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12/08/2019

Soutien médical:Les enjeux du transport

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Soutien médical:Les enjeux du transport

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07/06/2019

Drone et SAR. C'est pour demain

The potential use of unmanned aircraft systems (drones) in mountain search and rescue operations.

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Gagner du temps dans la localisation des victimes, c'est ce que pourrait apporter l'utilisation de drone. L'application opérationnelle pour la prise en charge de blessés de guerre comporte des contraintes différentes mais à n'en pas douter le train est en marche.

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Objective: This study explores the potential use of drones in searching for and locating victims and of motorized transportation of search and rescue providers in a mountain environment using a simulation model.

Methods: This prospective randomized simulation study was performed in order to compare two different search and rescue techniques in searching for an unconscious victim on snow-covered ground. In the control arm, the Classical Line Search Technique (CLT) was used, in which the search is performed on foot and the victim is reached on foot. In the intervention arm, the Drone-snowmobile Technique (DST) was used, the search being performed by drone and the victim reached by snowmobile. The primary outcome of the study was the comparison of the two search and rescue techniques in terms of first human contact time.

Results: Twenty search and rescue operations were conducted in this study. Median time to arrival at the mannequin was 57.3 min for CLT, compared to 8.9 min for DST. The median value of the total searched area was 88,322.0 m2 for CLT and 228,613.0 m2 for DST. The median area searched per minute was 1489.6 m2 for CLT and 32,979.9 m2 for DST (p b 0.01 for all comparisons).

 

Operation  Recherche classique Recherche par drone
First human contact 
(min)
Total searched area 
(m )
Searched area for a minute 
(m /min)
First human contact 
(min)
Total searched area 
(m )
Searched area for a minute 
(m /min)
1 39.0 66,408 1702.8 7.7 168,395 28,065.8
2 53.1 78,209 1475.6 8.2 217,624 33,225.1
3 67.1 88,664 1323.3 8.5 239,602 35,080.8
4 95.0 120,891 1272.5 11.2 310,981 32,734.8
5 50.2 85,861 1717.2 5.6 192,224 49,162.1
6 95.2 104,479 1099.8 13.1 346,268 30,294.7
7 54.0 98,385 1821.9 7.4 144,480 25,302.9
8 61.1 77,378 1268.5 4.2 138,945 54,488.2
9 59.1 87,980 1503.7 9.7 266,722 33,340.3
10 56.1 99,375 1774.6 12.9 313,525 27,968.3
Median 
(25–75%)
57.3 
(52.3–74.0)
88,322.0 
(78,001.3–100,651.0)
1489.7 
(1271.5–1731.6)
8.4 
(6.9–11.6)
228,613.0 
(162,416.0–311,617.0)
32,979.9 
(28,041.4–8601.1)

 

Conclusions: In conclusion, a wider area can be searched faster by drone using DST compared to the classical technique, and the victim can be located faster and reached earlier with rescuers transported by snowmobile

31/05/2019

Hémorragie du tronc non compressible: MEDEVAC COURTE

Impact of prehospital medical evacuation (MEDEVAC) transport time on combat mortality in patients with non-compressible torso injury and traumatic amputations: a retrospective study

BACKGROUND:

In combat operations, patients with traumatic injuries require expeditious evacuation to improve survival. Studies have shown that long transport times are associated with increased morbidity and mortality. Limited data exist on the influence of transport time on patient outcomes with specific injury types. The objective of this study was to determine the impact of the duration of time from the initial request for medical evacuation to arrival at a medical treatment facility on morbidity and mortality in casualties with traumatic extremity amputation and non-compressible torso injury (NCTI).

METHODS:

We completed a retrospective review of MEDEVAC patient care records for United States military personnel who sustained traumatic amputations and NCTI during Operation Enduring Freedom between January 2011 and March 2014. We grouped patients as traumatic amputation and NCTI (AMP+NCTI), traumatic amputation only (AMP), and neither AMP nor NCTI (Non-AMP/NCTI). Analysis was performed using chi-squared tests, Fisher's exact tests, Cochran-Armitage Trend tests, Shapiro-Wilks tests, Wilcoxon and Kruskal-Wallis techniques and Cox proportional hazards regression modeling.

RESULTS:

We reviewed 1267 records, of which 669 had an injury severity score (ISS) of 10 or greater and were included in the analysis. In the study population, 15.5% sustained only amputation injuries (n=104, AMP only), 10.8% sustained amputation and NCTI (n=72, AMP+NCTI), and 73.7% did not sustain either an amputation or an NCTI (n=493, Non-AMP/NCTI). AMP+NCTI had the highest mortality (16.7%) with transport time greater than 60 min. While the

NCTI.jpeg

AMP+NCTI group had decreasing survival with longer transport times, AMP and Non-AMP/NCTI did not exhibit the same trend.

