ICU Doc, Doug Powell, was on staff for the recent Prolonged Field Care train-the-trainer exercise in June, and he observed Medics running through multiple scenarios, each 24 hours in length.
He provided an in-depth evaluation of his AAR comments from the medical intensivist perspective. Some of the key points that are known to improve care in the ICU are directly transferable to PFC situations. In particular, documentation and communication – with your team, consultation experts, and at hand-off – are huge considerations, and implementing best practices doesn’t require fancy gadgets or new knowledge.
Other points: pharmacology – it’s boring and it sucks, but most importantly, it’s ESSENTIAL. If you carry the drug, know about it, and have a smart book or reference that details what it does.
Want to take it to the next level? Get out the ultrasound and make a point to learn and use it. Powerful clinical info at your fingertips. You have machines at Battalion – use them.
Most importantly, it comes down to training. Learn more about what you don’t know. Check out references on the website. Run through scenarios. Train your guys – your non-medical teammates may be essential to assist in patient care. Stay thirsty, my friends…
The AAR leads with 1 page of recommendations for critical care aspects of PFC.
Next are overall comments on critical care in PFC that the exercise brought into focus. These are followed by detailed comments on observations from and execution of the exercise.
PFC EXERCISE, JUNE 2015- CRITICAL CARE RECOMMENDATIONS
- Adopt PFC Casualty Card (latest version) as required documentation for critically ill/ injured patients in PFC environment. Train on its use to document, trend, interpret trends and act on interpretations in unit and MPT training.
- Develop protocol for hand-off of critical patients (format/ required information). This could be included on PFC casualty card or a stand-alone document.
- Improve pharmacology training and resources. Adopt, distribute and train with electronic reference (e.g. Lexicomp) that doesn’t require internet connection. Enhance PFC WG Comments to more detailed Recommendations/ Guidelines. Enhance pharmacology training at MPT sites.
- Replace “nursing care” with “patient care” and increase emphasis on patient care skills, e.g. flow-sheet documentation, written goals of care/ plan, closed-loop communication, preventive care (pressure ulcer, DVT/ PE risk reduction techniques). Identify and integrate critical care and flight nurses into PFC training and exercises.
- Increase critical care tele-consultation use, integrate into training (regional and local consultants), integrate suggested/ mandatory teleconsultation into critical task lists (e.g. mandatory for patient on ventilator, severe closed-head injury, etc…), study whether additional teleconsultation sites required, continue to work on more advanced tele-medicine capabilities (e.g. that include images, vitals trends).
- Identify Ultrasound as core PFC diagnostic, monitoring skill. Develop BN provider skills to SME level with courses, clinical practice. Increase frequency of 18D US training.
- Develop PFC guidelines for long-term monitoring and management of head injuries. None exist in JTTS Guidelines or TMEPs. Include monitoring (neuro exam/ GCS/ vitals), US evaluation of ICP (optic nerve-sheath [ONS] US), rough calculation of cerebral perfusion pressure using MAP/ ONS US, maneuvers to reduce ICP (positioning, hyperventilation, avoidance of hyperthermia, pain control, hyper-osmolar therapy).
- Develop enhanced ventilator training, initially using Impact vent, monitoring/ adjustment with pulse oximetry/ end-tidal CO2, basic troubleshooting, content to include classroom and G3 simulator training. Scope initially clinical, could grow to integrate basic CASEVAC vent considerations.
- Emphasize continuing education on PFC topics. PFC website and podcasts should be first recommended resource. PFC WG recommendations should be emphasized in training, tested in exercises. Encourage and fund subscriptions to medical journals/ podcasts.
- Encourage use of high-fidelity simulation resources in PFC training/ exercises. Provide training in running high-quality simulations for key 18Ds, PA’s, Surgeons. Draw on 18D experiences for case development. Work with JSOMTC and MPT sites on simulation development. Build library of simulator cases that Medics can use to build training events. Consider computer based individual simulation training (e.g. Humansim, Raleigh, NC).
- Continue to involve evac experts in exercises and CASEVAC/ en-route care critical task development and training.
OVERALL CRITICAL CARE COMMENTS
Improvement in ICU “systems” is the principal reason that mortality in the critically ill and injured has fallen by nearly 50% over the last 15 years. The main components of ICU systems improvement consist of improved communication, and reduction of preventable complications.
