigate trends in the use of ketamine during Operation Enduring Freedom (OEF) and Operation Freedom's Sentinel (OFS) during the years 2011-2016. MATERIALS AND METHODS: A retrospective review of Department of Defense Trauma Registry (DoDTR) data was performed for all patients receiving ketamine during OEF/OFS in 2011-2016. Prevalence of ketamine use, absolute use, mechanism of injury, demographics, injury severity score, provider type, and co-administration rates of various medications and blood products were evaluated. RESULTS: Total number of administrations during the study period was 866. Ketamine administration during OEF/OFS increased during the years 2011-2013 (28 patient administrations in 2011, 264 administrations in 2012, and 389 administrations in 2013). A decline in absolute use was noted from 2014 to 2016 (98 administrations in 2014, 41 administrations in 2015, and 46 administrations in 2016). The frequency of battlefield ketamine use increased from 0.4% to 11.3% for combat injuries sustained in OEF/OFS from 2011 to 2016. Explosives (51%) and penetrating trauma (39%) were the most common pattern of injury in which ketamine was administered. Ketamine was co-administered with fentanyl (34.4%), morphine (26.2%), midazolam (23.1%), tranexamic acid (12.3%), plasma (10.3%), and packed red blood cells (18.5%). CONCLUSIONS: This study demonstrates increasing use of ketamine by the U.S. Military on the battlefield and effectiveness of clinical practice guidelines in influencing practice patterns.

Comparison of Air Force, Army, and Navy Emergency Medical Technician Candidates' Performance on the National Registry Cognitive Examination.

INTRODUCTION: Military medics function similarly to civilian emergency medical technicians (EMTs); however, they perform their emergency medical care in combat zones and military treatment facilities. Both civilian and military EMTs must take and pass the National Registry of EMT's cognitive examination to be certified as a Nationally Registered EMT; however, there is a discrepancy in requirements for obtaining and maintaining National EMT Certification between the military branches of the DoD. In our study, we aimed to compare the performance of the U.S. Air Force (USAF), U.S. Army (USA), and U.S. Navy (USN) EMT candidates on the National EMT Certification cognitive examination from 2015 to 2017. MATERIALS AND METHODS: We performed a cross-sectional analysis of the National Registry of EMT's database for the examination results of all military EMT candidates who attempted the National EMT Certification cognitive examination between January 1, 2015, and December 31, 2017. First and cumulative third attempt pass rates and cognitive performance from mean ability estimates (MAEs) on the examination were assessed. Descriptive statistics were calculated and comparisons between branches with regard to passing rates and MAEs were made using chi-square tests and ANOVA, respectively, at the alpha level of 0.05. RESULTS: During the 3-year study period, a total of 3,642 USAF, 14,050 USA, and 1,187 USN candidates attempted the cognitive examination one or more times. The USA candidates demonstrated the highest first attempt pass rates (2015: 78%; 2016: 78%; and 2017: 81%) followed by the USAF candidates (2015: 58%; 2016: 62%; and 2017: 64%) and the USN candidates (2015: 41%; 2016: 56%; and 2017: 62%). The cumulative third attempt pass rates followed a similar trend (e.g., USA: 2015: 94%; 2016: 95%; and 2017: 96%). These differences by branch were statistically significant for each year (P < .001). The overall test MAE scores also differed by branch, but only the USN candidates' MAE scores differed by year. The USA candidates demonstrated the highest MAE from 2015 to 2017 (523) followed by the USAF (489) and the USN (464) candidates. The overall test MAE scores for the USN candidates improved over the study period (2015: 449; 2016: 475; and 2017: 479, P < .001). CONCLUSION: Military EMT candidates had different performances on the EMT cognitive examination between branches. The USA candidates demonstrated higher pass rates and cognitive performance on the examination compared to their counterparts from the USAF and USN from 2015 to 2017. Further work should be directed at defining the cause of the differences in military EMT candidate performance and determining the characteristics that impact these differences.

Impact of a Standardized Patient Hand-off Tool on Communication between Emergency Medical Services Personnel and Emergency Department Staff.