CONCLUSIONS:

A decreased transport time from the point of injury to a medical treatment facility was associated with decreased mortality in patients who suffered a combination of amputation injury and NCTI. No significant association between transport time and outcomes was found in patients who did not sustain NCTI. Priority for rapid evacuation of combat casualties should be given to those with NCTI.

08/04/2019

CCATT: LA voie à suivre pour les EVAC

En Route Resuscitation – Utilization of CCATT to Transport and Stabilize Critically Injured and Unstable Casualties 

Maddry JK et Al Mil Med. 2018 Dec 7. doi: 10.1093/milmed/usy371.

 

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Une démarche qui prône l'emploi de spécialistes ayant une pratique régulière et avancée de la réanimation et de l'anesthésie du  traumatisé pour le transport des blessés de guerre. Elle doit être rapprochée du concept des MERT-Enhanced UK. 

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Introduction:

The U.S. Air Force utilizes specialized Critical Care Air Transport Teams (CCATT) for transporting “stabilized” patients. Given the drawdown of military forces from various areas of operation, recent
CCATT operations have increasingly involved the evacuation of unstable and incompletely resuscitated patients from far forward, austere locations. This brief report describes unique cases representative of the evolving CCATT mission and provides future direction for changes in doctrine and educational requirements in preparation for en route combat casualty care. Methods and Materials: This case series describes three patients who required significant resuscitation during CCATT transport from austere locations between April and November 2017. Approval for this project was received from the US Air Force 59th Medical Wing Institutional Review Board as non-research.

Results:

Case 1:


CCATT was dispatched to transport patient 1 who was reported to have a head injury after a fall. Upon evaluation of the patient onboard the aircraft, it was discovered that the patient was in cardiac arrest. Cardiopulmonary resuscitation was performed during tactical takeoff with frequent combat maneuvers. The patient developed a palpable pulse after three rounds of CPR, three doses of epinephrine, and one unit of packed red blood cells. Point of care laboratory analysis demonstrated a profoundly elevated lactate level. Cyanide poisoning was a concern but there was no antidote available in the available equipment set. After delivery to a medical facility, blood samples were positive for cyanide. Over the next 2 weeks, the patient improved and was discharged home, neurologically intact.

Case 2:

Patient 2 sustained complex blast injuries and bilateral lower extremity amputations. He required early transport for continuous renal replacement therapy (CRRT). The patient received 200 units of blood products in the 24 hours prior to transport and developed renal failure, pulmonary edema, and elevated ICP. During the 7 hour flight, Patient 2 received frequent adjustments of vasopressor medications, multiple Dakins solution soaks and flushes, and 1 unit of fresh frozen plasma. He  mained alive 2 months later.

Case 3:

The team was notified to collect an urgent patient with a blast lung injury and bilateral lower extremity amputations. The ground team encountered difficulty ventilating the patient. Patient 3 arrived in the back of a pickup truck accompanied by medics and being bag valve mask ventilated with a pulse oximetry reading of 65%. He was secured to the floor of the aircraft which departed within 5 minutes of arrival. An ultrasound of the lungs showed no pneumothorax. By the end of the flight, the patient’s oxygen saturation had risen to 95% and he was delivered to the emergency department in stable condition. He later passed away in the operating room due to severe blast lung and cardiac contusion.

Conclusion: This brief report demonstrates the need of CCATT in the transport of unstable patients from forward deployed locations. The Air Force has adapted and is continuing to adapt CCATT training, equipment, onboard diagnostics and therapies, and team members’ clinical skills to meet en route care combat casualty needs.

16/03/2019

CASE EVAC/MEDEVAC: Besoin de clarification

A Descriptive Analysis of Causalities Undergoing CASEVAC from the Point-of-Injury in the Department of Defense Trauma Registry

 
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Ce travail porte sur l'analyse des blessés pris en charge du point de blessure jusqu'au premier échelon chirurgical par des moyens non dédiés spécifiquement. Si les lésions des membres sont les pljus fréquentes, les lésions les plus graves intéressent le thorax. La survie est importantes. Les auteurs pointent cependant du doigt les difficultés d'interprétation de leurs registres et le recours à des moyens non santé armés par du personnel médical, notamment pour les opérations spéciales. A noter la présence de données concernant les opérations en irak et en syrie.
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Introduction

The recent conflicts in Iraq and Afghanistan entail an asymmetric battlefield without clearly defined forward lines of troops as seen in previous wars. Accordingly, the United States military medical services have increasingly adopted casualty evacuation (CASEVAC) platforms. We describe CASEVAC events reported within the Department of Defense Trauma Registry (DODTR).