Prolonged field care of critical patients is essentially ICU care by a small number of providers in a resource limited environment. Although many of the resources of a modern ICU are not available in PFC, many of the “system improvements” that have improved ICU outcomes are. It should be a goal of PFC critical care to identify and emphasize these practices to PFC providers since they will impact their patients’ outcomes more than any technical skill or piece of knowledge.
The most important ICU system is communication. Elements of communication include:
- Clinical charting to capture trends, responses to interventions, facilitate early recognition of changes in clinical condition. Solution: critical care flow-sheet.
- Closed-loop communication among all providers involved in patients’ care. Solution: emphasize in 2-18D and full A Team scenario training.
- Multi-provider involvement in management of critically ill/ injured patients. Solution: tele- consultation.
- Listing of goals of care and review of key quality items on a checklist. Solution: critical care flow-sheet (key quality items R column; plan of care on back side).
- High-quality patient hand-offs. Solutions: i) use flow-sheet, ii) develop hand-off checklist.
The second most important ICU system is reduction of preventable complications. In PFC, preventable complications consist of:
- Provider errors: in PFC as in the hospital, usually due to fatigue. Solution: work-rest cycle, task delegation (guide w/plan of care on flow-sheet)
- Pressure ulcers. Solution: padding, turning training (hospital MPT, simulation)
- Deep venous thrombosis, pulmonary embolism (DVT/ PE). Solution: passive range-of-motion hourly (easily delegated).
- Core knowledge priorities:Shock, inflammatory response: The “why” of the golden hour. The physiologic rationale behind the close monitoring, documentation and trend tracking of critically ill patients to detect and intervene on deterioration at the earliest possible moment before the “genie” of inflammatory response “gets out of the bottle.”
- Trend assessment: Ties in with shock. Ideally, teach shock/ inflammatory response then go right into simulation where subtle changes in vital signs should be seen, documented and acted upon (and consequences demonstrated if they are not).
- Pharmacology: Medication administration has much greater emphasis in PFC vs. procedural skills because trauma patients will be managed for longer periods of time and will need analgesia, antibiosis and other symptom relief (e.g. antipyretics, anti-emetics). Many PFC casualties will also be due to non-trauma illness, e.g. severe infections, sepsis, septic shock requiring medical management.
- Core skills
- Ultrasound: The most powerful diagnostic tool in the SF Tacset and the ED, ICU. It should be a top procedural skill goal for all SOF Providers to become US SMEs and for 18Ds to become comfortable w/US.
- Ventilators: Will be critical equipment for some SOF missions. Basic set-up, monitoring/ setting changes and troubleshooting skills should be taught. Monitoring should be pulse-oximetry and end-tidal CO2 (not lab, acid-base based). Training should emphasize early tele-consultation.
- Education: PFC will place a higher burden of medical sustainment training on the 18D than is required to maintain proficiency with TCCC skills. Adding more medical training will be difficult. However as “big AMEDD” and MEDEVAC/ STRATEVAC support become less available, the burden of medical care from point-of-injury to (potentially) MEDCEN will fall on unit or theater-level resources, crucially the 18D. Commands need to be aware of the changing medical tactical situation in order to balance these new training requirements with the other responsibilities of the Team medic.
Creative medical training can incorporate newer modalities along with traditional methods. Ideas include:
- Clinical time: The recognition and management of critically ill/ injured patients over time in the PFC environment requires skills that are best learned from human models. It is best learned by mentored observation of sick patients and with hands-on patient care working with critical care nurses. MPTs in their current form, frequency may be insufficient to adequately sustain PFC skills. More frequent MPTs or other, more frequent, shorter-duration clinical experiences may need to be developed and integrated into the 18D training cycle.
- Podcasts: A good way to fit medical training into dead time. The Prolonged Field Care website has an expanding library of podcasts. Other sources include emergency medical and EMS journals.
- Journals/ Journal Club: A survey of paramedics working in emergency departments reported that many wanted more access to medical journals and discussion of medical topics with physician assistants and physicians. Examples for the PFC community include Journal of Special Operations Medicine, Journal of Emergency Medicine, Journal of Emergency Medical Services, Journal of Humanitarian Assistance, Journal of Military Medicine and Bulletin of the World Health Organization.
CRITICAL CARE CLINICAL SUBJECTS COMMENTS
Pharmacology: One of the biggest clinical knowledge gaps
Need better understanding of drug dose, time to effect, duration of effect by route (IM vs IV/IO)
– Very obvious w/Ketamine, where IM doses of 25 mg were often given resulting in inadequate dose because IM ketamine is only 25% the strength of IV (thus, 25 mg IM ~ 6mg IV/ IO).
