Thursday, April 8, 2010

Fly me to the moon

The military's air evacuation system is multifaceted and complex.  I am more of the end user.

For instance: Infantry gets shot.  BattleBuddies carry guy to bunker and triage him.  Helicopter (or truck, then helicopter) brings him to the local hospital or medical unit.  Guy gets stabilized as best as possible.  Helicopter or small plane brings guy here.  Guy gets more stabilized.  Guy gets sent to US via Germany.

As a small and compact, but true Level I trauma center, we are prepared to do a variety of things here which include vascular, neurological, urological, orthopedic, ophthamologic and head and neck surgery.  We are not a multifaceted medical facility, however, insofar as we do not have a catheterization laboratory, dialysis, chemotherapy or endoscopy.  This is by design and for obvious reasons, but as one can imagine, it limits what we can do for the ill surgery patients, and obviates definitive care for the medical patients.  For example, there is no heart surgeon or stent-placing cardiologist to rescue a patient in cardiac shock after a heart attack.  We maximize medical managment, package, and ship.  As a service to the many contractors in theater, the military provides medical care and transportation, for an undisclosed and negotiated contract, to ill service members.  This seems like the right thing to do for the multinational work force that supports the military.  As I have discussed previously, it is neither safe to send most of the individuals to local hospitals where they may be perceived as complicit with imperialists by the Bad Guys, nor is it a standard of medical care that Americans are prepared to accept, given the departure of senior physicians and scientists and a now fledgling medical education system.  Recall, however, that there are 100,000 contractors in the AOR.  Most companies do not screen deployed individuals as does the military; ergo, the 58 yo smoker with diabetic-foot who presents to our ER in sepsis.  As the planned withdrawal ensues, and the smaller bases close, we are all curious as to what will happen to these individual who are placed throughout the country.  Will they all come here?  Anyway, that is not the point of this piece, and I will save room to debate that another day.

More interesting at the moment, is the evacuation of patients, at least from the end use perspective.  We provide definitive therapy (ie, sewing up bowel in a IED victim, neurosurgery from gunshot wound--or soccer ball as shared earlier--or antibiotics, vasopressive agents and supportive care in the patients with severe infection and sepsis), and often, just stabilize patients (eg nitroglycerin drip, morphine and aspirin for a patient with a new heart attack) for the 5 hour flight to Landshtuhl Medical Center (LRMC) in Germany.  American military all go this route, eventually, on their way back to the states.  American contractors most often use the same channel.  The non-American contractors, however, are usually sent at the expense of their contracting agency to some place closer, and in this part of the world, that means Kuwait, Saudi, Egypt or Jordan, which are replete with excellent physicians and facilities.  [I understand the Emirates are also well equipped, but are likely too expense.  Given the price of a night at Dubai's Grand Hyatt (starting at $960, I can understand this].

Ideally, the contract agency is suppose to arrange for pick up of the patient at the US Air base.  As can be imagined, however, it doesn't always go so smooth.  With Germany, it is really easy as there one hospital and a set of people who know the rules and each other.  When contractors are ferried around the region, however, it is not uncommon for the plane to arrive without a proper hand-off of the baton.  Meaning, of course, that the transporting military team is not met with the reception promised them by the contractor.

Most people aren't malicious, and this is usually due to a miscommunication, but this can lead to less than desirable situations.  Take for instance, the other night, when I sent the intubated Asian stroke patient to Kuwait with the CCATT (critical care air transport team) team.  The contracting agency had arranged for transportation to a civilian hospital to be ready at the terminal when the CCATT arrived.  Well, the ambulance wasn't there, the hospital, 45 minutes away, had no room and had never heard of the patient.  The CCATT team, being medical people and doing what was right for the patient, brought the patient to appropriate care.  Clearly, however, not the role of military folk, and an example of how if you offer the contracting agencies a nibble, they bite off your finger.  I can imagine this scenario repeating itself, potentially putting uniformed military medical personnel, without a security detail, at risk and the expense of the tax payer.  Let's hope not. 

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