Materials and Methods

This is a secondary analysis of previously published data from two datasets spanning from 2007 through 2017. We isolated casualties within our dataset that had a documented evacuation method from the point-of-injury other than dedicated medical evacuation platforms (e.g., MEDEVAC, etc.).

Results

During OPERATION IRAQI FREEDOM, three casualties underwent CASEVAC. The median age was 30 and all were male. Most sustained injuries from explosives (67%) and the median composite injury scores were low (10). The most frequent seriously injured body region was the thorax (67%). All survived to hospital discharge. During operations in Afghanistan (OPERATION ENDURING FREEDOM, OPERATION FREEDOMS SENTINEL, OPERATION NEW DAWN), 248 casualties underwent CASEVAC. The median age was 28 and most (96%) were male. Most sustained injuries from explosives (58%) and the median injury score was low (9). The most frequent seriously injured body region was the extremities (24%). Most (97%) survived to hospital discharge. During OPERATION INHERENT RESOLVE, 247 casualties underwent CASEVAC. The median age was 21 and most (96%) were male. The majority sustained injuries from explosives (61%) and the median injury score was low (9). The most frequent seriously injury body region was the extremities (27%). Most survived to hospital discharge (94%).

Conclusions

In our dataset, CASEVAC events most frequently involved US military personnel service members with most surviving to hospital discharge. Developing new terminology that distinguishes different types of CASEVAC would allow for more accurate future analyses of casualty evacuation and outcomes – such as those transports that are truly in a non-medical versus the various medical platforms that do not fall with into the confines of the MEDEVAC platforms.

02/11/2018

Blessés admis en role 2: Le bilan afghan

Review of Casualties Transported to Role 2 Medical Treatment Facilities in Afghanistan.

Kotwal RS  et Al. Mil Med. 2018 Mar 1;183(suppl_1):134-145

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Ce document met en évidence tout l'apport d'une chaine coordonnée de prise en charge du traumatisé par des équipes entraînées appliquant une stratégie médico-chirurgicale moderne.

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Critically injured trauma patients benefit from timely transport and care. Accordingly, the provision of rapid transport and effective treatment capabilities in appropriately close proximity to the point of injury will optimize time and survival. Pre-transport tactical combat casualty care, rapid transport with en route casualty care, and advanced damage control resuscitation and surgery delivered early by small, mobile, forward-positioned Role 2 medical treatment facilities have potential to reduce morbidity and mortality from trauma. This retrospective review and descriptive analysis of trauma patients transported from Role 1 entities to Role 2 facilities in Afghanistan from 2008 to 2014 found casualties to be diverse in affiliation and delivered by various types and modes of transport. Air medical evacuation provided transport for most patients, while the shortest transport time was seen with air casualty evacuation. Although relatively little data were collected for air casualty evacuation, this rapid mode of transport remains an operationally important method of transport on the battlefield. For prehospital care provided before and during transport, continued leadership and training emphasis should be placed on the administration and documentation of tactical combat casualty care as delivered by both medical and non-medical first responders.

08/09/2018

Le TCCC dans la vraie vie

Survey of Casualty Evacuation Missions Conducted by the 160th Special Operations Aviation Regiment During the Afghanistan Conflict.

 
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Une vision des techniques mises en oeuvre en préhospitalier par des équipes américaines en afghanistan. Les pratiques gestuelles mies en oeuvre sur le terrain et en cours d'évacuation sont décrites. Ces dernières doivent être maîtrisées, ce qui est un vrai challenge en terme de formation et d'implication des équipes
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BACKGROUND:

Historically, documentation of prehospital combat casualty care has been relatively nonexistent. Without documentation, performance improvement of prehospital care and evacuation through data collection, consolidation, and scientific analyses cannot be adequately accomplished. During recent conflicts, prehospital documentation has received increased attention for point-of-injury care as well as for care provided en route on medical evacuation platforms. However, documentation on casualty evacuation (CASEVAC) platforms is still lacking. Thus, a CASEVAC dataset was developed and maintained by the 160th Special Operations Aviation Regiment (SOAR), a nonmedical, rotary-wing aviation unit, to evaluate and review CASEVAC missions conducted by their organization.

