Hi guys, thank you for coming. I see a great attendance here. But thank you all for coming. I think this is something very unique that we decided to do. We felt that this has not been done in the past. And it is something that, you know, a lot of our speakers feel very passionate about. So I'm glad that they were available to give this talk. So I appreciate everybody. And please remember that all sessions can be evaluated through the mobile app. And please don't forget to do that. I'm just going to do a little brief overview and then I'll hand it over to our speakers. So we just want to talk about the medical transport of our critically ill patients. And I'm Humayun Anjum, and I'm out of Baylor Scott and White, and I'm the director for critical care services over there. But we just wanted to see that, you know, we know that ICU patients are just so sick. They have deranged physiology. They require a lot of invasive monitoring. They require a lot of organ support. And they tend to become unstable during transport. We realize that. And how do we overcome that? How do we make it happen? How do we transport these patients, especially the interhospital transfer? And, you know, on top of it, we have all these changes that happen during transport, whether these are temperature changes or pressure changes, and how the air physiology changes and what do we need to do to make sure that these patients are transferred in a stable manner. This is sort of becoming very common now because there are specialized centers for everything. The interhospital transfers are happening more frequently than they were before. It does require a lot of resources. And then, obviously, there's a lot of risks that are associated with it. So the purpose of this talk is to just go over all of these aspects and see what we can do to help our patients. And this is something that I've also realized that I don't have a very good knowledge about, in the sense that we think that we are in that hospital setting and we know everything that is going on with our critically ill patients, but it's just hard to imagine what these people face when they're transporting these patients. So I think this would be a good talk to realize that what, you know, these people do. It is very time consuming, of course, we know. And then as we talked about, the out-of-hospital environment is just so different from the inpatient environment. Something that I came across was this Dunning-Kruger effect where, you know, people have this cognitive bias and it can happen in a particular scenario where you're not well-versed with something, but you think that you know it all and then you don't, you know, learn about it or you don't practice it. So I think practice, learning is important. It has to be done in a structured way where somebody gives that education rather than us learning in the field with the pitfalls that the, you know, the transfer may predispose our patients to. So I think it's a structured environment where somebody needs to do the learning, somebody needs to do the education and teach us how these things are done in a proper way. And, you know, again, we don't have any national standards pertaining to that. So that becomes a little difficult as compared to, you know, taking care of these patients in the hospital setting where we have good standard of cares and, you know, proper guidelines as to how do we approach these patients. So with that, I think I'm just going to go ahead and hand over to Scott, who will go on to our next session. Thanks, Dr. Anjum. I'm going to be talking about the helicopter EMS and a little bit of introduction on it and then why we fly patients and who we fly patients. My name is Scott Van Poppel. I hail out of Plano, Texas, and the suburb of Plano is Dallas, Texas. So you may have heard of that place a little bit better. I've been in the critical care transport field since 2016, mostly rotor wing. And I am just an intensivist. And, in fact, that is what I told my boss and my crews when they approached me in 2016 and said, will you be the medical director for our helicopter service? And I said, I've never been in a helicopter. I'm not even sure which way the rotor blades turn. So I was a little bit confused about why they wanted a critical care physician. But I've since made my way through the system, and I've made my way to understand some of the historical perspective of EMS and then what it takes to fly these patients and really get to know the crews and the configurations. And this is what I want to share with you guys today, because I think as critical care doctors and pulmonary critical care doctors, I think we lose track of what happens outside of the double doors. We accept patients all the time, and we send patients all the time, but we're not sure whose hands we're putting these into. I'm a historical buff, so a little bit of a history about helicopter rescue. Jules Verne kind of made fun of the current fad in the 1870s about hot air balloons, and he said, I could create a machine that is heavier than air, and it's going to rescue people. So the Robber of the Conqueror is a story about this helicopter machine rescuing people in the ocean. In real life, we know that