INTRODUCTION: Handoff communication between Emergency Medical Services (EMS) and Emergency Department (ED) staff is critical to ensure quality patient care. In January 2016, the Southwest Texas Regional Advisory Council (STRAC) implemented MIST (Mechanism, Injuries, vital Signs, Treatments), a standardized EMS to ED handoff tool. The En route Care Research Center conducted a Pre-MIST implementation survey of ED staff in December 2015 and a Post-MIST follow-up survey in July 2017 to determine the impact of the MIST handoff tool on the perceived quality of transmission of pertinent patient information and in the overall handoff experience. METHODS: We administered a nine-item Likert scale questionnaire to Brooke Army Military Medical Center (BAMC) ED providers and nurses before and after implementation of MIST. The questionnaire captured perceived competence and satisfaction with handoff communication (Cronbach's alpha 0.73). We analyzed responses for the total sample and by occupation (providers and nurses), and we calculated odds ratios to determine items that may be most predictive of a positive handoff experience from the perspective of the ED staff. We performed chi-square tests and reported data as percentages. RESULTS: Total respondents Pre- and Post-MIST were 128 (62%) nurses and 80 (38%) providers (MDs, DOs, and PAs). Following the implementation of MIST, more respondents reported that they were "informed of prehospital treatments" (p < 0.001), that "Red/Blue Trauma Alert Criteria were conveyed" (p < 0.001), and that the "time to give the report was sufficient to convey pertinent information" (p < 0.001). Nurses more frequently reported that "Red/Blue Trauma Alert Criteria were conveyed" post-MIST (p < 0.01). Providers more frequently reported that "Assessment findings were conveyed" (p < 0.05), that they 'interrupted the report for clarification" (p < 0.04), that "time to give the report was sufficient to convey pertinent information" (p < 0.001) and that they "felt positive about the overall handoff experience" (p < 0.03) Post-MIST. Overall satisfaction with the handoff was associated with frequently being informed of prehospital treatments (OR 5.5; 2.1-14.4) and frequently receiving a copy of the prehospital record (OR 2.9; 1.1-7.2). CONCLUSIONS: These data demonstrate that providers and nurses reported an improvement in the handoff experience Post-MIST. This study supports the use of a standardized handoff tool at this critical step in patient care.

The Use of Tranexamic Acid in Tactical Combat Casualty Care: TCCC Proposed Change 20-02.

The literature continues to provide strong support for the early use of tranexamic acid (TXA) in severely injured trauma patients. Questions persist, however, regarding the optimal medical and tactical/logistical use, timing, and dose of this medication, both from the published TXA literature and from the TCCC user community. The use of TXA has been explored outside of trauma, new dosing strategies have been pursued, and expansion of retrospective use data has grown as well. These questions emphasize the need for a reexamination of TXA by the CoTCCC. The most significant updates to the TCCC Guidelines are (i) including significant traumatic brain injury (TBI) as an indication for TXA, (ii) changing the dosing protocol to a single 2g IV/IO administration, and (iii) recommending TXA administration via slow IV/IO push.

Transition From Military Prehospital Medicine to Civilian EMS.

INTRODUCTION: Currently, there is a disconnection between veteran military medics and the civilian Emergency Medical Services (EMS) workforce. This project aimed to characterize the rate of civilian certification among military medics, both active duty and retired, and identify perceived barriers to continuing a career in EMS after military separation. MATERIALS AND METHODS: The National Association of Emergency Medical Technicians (EMTs) administered a 21-question online survey to participants. Individuals were recruited through the National Association of EMTs membership communications, Military Relations Committee members, and social media. All responses were anonymous and no identifiable information was collected. Survey questions were compiled and reported as a percentage of respondents. Free-text responses were categorized based on broad themes identified by the authors and are reported as a percentage of respondents. RESULTS: Results included 456 veteran and active duty respondents, of whom 304 (70.7%) had prehospital experience while in the military and 250 (58.1%) had emergency department experience. Over 60% of respondents participated in combat-related duty with 37% having at least 18 months of overseas deployment. Civilian EMT certification was held by 164 (36.7%) survey participants and 170 held paramedic certification (38.1%), while 65 (14.6%) held no EMS certification. There were 119 (28.1%) respondents who stated that they did not plan to work in civilian EMS. Top selected reasons for not pursuing civilian EMS careers included: pursuing a medical career that was not prehospital (28.5%), pay disparity (18.1%), and no interest in civilian prehospital medicine (16.4%). Write in responses indicated general frustration with maintaining certification and a desire for advanced certification (AEMT, paramedic) to be supplied by the military prior to transitioning to a civilian workforce as many respondents felt their military-endowed skills and experiences were better aligned with these advanced EMS licenses. CONCLUSION: The majority of survey respondents held an EMS certification of some kind and suggests that recent efforts to supply military medics with civilian certifications have been largely successful. However, there is still a large portion that remains noncertified or expresses disinterest with entering the civilian workforce. Generally, many of those certified feel their military scope of practice exceeded civilian EMT certification and requested AEMT or paramedic licensure opportunities while still active duty military.

Rapid Ketamine Infusion at an Analgesic Dose Resulting in Transient Hypotension and Bradycardia in the Emergency Department.