METHODS:

A retrospective review and descriptive analysis were performed on data from all documented CASEVAC missions conducted in Afghanistan by the 160th SOAR from January 2008 to May 2015. Documentation of care was originally performed in a narrative after-action review (AAR) format. Unclassified, nonpersonally identifiable data were extracted and transferred from these AARs into a database for detailed analysis. Data points included demographics, flight time, provider number and type, injury and outcome details, and medical interventions provided by ground forces and CASEVAC personnel.

RESULTS:

There were 227 patients transported during 129 CASEVAC missions conducted by the 160th SOAR. Three patients had unavailable data, four had unknown injuries or illnesses, and eight were military working dogs. Remaining were 207 trauma casualties (96%) and five medical patients (2%). The mean and median times of flight from the injury scene to hospital arrival were less than 20 minutes. Of trauma casualties, most were male US and coalition forces (n = 178; 86%). From this population, injuries to the extremities (n = 139; 67%) were seen most commonly. The primary mechanisms of injury were gunshot wound (n = 89; 43%) and blast injury (n = 82; 40%). The survival rate was 85% (n = 176) for those who incurred trauma. Of those who did not survive, most died before reaching surgical care (26 of 31; 84%).

CONCLUSION:

Performance improvement efforts directed toward prehospital combat casualty care can ameliorate survival on the battlefield. Because documentation of care is essential for conducting performance improvement, medical and nonmedical units must dedicate time and efforts accordingly. Capturing and analyzing data from combat missions can help refine tactics, techniques, and procedures and more accurately define wartime personnel, training, and equipment requirements. This study is an example of how performance improvement can be initiated by a nonmedical unit conducting CASEVAC missions.

08/08/2018

A 400M allemand : Prêt pour les MEDEVAC

JAV20180801172118.jpg

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L'Allemagne dispose à présent de la capacité d'évacuation aéromédicale à bord d'un A400M. Le premier kit « Intensive care aeromedical evacuation » (ICAE) a été mis en service ce 1er août, avec un délai d'alerte à 12 heures. Au total, la Luftwaffe disposera à terme de quatre kits, intégrable aux A400M en quatre heures, pour prendre en charge le rapatriement de blessés - aussi bien allemands qu'européens, voire des autres pays membres de l'OTAN.


Le kit ICAE permettra de prendre en charge jusqu'à six blessés allongés avec oxygénothérapie et appareils de réanimation, dont deux en unité de soins intensifs, deux blessés de catégorie intermédiaire et deux blessés plus légers. L'équipe médicale est quant à elle composée de 11 personnels, de différentes spécialités. (source).

12/04/2018

La vitesse ne fait pas tout

Speed is not everything: Identifying patients who may benefit from helicopter transport despite faster ground transport.

Chen X et Al.  J Trauma Acute Care Surg. 2018 Apr;84(4):549-557

 

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Ne pas perdre de temps est bien. Mais il ne faut pas oublier également que la réalisation de gestes avancés de réanimation est aussi utile en préhospitalier. Ceci milite pour la constitution d'équipes dont l'expertise en matière de gestion des voies aériennes/Trauma thoracique-Crânien est le métier. Cette question se pose tout particulièrement pour les vecteurs d'EVASAN à voilure tournante.

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BACKGROUND:

Helicopter emergency medical services (HEMS) have demonstrated survival benefits over ground emergency medical services (GEMS) for trauma patient transport. While HEMS speed is often-cited, factors such as provider experience and level of care may also play a role. Our objective was to identify patient groups that may benefit from HEMS even when prehospital time for helicopter utilization is longer than GEMS transport.

METHODS:

Adult patients transported by HEMS or GEMS from the scene of injury in the Pennsylvania State Trauma Registry were included. Propensity score matching was used to match HEMS and GEMS patients for likelihood of HEMS, keeping only pairs in which the HEMS patient had longer total prehospital time than the matched GEMS patient. Mixed-effects logistic regression evaluated the effect of transport mode on survival while controlling for demographics, admission physiology, transfusions, and procedures. Interaction testing between transport mode and existing trauma triage criteria was conducted and models stratified across significant interactions to determine which criteria identify patients with a significant survival benefit when transported by HEMS even when slower than GEMS.

RESULTS:

From 153,729 eligible patients, 8,307 pairs were matched. Helicopter emergency medical services total prehospital time was a median of 13 minutes (interquartile range, 6-22) longer than GEMS. Patients with abnormal respiratory rate (odds ratio [OR], 2.39; 95% confidence interval [CI], 1.26-4.55; p = 0.01), Glasgow Coma Scale score of 8 or less (OR, 1.61; 95% CI, 1.16-2.22; p < 0.01), and hemo/pneumothorax (OR, 2.25; 95% CI, 1.06-4.78; p = 0.03) had a significant survival advantage when transported by HEMS even with longer prehospital time than GEMS. Conversely, there was no association between transport mode and survival in patients without these factors (p > 0.05).