– One team burned through their ketamine doses because they kept giving IM, needing 4 times more drug than had they converted to IV/ IO dosing.
The PFC Working Group paper on sedation and analgesia is a good overview, but doesn’t detail all of the important side effects of the drugs.
– e.g. the risk of respiratory depression with narcotics, benzodiazepines (midazolam).
– We had several patients over-dosed w/midazolam whose respirations went to 4/ min. Several teams intubated/ cric’d these patients because they didn’t recognize the mechanism of respiratory distress (over-dose of short-acting medication). They could have bagged these patients or assisted their breathing with a BVM for ~30 minutes and avoided taking control of the airway.
– Emphasize pharmacology in all PFC training, exercises.
– If possible, emphasize pharmacology training at MPT sites (if sites can make applicable to meds used by medics)
– A more detailed reference for the drugs used by SF medics is needed. Ideally written and digital/ app. Should include:
- Time to peak effect
- Half-life/ duration of effect
- Major side effects (especially effects on blood pressure, respirations)
- Differences in pharmacology between IM, IV/ IO dosing
- How to set up drips (n.b. epinephrine)
– Update PFC WG Sedation-Analgesia Comments to more detailed “Recommendations/ Guidelines”
– All medics should have a drug handbook (recommend Lexicomp on smartphone).
- Airway Management: Implications of intubation, cric’ing much greater in PFC.
- Without vent, need to bag
- Pulmonary care adds additional demands to stressed team (suctioning)
- Advanced airway takes P.O. medications, hydration, nutrition out of play.
- If intubated, need to sedate- potential drain on drug resources
- If vent available, adds difficulty to transport (cumbersome, difficult to secure).
- If vent available, adds additional equipment requirement (tubing)
Suggestion: Consider recommending trial of assisted ventilation for cases where patient can be mask ventilated and cause of respiratory failure is not obvious.
- Not all teams had Foley catheters, nasogastric tubes.
- Most considered oral, enteral fluids.
– Incorporate oral, enteral, rectal fluid administration into teaching, scenarios.
– Educate MPT providers that 18Ds may have to rely on non-IV fluid resuscitation due to resource limitations.
- Signs, symptoms of compartment syndrome missed by some groups
– Pain is cardinal symptom. Many teams responded by upping analgesia instead of assessing peripheral pulses, moving to escharotomy earlier.
1. Need to emphasize escharotomy depth, anatomic landmarks, length (cadaver lab?)
2. Include burn care in MPT, refresher training.
– Some difficulty calculating fluid requirements, rate.
– Many did not account for 2 hours prior to arrival so patient started behind .
– Few teams considered bolus fluids to make up deficit on top of hourly rate suggested by burn formula.
– Emphasize that formula merely suggests initial rate, which should be titrated to urine output after a few hours (thus all burn patients need Foley) to minimize risk of abdominal compartment syndrome.
Suggestion: Need to develop recs for burn wound care in PFC environment.
– Dressing type, frequency of changing
– Wound care: issues include cleansing, debridement. Recs for people w/access to burn unit and for those without burn unit access (e.g. local nationals).
– Systemic antibiotic recs
3. Blood products-Probably could have included a scenario that required fresh whole blood, giving medics a chance to role-play the equipment setup.
– Practice reconstituting freeze-dried plasma.
– Develop a simulator for whole blood donation/ transfusion.
4. Self-perceived significant knowledge gap. Confidence did not improve much after the scenario.
– Develop neuro critical care training for PFC. To include:
- Overview that goal of neuro-critical care is to minimize secondary injury
b. Evaluation closed head injury, elevated ICP: Clinical exam, vital signs trends, optic nerve sheath US.
- Treatment of elevated ICP: Calculation of cerebral perfusion pressure (CPP), mean arterial pressure (MAP) pushes, ICP lowering maneuvers (position, mild hyperventilation, hyper-osmolar therapy)
- Neurogenic shock: risk factors (T4 and above spinal injury) and treatment (BP support w/fluids, pressors).
– Integrate cases into PFC training, exercises.
– Consider adding neuro critical care experience to MPT.
COMMUNICATION, DOCUMENTATION, TRANSFER OF CARE COMMENTS
- Critical Care Documentation: Biggest “systems” gap. This and the gap in pharmacology knowledge were the two biggest risks to patient safety.