the hot air balloons, i.e. the fad in the 1870s, rescued people in the siege of Paris. And the whole goal of this was to deliver to the appropriate provider, essentially snatch up the patient and bring it to the appropriate provider. When we get into more of the modern age, especially on the United States front, we have the military to look back at as far as the history of HEMS, and especially in the Korean War. With the geography of Korea, the mountainous area and the smaller roads, it was difficult to get ambulances in. So we would use helicopters literally to pick up patients, strap them to the outside of the helicopter, and fly them. I think in EMS terms, this is called a scoop and run. And I put down there at the bottom that this is stabilized in quotes, very small, because it's more about picking up the patient and delivering to the appropriate provider. This is very well documented for those of you that know TV shows, MASH, and the movie MASH as well, too. We get a little bit more sophisticated in the Vietnam War, where we actually have the development of combat medics or paramedics that fly with the UEs, and they land, they stabilize the patient on the scene, then provide advanced care en route, and then deliver to the appropriate provider. This has definitely been credited with decreasing the mortality of soldiers in the Vietnam War, even compared to what was happening in World War II. And so in the 1960s, the government, the National Research Council, put out a landmark paper in 1966. And the reason this paper was put out was because they realized that more people were dying in traffic accidents than actually in all the previous wars. And they said, we need to do something about that. And so this paper really sets forth the structure of a lot of things we know right now, including basic accident injury prevention, the leveling of trauma centers, the more structural EMS system. And then when it comes to helicopters, it does mention helicopters, and I'll zoom in a little bit, that helicopters have been successful in the combat theater, so maybe we should try them, especially in rural America. And in fact, this paper led to several grants and opening of civilian projects. The Project CareSum, which you see the helicopter there on the left, it's my favorite picture of the Roscoe Pico train, Dukes of Hazzard kind of guy, standing there next to the Project CareSum helicopter. And Project CareSum was a federally funded grant for Mississippi to open three civilian helicopters, one of those still being in place. The military also built a civilian service that's out of Fort Sam Houston. And then the government also funded the Maryland State Police, and you can see the helicopter there on the right, and that is considered still one of the premier HEMS services in the country. And on the West Coast, St. Anthony's in Denver was getting started as well, too. You can see that while our number of medical helicopters has grown through the roof, the data's a little bit old, but trust me in saying this number, this chart keeps going up. Our number of medical helicopter programs actually is about the same, if not down a little bit, because of a lot of companies getting together and joining teams. But the number of helicopters is significant. So now we know why we're doing it, but who are we flying? This was the question that was proposed to me, and my first question was, who is we? I think it's more important, and we're going to talk about the crews that are flying. I think that's important for you to understand as a critical care doctor, and my last two slides will be a little bit about the patients, but mostly about the crews, because I want you as critical care doctors to be familiar with whose hands you're putting these patients in. So there are really two configurations that are popular across the world. There's the Anglo-American system, which is the United States and Canada, where greater than 90% of our crews are flight medics and flight nurses, and then there's the Franco-German system, which is the European system, where 70% are flown with an MD, and this is obviously in the civilian setting. The Franco-German system, European system, flies with MDs more because of history, geography, government, finance. Most of these MDs are anesthesia trained, some trauma surgeon trained, some ER, but the ER doctor system is way different in Europe than it is here in the United States. And there are two different approaches. The United States kind of continued to say, look, we're going to continue what the military did, and we're going to stabilize the patient on the scene with flight medics and flight nurses. We're going to provide advanced care, and then we're going to deliver the patient. The European system said, look, what we're going to do is we're going to deliver the appropriate provider or the MD to the scene, stabilize the patient, and then provide advanced care. As a matter of fact, if you go to Europe and they call out a helicopter and the doctor arrives on scene, 70% to 80% of the time you don't fly back with the helicopter. You're actually stabilized and you get brought back by ground. Outside of you being stuck on a mountain in Italy or something like