CONCLUSION:

Patients with abnormal respiratory rate, Glasgow Coma Scale score of 8 or less, and hemo/pneumothorax benefit from HEMS transport even when GEMS transport was faster. This may indicate that these patients benefit primarily from HEMS care, such as advanced airway and chest trauma management, rather than simply faster transport to a trauma center.

| Tags : evasan

18/10/2017

On peut rêver

 

2831672018.2.jpg

Philippe Chapleau nous apprend que dans le cadre de son déploiement en Europe, les 1900 soldats de la 1st Air Cavalry Brigade disposera disposeront de 12 Chinook, 38 Black Hawk, 24 Apache e15 Black Hawk médicalisés. On peut rêver.

| Tags : medevac

26/03/2017

MEDEVAC Sangaris: Du médical avant tout

Évacuations médicales aériennes tactiques et stratégiques en République centrafricaine au cours de l’opération « Sangaris ». Synthèse des onze premiers mois d’opérations

Beylot V. et Al. médecine et armées, 2016, 44, 4, 087-096

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Un état des lieux intéressants qui n'est pas sans rappeler l'histoire de nos anciens confrontés à l'isolement et à la dureté du climat. Les causes médicales de MEDEVAC en première ligne dont le Paludisme ?, les envenimations scorpioniques, les problèmes dentaires. Les blessures par armes de guerre apparaissent beaucoup moins fréquentes. Le contexte d'intervention: une guerre civile, les élongations et les problèmes climatiques expliquent beaucoup de chose. Une grosse différence l'emploi quasi systématique, hors Bangui, du vecteur aérien pour les medevac, vecteur ldont la mise en oeuvre a pu être optimisé par un centre de coordination dont le rôle est essentiel.

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Au cours des onze premiers mois de l’opération « Sangaris », 249 évacuations médicales aériennes tactiques et 186 évacuations médicales aériennes stratégiques ont été réalisées. Nous proposons ici une présentation synthétique de ces évacuations. Dans les motifs d’évacuation, la place importante du paludisme (29 % des évacuations tactiques) est un reflet de l’épidémie à laquelle les forces françaises ont été confrontées. Les conditions de déploiement en interposition ont pu amplifier l’impact psychiatrique de cette mission (28 % des évacuations stratégiques) et participer à la réouverture du sas de fin de mission. La place des blessures de guerres (9 % des évacuations tactiques et 13 % des évacuations stratégiques) majoritairement dues à des éclats de grenades reste importante et illustre le risque inhérent à cet engagement.

MEDEVAC Sangaris 1.jpg

 

Enfin, si la chaîne de santé complète déployée au plus proche, en passant notamment par la nomadisation des équipes héliportées, a permis d’assurer un soutien médical de qualité, l’étendue de ce théâtre nous interpelle sur les délais et la catégorisation utilisée lors des évacuations tactiques.

 

| Tags : medevac

17/03/2017

CSAR: Expérience israélienne

Prehospital Blood Transfusion During Aeromedical Evacuation of Trauma Patients in Israel: The IDF CSAR Experience.

 Chen J et Al. Mil Med. 2017 Mar;182(S1):47-52

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L'expérience d'une unité CSAR un peut particulière, très entraînée et dépendant des Forces spéciales. La transfusion se fait sur la basse d'un njugement clinique. Il est intéressant de voir que ces équipes intubent, drainent, exsuffle autant qu'elles posent de garrots.

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BACKGROUND: Data regarding the effect of prehospital blood administration to trauma patients during short-to-moderate time evacuations is scarce. The Israel Air Force Airborne Combat Search and Rescue is the only organization that deals with aeromedical evacuation for both military and civilian casualties in Israel and the only one with the ability to give blood in the prehospital setting.

METHODS: Data on packed red blood cells (PRBCs) administration in the evacuation missions from January 2003 to June 2010 were analyzed and actual transfusion practice was compared to clinical practice guidelines (CPGs).