Ketamine's favorable hemodynamic and safety profile is motivating increasing use in the prehospital environment. Despite these advantages, certain side effects require advanced planning and training. We present a case of rapid intravenous administration of ketamine causing bradycardia and hypotension. A 46-year-old man presented to the emergency department for an exacerbation of chronic shoulder pain. Given the chronicity of the pain and multiple failed treatment attempts, ketamine at an analgesic dose was used. Despite the local protocol directing administration over several minutes, it was pushed rapidly, resulting in malaise, nausea, pallor, bradycardia, and hypotension. The patient returned to his baseline without intervention. This and other known side effects of ketamine, such as behavioral disturbances, altered sense of reality, and elevated heart rate and blood pressure, are well documented in the literature. With this report, the authors aim to raise awareness of transient bradycardia and hypotension associated with the rapid administration of ketamine at an analgesic dose.

The Joint Emergency Medicine Exercise: A Capstone Training Evolution of a Military Unique Curriculum for Emergency Medicine Residents.

INTRODUCTION: The role of the Emergency Medicine (EM) physician in the U.S. military continues to expand, and current Accreditation Council for Graduate Medical Education general training requirements do not optimally prepare military EM graduates to be successful in postresidency operational assignments. To address this gap, the Naval Medical Center San Diego EM residency program introduced a Military Unique Curriculum (MUC) culminating in a capstone event, the Joint Emergency Medicine Exercise (JEMX). METHODS: Part of an approved Quality Improvement project, annual survey results from 2012 to 2017 evaluated graduate opinion on the strengths and weaknesses of the MUC. We describe a pilot project conceived by tri-service EM physicians to evaluate the feasibility of the JEMX. RESULTS: Forty-eight graduate residents responded to surveys, 18 of which were administered pre-MUC implementation. With a 100% response rate from graduate residents, overall trends showed greater perceived readiness for postresidency operational assignments after MUC implementation. Written comments received cited the MUC as areas where the Naval Medical Center San Diego EM program excelled and the successful JEMX evolutions as the most valuable curricular component of the MUC. CONCLUSION: An integrated MUC with a capstone exercise, such as our JEMX, provides a feasible and effective educational experience that improves operational readiness of graduating EM residents.

Balancing Patient Care and Force Protection at Military Medical Treatment Facilities.

OBJECTIVES: This study aimed to identify delays of care due to base access security protocols at a stateside military medical treatment facility (MTF) for patients with a time-sensitive medical condition who are seeking emergency medical care at the MTF. METHODS: We retrospectively analyzed emergency medical services (EMS) run reports from January 1, 2017 to November 12, 2017 to hospital access points to assess patients who were initially denied access to the MTF. Time from EMS activation until patient delivery at the emergency department, number of time-sensitive complaints, number of time-sensitive conditions, and number of unauthorized access attempts are reported. RESULTS: During the 11-month period of review, 42 delays of care related to EMS activation by the sentry at hospital access points were identified. Of the 42, 14 were associated with a time-sensitive complaint, 2 with time-sensitive conditions, and none were unauthorized access attempts. CONCLUSION: We identify the potential for patient harm due to delays in care resulting from the security protocols at our MTF. A review of force protection requirements with consideration for their impact on patient safety, especially in cases of time-sensitive conditions, has been conducted.

An Assessment of Flight Surgeon Confidence to Perform En Route Care.

INTRODUCTION: En Route Care (ERC) is often an ad hoc mission for the USN. In a review of 428 Navy patient transports, a Flight Surgeon (FS) was the sole provider or a member of crew in 118 of the transports. Naval FSs receive approximately 4 hours of didactic ERC training during their 24-week Naval FS course. Regardless, an FS may be caring for a critically ill patient in a helicopter. We conducted a survey to evaluate FS confidence in their ability to perform ERC and to establish their understanding of the training of Search and Rescue Medical Technicians (SMT). MATERIALS AND METHODS: A convenience sample of FSs completed a needs analysis survey as part of a process improvement project. Flight Surgeons surveyed were actively assigned or had been assigned within the past year to a squadron with Search and Rescue/MEDEVAC capabilities. RESULTS: A total of 25 surveys were completed. An average of 13 (range 0-100) patient transport missions were performed by the respondents. Twenty-five percent reported feeling confident in their ability to provide ERC without senior level direction, while 41% stated they would require direction. Nearly 70% of the FSs surveyed expressed "minimal" or less understanding of the training of the SMT. CONCLUSIONS: Our survey results reveal most FSs are confident in neither their ability to perform ERC nor the ability of their hospital corpsman to provide care during patient movement.

Airway Management for Trauma Patients.

Trauma airway management is a critical skill for medical providers supporting combat casualties since it is an integral component of damage control resuscitation and surgery. This clinical practice guideline presents methods for optimizing the airway management of patients with traumatic injury in the operational medical treatment facility environment. The guidelines represent the knowledge and experience of 10 co-authors from 3 allied countries representing Emergency Medicine, Surgery and Anesthesia.

En Route Care Provided by US Navy Nurses in Iraq and Afghanistan.