- Most teams used variation of white board, butcher-block recording of vitals, interventions.
- Made interpretation of trends difficult (vs linear graphics on ICU flowsheet)
- Many teams missed key diagnoses (respiratory depression by over-medication w/midazolam, circulatory shock due to under-resuscitation of burns, compartment syndrome) early because trends not easy to spot.
- Required transcribing IOT hand patient off to flight crew. Most transcribed handoff documentation was suboptimal, could have resulted in poor/ harmful care en route.
– Adopt some form of a flowsheet as a standard documentation for the care of critically ill, injured patients.
– Require this as hand-off documentation.
– Emphasize, teach use in training, exercises.
- Medics gave good reports, asked good questions.
- Only some wrote down answers.
- Only one group used PFC flowsheet which has space for “tele-medicine recommendations”
– Continue to develop Critical Care (CC) tele-consultation capabilities. Phone-only is valuable first step and should be prioritized while other multi-media modes are investigated.
– Call-back capability from consultant to medic is important capability to ensure.
– Goal should be to have CC tele-consultation PACE plan that includes 24-hour CC Consultant as “A” (alternate) available 24-7 ASAP
– Teleconsultants should understand capabilities of medic, ideally by observing PFC training, alternatively by watching video from training events/ exercises.
– A more refined critical care tele-consultation script should be developed. PFC WG should designate committee of medics/ docs to work on this.
– Tele-medicine should be emphasized in PFC training events/ exercises. If training need is too much for LRMC to support, alternate local or AMEDD critical care resources should be identified.
– Should share tele-consultation efforts with AMEDD ICU tele-medicine working group to explore possibility of more advanced clinical information sharing (e.g. vitals, imaging).
- Hand-offs: Quality of written information for flight crew, next echelon of care to refer to is significant gap.
- Only one team used good flowsheet as hand-off document.
- A well-completed flowsheet is the most important piece of “equipment” for managing a critically ill patient in prolonged field care.
- On a long evac, a lot of things can be mis-managed en route without good documentation to refer to. Examples include:
- Amount of fluid given in burn resuscitation (did patient arrive w/too much, too little?
Do we need to play catch up en route? Slow down?)
ii. Last dose of important medications: e.g. paralytics (to ensure sedation is given so paralyzed patient won’t be unsedated), pain medications (to reduce risk of over-dose), antibiotics (to ensure no gap in antibiotic dosing).
– Adopt critical care flowsheet as standard and train to use on all critically ill/ injured PFC patients. Examples include PFC WG flowsheet
Patient packaging: Uneven. Some well packaged, others poorly.
– Incorporate packaging into training.
– Continue to involve medical transport SMEs (MEDEVAC) in PFC training, exercises.
SCENARIOS, SIMULATIONS COMMENTS
- Length of exercise:
– Some comments that participants pushed to stay awake for entire exercise so they would not miss “training benefit” and that optimum length should be 12 – 18 hours.
– Conversely, if setting rest cycles, delegation of work is a goal; maybe exercises have to be longer, e.g. days as in Swedish Remedy, to force participants to rest.
– Scenarios were pretty good test of PFC skills and pretty well-spaced to push but not overwhelm participants.
– Format that scenarios were written up in, with “if-thens,” “goals” seemed pretty good starting point for proctors to use to run their lanes.
– Develop “library” of PFC cases with proctor notes that units can draw on for training.
– Use the format for scenario write-ups as a standard for this type of training, exercise.
– Very well set-up and run by the MSTC. Using professional simulation resources should be a standard for this sort of training, exercise.
– Simulator operators did very well, however most were not pre-briefed by the Cadre and some took a bit of time to get comfortable running their scenarios.
– Simulations and human role-players have a much more important role in PFC than in TCCC because they can provide ongoing clinical data (e.g. vital signs, urine output), exams and feedback to interventions (e.g. pain control)
– More time for Cadre to work with the sim operators assigned to their lanes to rehearse the cases.
– Work-rest cycle for sim operators (4 – 6 hours on before resting).
– Encourage use of high-fidelity simulation resources in PFC training/ exercises. Examples include: MSTC, MEDCOM hospital based simulation labs, civilian hospital based (e.g. Campbell in Fayetteville, Baylor in Dallas) simulation labs.
– Promote training in running high-quality simulations for key 18Ds, PA’s, Surgeons.
– Simulation cases developed for PFC should become intellectual property of USASOC, to facilitate sharing across Groups.
9 July 2015