RESULTS: Over the studied 101 months, a total of 1,721 patients were evacuated by Combat Search and Rescue. Of these, 87 (5.1%) trauma patients were transfused with PRBC. Demographics included 83% male and 17% female with a median age of 23 years. Main mechanisms of injury included gunshot wounds (36%), motor vehicle accidents (28%), and blast injuries (24%) with an average of 2.6 injured regions per casualty. The most commonly injured body regions included lower extremities (52%), chest (45%), and abdomen (38%). Overall, 10 (11%) casualties died. Lifesaving intervention included tourniquets (27%), endotracheal intubation (24%), tube thoracostomy (24%), and needle thoracostomy (21%) times. For 98% of the patients, clinical judgment led to administration of red blood cells before indicated by the CPG. The heart rate tended to decrease during the evacuation, whereas there was no clear trend in systolic or diastolic blood pressure or shock index.

CONCLUSIONS: In our aeromedical experience, transfusion of PRBCs for trauma patients was safe, feasible, and most likely beneficial. PRBCs were administered according to the flight surgeons' clinical judgment and not in complete adherence to CPGs in most cases. Data collected from this and similar studies worldwide have led to change in CPGs with the shift from hypertensive resuscitation to hypotensive-hemostatic Remote Damage Control Resuscitation.

18/01/2017

MEDEVAC de la BSS: En gros que fait on ?

Forward medevac during Serval and Barkhane operations in Sahel: A registry study.

Carfantan C, et Al. Injury. 2017 Jan;48(1):58-63.

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Une activité particulièrement sensible dont la lecture permet de comprendre toute la complexité de la prise en charge de nos soldats dans un contexte d'élongation majeure. On comprend également tous les enjeux de positionnement d'équipes sanitaires ayant la maîtrise de certaines pratiques avancées de réanimation préhospitalière.

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INTRODUCTION:

The French army has been deployed in Mali since January 2013 with the Serval Operation and since July 2014 in the Sahel-Saharan Strip (SSS) with the Barkhane Operation where the distances (up to 1100km) can be very long. French Military Medical Service deploys an inclusive chain from the point of injury (POI) to hospital in France. A patient evacuation coordination cell (PECC) has been deployed since February 2013 to organise forward medical evacuation (MEDEVAC) in the area between the POI and three forward surgical units. The purpose of this work was to study the medical evacuation length and duration between the call for Medevac location accidents and forward surgical units (role 2) throughout the five million square kilometers French joint operation area.

MATERIALS AND METHODS:

Our retrospective study concerns the French patients evacuated by MEDEVAC from February 2013 to July 2016. The PECC register was analysed for patients' characteristics, NATO categorisation of gravity (Alpha, Bravo or Charlie who must be respectively at hospital facility within 90min, 4h or 24h), medical motive for MEDEVAC and the time line of each MEDEVAC (from operational commander request to entrance in role 2).

RESULTS:

A total of 1273 French military were evacuated from February to 2013 to July 2016; 533 forward MEDEVAC were analysed. 12,4% were Alpha, 28,1% Bravo, 59,5% Charlie. War-related injury represented 18,2% of MEDEVAC. The median time for Alpha category MEDEVAC patients was 145min [100-251], for Bravo category patients 205min [125-273] and 310min [156-669] for Charlie. The median distance from the point of injury to role 2 was 126km [90-285] for Alpha patients, 290km [120-455] km for Bravo and 290km [105-455] for Charlie.

CONCLUSIONS:

Patient evacuation in such a large area is a logistic and human challenge. Despite this, Bravo and Charlie patients were evacuated in NATO recommended time frame. However, due to distance, Alpha patients time frame was longer than this recommended by NATO organisation. That's where French doctrine with forward medical teams embedded in the platoons is relevant to mitigate this distance and time frame challenge.

| Tags : evasan

03/12/2016

Combat MEDEVAC: Par qui ?

Combat MEDEVAC: A comparison of care by provider type for en route trauma care in theater and 30-day patient outcomes.

Maddry JK et Al. J Trauma Acute Care Surg. 2016 Nov;81(5 Suppl 2 Proceedings of the 2015 Military Health System Research Symposium):S104-S110.