BACKGROUND: US Navy nurses provide en route care for critically injured combat casualties without having a formal program for training, utilization, or evaluation. Little is known about missions supported by Navy nurses. OBJECTIVES: To characterize the number and types of patients transported and skill sets required by Navy nurses during 2 combat support deployments. METHODS: All interfacility casualty transfers between 2 separate facilities in Iraq and Afghanistan were assessed. Number of patients treated, number transported, en route care provider type, transport priority level and duration, injury severity, indication for critical care transport, en route care interventions, and vital signs were evaluated. RESULTS: Of 1550 casualties, 630 required medical evacuation to a higher level of care. Of those, 133 (21%) were transported by a Navy nurse, with 131 (98.5%) classified as "urgent," accounting for 46% of all urgent transports. The primary indication for en route care nursing was mechanical ventilation of intubated patients (97%). Mean (SD) patient transport time was 29.8 (7.9) minutes (range, 17-61 minutes). The most common en route care interventions were administration of intravenous sedation (80%), neuromuscular blockade (79%), and opioids (48%); transfusions (18%); and ventilation changes (11%). No intubations, cricothyroidotomies, chest tube placements, or needle decompressions were performed en route. No deaths occurred during transport. CONCLUSIONS: US Navy nurses successfully transported critically injured patients without observed adverse events. Establishing en route care as a program of record in the Navy will facilitate continuous process improvement to ensure that future casualties receive optimized en route care.

An Evaluation of Navy En Route Care Training Using a High-Fidelity Medical Simulation Scenario of Interfacility Patient Transport.

INTRODUCTION: Military prehospital and en route care (ERC) directly impacts patient morbidity and mortality. Provider knowledge and skills are critical variables in the effectiveness of ERC. No Navy doctrine defines provider choice for patient transport or requires standardized provider training. Frequently, Search and Rescue Medical Technicians (SMTs) and Navy Nurses (ERC RNs) are tasked with this mission though physicians have also been used. Navy ERC provider training varies greatly by professional role. Historically, evaluations of ERC and patient outcomes have been based on retrospective analyses of incomplete data sets that provide limited insight on ERC practices. Little evidence exists to determine if current training is adequate to care for the most common injuries seen in combat trauma patients. MATERIALS AND METHODS: Simulation technology facilitates a standardized patient encounter to enable complete, prospective data collection while studying provider type as the independent variable. Information acquired through skill performance observation can be used to make evidence-based recommendations to improve ERC training. This IRB approved multi-center study funded through a Congressionally Directed Medical Research Program grant from the Combat Casualty Care Intramural Research Joint En Route Care portfolio evaluated Navy ERC providers. The study evaluated 84 SMT, ERC RN, and physician participants in the performance of critical and secondary actions during an immersive, high-fidelity, patient transport simulation scenario focused on the care during an interfacility transfer. Simulation evaluators with military ERC expertise, blinded to participant training and background, graded each participant's performance. Inter-rater reliability was calculated using Cohen's Kappa to evaluate concordance between evaluator assessments. Categorical data were reported as frequencies and percentages. Performance attempt and accuracy rates were compared with likelihood ratio chi-square or Fisher's exact test where appropriate. Tests were two-tailed and we considered results significant, that is, a difference not likely due to chance exists between groups, if p < 0.05. Confidence intervals were used to present overlap in performance between provider types. RESULTS: Critical and secondary actions were assessed. A majority of providers completed at least one of the critical life-saving actions; only one participant completed all critical actions. Evaluation of critical actions demonstrated that a tourniquet was applied by 64% of providers, blood products administered by 46%, needle decompression performed by 51%, and a complete handoff report performed by 48%. Assessment of secondary actions demonstrated analgesic was accurately administered by 24% of all providers, and 44% reinforced the "hemorrhaging amputation site dressing." CONCLUSION: Over 98% of participants failed to properly perform all critical actions during the interfacility transfer scenario, which in a real-life combat casualty transport scenario could result in a preventable death. Study results demonstrate serious skill deficits among all types of Navy ERC providers. These data can be used to improve the training of Navy ERC providers, ultimately improving care to injured soldiers, sailors, airmen, and marines.

Benefit of Critical Care Flight Paramedic-Trained Search and Rescue Corpsmen in Treatment of Severely Injured Aviators.

During routine aircraft start-up procedures at a US Naval Air Station, an aviation mishap occurred, resulting in the pilot suffering a traumatic brain injury and the copilot acquiring bilateral hemopneumothoraces, a ruptured diaphragm, and hepatic and splenic contusions. The care of both patients, including at point of injury and en route to the closest trauma center, is presented. This case demonstrates a benefit from advanced life-saving interventions and critical care skills beyond the required scope of practice of search and rescue medical technicians as dictated by relevant instructions.