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L'intérêt e la présence d'un personnel à bord d'un vecteur d'évacuation est l'objet de débats passionnés. Le travail présenté ici rapporte l'analyse de MEDEVAC conduites sur le territoire afghan par nos alliés américains. Il ne met pas en évidence d'apport significatif d'équipes disposant de pratiques avancés en traumatologie, y compris pour les blessés les plus sévères. Il confirme le nombre limité de procédures mises en oeuvre (1). Il met même en évidence le moindre recours à des pratiques transfusionnelles dans ce groupe de personnels par rapport au groupe Paramedic, alors que plus d'abord vasculaire et d'apport de liquide de remplissage est conduit. On peut légitimement s'étonner de ces résultats car d'autres publications mettent en avant l'apport de la présence de praticiens disposant de connaissances avancées dans ce domaine (2). la composition de ce groupe de personnels aux pratiques avancées interpelle quand même car il contient des infirmiers des médecins et des assistants médecins dont l'expertise réelle en matière de prise en charge de traumatisés reste non décrite. On peut se poser la question d'une expertise moindre que celle des Paramedics dont le cursus de formation est d'excellente qualité (3). Une autre explication peut être trouvée par la spécificité du territoire afghan où les temps de transport étaient au final assez brefs, sans commune mesure avec celui d'autres théâtres d'intervention, notamment africains (4). Les conditions actuelles de soutien médical nous montre bien que la mise en oeuvre de pratiques avancées par du personnel non seulement PRATIQUANT mais aussi EXPERT doit rester l'objectif essentiel. Un vrai challenge pour les années à venir.

BACKGROUND:

Medical evacuation (MEDEVAC) is the movement and en route care of injured and medically compromised patients by medical care providers via helicopter. Military MEDEVAC platforms provide lifesaving interventions that improve survival in combat. There is limited evidence to support decision making related to en route care and allocation of resources. The association between provider type and en route care is not well understood. Our objective was to describe MEDEVAC providers and identify associations between provider type, procedures performed, and outcomes.

METHODS:

We conducted an institutional review board-approved, retrospective record review of patients traumatically injured incombat, evacuated by MEDEVAC from the point of injury, between 2011 and 2014. Data abstracted included injury description, provider type, procedures performed, medications administered, survival, and 30-day outcomes. Subjects were grouped according to provider type: medics, paramedics, and ADVs (advanced-level providers to include nurses, physician assistants, and physicians). Groups were compared. Analyses were performed using χ tests for categorical variables and analysis of variance tests (Kruskal-Wallis tests) for continuous variables; p < 0.05 was considered significant.

RESULTS:

The MEDEVAC records were reviewed, and data were abstracted from 1,237 subjects. The providers were composed of medics, 76%; paramedics, 21%; and ADVs, 4%. Patient and injury demographics were similar among groups. The ADVs were most likely to perform intubation, chest needle decompressions (p < 0.0001), and hypothermia prevention (p = 0.01). Paramedics were most likely to administer blood en route (p < 0.0001). All other procedures were similar between groups. Paramedics were most likely to administer ketamine (p < 0.0001), any analgesic (p < 0.0001), or any medication en route (p < 0.0001). Incidence rates of en route events (pain, hypoxia, abnormal hemodynamics, vital signs) were similar between provider types. In-theater and 30-day survival rates were similar between provider types.

CONCLUSION:.

Providers with higher-level training were more likely to perform more advanced procedures during en route care. .y found no.ficant .ociati. bet.ee. More evidence is needed to determine the appropriate level of MEDEVAC personnel training and skill maintenance necessary to minimize combat mortality.

| Tags : medevac

10/11/2016

Evasan: Surtout des blessés non en rapport avec la guerre

Surveillance of Disease and Nonbattle Injuries During US Army Operations in Afghanistan and Iraq.
Hauret KG et Al. US Army Med Dep J. 2016 Apr-Sep;(2-16):15-23.

 

Disease and nonbattle injury (DNBI) are the leading causes of morbidity during wars and military operations. However, adequate medical data were never before available to service public health centers to conduct DNBI surveillance during deployments. This article describes the process, results and lessons learned from centralized DNBI surveillance by the US Army Center for Health Promotion and Preventive Medicine, predecessor of the US Army Public Health Command, during operations in Afghanistan and Iraq (2001-2013).The surveillance relied primarily on medical evacuation records and in-theater hospitalization records. Medical evacuation rates (per 1,000 person-years) for DNBI were higher (Afghanistan: 56.7; Iraq: 40.2) than battle injury rates (Afghanistan: 12.0; Iraq: 7.7). In Afghanistan and Iraq, respectively, the leading diagnostic categories for medical evacuations were nonbattle injury (31% and 34%), battle injury (20% and 16%), and behavioral health (12% and 10%). Leading causes of medically evacuated nonbattle injuries were sports/physical training (22% and 24%), falls (23% and 26%) and military vehicle accidents (8% and 11%).

Bilan US.jpg

This surveillance demonstrated the feasibility, utility, and benefits of centralized DNBI surveillance during military operations.

24/09/2016

MEDEVAC: Une réanimation avancée rapporte

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

Ingals N et Al. JAMA Surg. 2014 Aug;149(8):807-13

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Ce document est très intéressant car il met en avant l'intérêt du transport des blessés de guerre par des équipes maîtrisant toutes les facettes du damage control resusictation tant au niveau médical que paramédical. Une approche très similaire est celle des MERT-E

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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 ofoperations.

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.

| Tags : medevac

Transfusion en vol: Sécurité assurée

Risk Management Analysis of Air Ambulance Blood Product Administration in Combat Operations

 

BACKGROUND:

Between June-October 2012, 61 flight-medic-directed transfusions took place aboard U.S. Army Medical Evacuation (medevac) helicopters in Afghanistan. This represents the initial experience for pre-hospital blood product transfusion by U.S. Army flight medics.

METHODS:

We performed a retrospective review of clinical records, operating guidelines, after-action reviews, decision and information briefs, bimonthly medical conferences, and medevac-related medical records.

RESULTS:

A successful program was administered at 10 locations across Afghanistan. Adherence to protocol transfusion indications was 97%. There were 61 casualties who were transfused without any known instance of adverse reaction or local blood product wastage. Shock index (heart rate/systolic blood pressure) improved significantly en route, with a median shock index of 1.6 (IQR 1.2-2.0) pre-transfusion and 1.1 (IQR 1.0-1.5) post-transfusion (P < 0.0001). Blood resupply, training, and clinical procedures were standardized across each of the 10 areas of medevacoperations.

DISCUSSION:

Potential risks of medical complications, reverse propaganda, adherence to protocol, and diversion and/or wastage of limited resources were important considerations in the development of the pilot program. Aviation-specific risk mitigation strategies were important to ensure mission success in terms of wastage prevention, standardized operations at multiple locations, and prevention of adverse clinical outcomes. Consideration of aviation risk mitigation strategies may help enable other helicopter emergency medical systems to develop remote pre-hospital transfusion capability. This pilot program provides preliminary evidence that blood product administration by medevac is safe.

| Tags : transfusion

31/01/2016

MEDEVAC hélico: + compliqué qu'on le croit

Interhospital Patient Transport by Rotary Wing Aircraft in a Combat Environment: Risks, Adverse Events, and Process Improvement

Lehmann R et Al. J Trauma. 2009 Apr;66(4 Suppl):S31-4

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Le transport secondaire de blessés de guerre peut s'envisager entre deux structures hospitalières ou bien à partir un role 1 distant vers un role 2/3. Le document présenté exprime que malgré un haut degré de préparation, un certain nombre de difficultés risque d'apparaître en vol. Ceci impose de professionaliser à un haut standard les équipes de convoyage (1) et tout particulièrement celles de longue durée.

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Background: Helicopter transport of injured or ill patients in Operation Iraqi Freedom is a necessary but often high-risk endeavor. Our facility initiated a thorough process improvement and standardization initiative after several adverse outcomes. This report describes the results after this initiative, and evaluates the applicability of a civilian transport risk assessment tool to the combat environment.

Methods: Review of all preflight, in-flight, and postflight records for helicopter medevac missions over a 7-month period. Adverse events included major equipment failures, clinical deterioration, or the need for urgent interventions on arrival. Transport risk scores (TRS) were calculated and assessed for correlation with adverse events.

Results: There were 149 patient transports identified, 95 (64%) for trauma (mean Injury Severity Score, 21) and 54 (36%) for medical illness. Major surgical intervention before the flight was required in 66 (44%), massive transfusion in 29 (20%), and the majority were transported within 8 hours of surgery. In-flight mechanical ventilation was required in 53%, and 20% required vasopressors or cardioactive medications. Adverse events included equipment failures in 17% of flights, in-flight clinical deterioration in 30%, and 9% required an urgent intervention on arrival. However, there were no deaths or significant flight-related morbidities identified. The mean TRS was significantly higher in patients with adverse events (9.1) versus those without (7.4, p < 0.05), but it showed only moderate discriminative ability (area under curve  0.65, p < 0.01).

"Documented adverse events included equipment failures in 17% of flights, in-flight clinical deterioration in 30%, and 9% required an urgent intervention on arrival. In-flight deteriorations included hypotension in 10%, oxygen desaturation in 7%, arrhythmia in 6%, and tachycardia or bradycardia (rate, 120 or 60 beats per minute) in 32%."

Conclusions: Helicopter transport in a combat environment carries significant risk of adverse events because of the patient characteristics and inherent limitations of the transport platform. Strict attention to standardization, training, and process improvement is necessary to achieve optimal outcomes. The civilian TRS had lower discriminative ability in this military setting.

21/10/2015

Conditionner un blessé grave

Medevac David.jpg

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| Tags : medevac