that. So do we know the differences? If we look at the research about this, and I only have 15, 16 minutes, so I'm not going to go through all the 18 papers, but there's a little bit of a timeline here. So the 1970s and 1980s, we had an improved mortality if we had a doctor on board. In the 1990s, early 2000s, we noticed that this was a little bit clearer or was only significant when we had really higher ISS scores and traumatic brain injury. And in the late 2000s, we discovered that this doesn't really make a difference. The reason this doesn't make a difference is because our flight medics and flight nurses have gotten so good. In the 1970s and 80s, only a doctor was allowed to intubate, paralyze the patient, give blood transfusions, do CPR. All the stuff we normally think of flight medics do, they do that regularly every day. So now only a few exceptions are when a medical director kind of wants to fly. Or if you have ECMO or a FAT team, which is my favorite acronym for field amputation team. But even those are a few exceptions because those are also being replaced with nurse practitioners and PAs that are flying as well. So while I like to think of looking at my nitric retrieval team here as me being the front guy, being the captain of the team, the crews would look at me as just being the guy that can carry the extra bag that they have to load. Because that's really all I do when I fly with my crews. I don't often need to give them any guidance. I just carry the extra bags. So let's talk about, in the United States, let's talk about why we fly with a critical care paramedic and a critical care nurse. Why do we combine the two? Why don't we just fly with two flight nurses? And they both have different skill sets. The combat medic, I'm sorry, the flight medic is based out of the combat medic. They have the skills to take their medical knowledge to the scene. You can see us in the snow. You can see us on the side of the road when we're trying to pull people out of a ditch. And this is really, truly their skill set. But if you look at the data, and I work, my medical director for PHI Air Medical, which we do 30,000 flights, and this is consistent across Europe and across Canada, is that 70% of our patients are actually patients you guys receive or send. They're inter-facility patients. So you have where the critical care nurse in the top right, or the critical care scenario in the top right, is needed. That's not the specialty of the medic. So we need to add a flight nurse to that. So we need to add a flight nurse to that that can handle that mobile ICU as well. And if you combine the two, you really get an incredible team that can handle a lot of different things. This is actually Don and Brian at the Sim Cup Games. That's at AMTC, which is the Air Medical Transportation Conference, the national conference, probably similar size to the chest. It's happening in just as exciting place as Hawaii. It's happening in Columbus, Ohio. But the Sim Cups are great to watch, and the skill level is incredible, and it's fun to watch the two specialties come together. But we have to have an overall accrediting body. We have to have a body that says, look, we're going to take all these air medical programs and all these air medical teams, and we're going to put them all together, and we need to make sure they're all doing the right thing. They have quality initiative programs. They have the appropriate people working on the appropriate lines. And so CAIMS was established in 1991 to do this, and more than 90% of the air medical programs, maybe even more, are CAIMS accredited. Even some of the ground services are. And you can see all the associations that are involved in CAIMS and sit on the board. And of note, that includes the American College of Surgeons, the American College of Emergency Physicians, the American Academy of Pediatrics. What I will note there is that there's no critical care association there, not FCCP or SCCM. And CAIMS says specifically, and I'm not going to read the whole boring slide to you, but it says your scopic care has to be able to deliver out-of-hospital care at the equivalent level of what's happening in an ER or close to what's happening in an ICU. And in order to do that, it says that every provider, regardless of whether you're a physician or a nurse or a medic, has to have at least three years of critical care experience. So if you're signing on to be a flight nurse, that's three years in an ICU or three years in an ER. If you're signing on to be a medic, that means three years in a critical care ground service. Not a critical care ground service in the middle of nowhere United States where you only get one call a day, but a critical care service like in Dallas, Texas or Chicago or Boston. And then we have the International Board of Specialty Certifications that says that if you become a critical care paramedic or a flight medic, you have to pass this exam within two years. To be honest, as a person who writes for both of these exams and has taken both of these exams, I'm very, very close to almost critical care board level questions. They're very difficult exams, has a pass rate of about 60%. In addition to our crews have to have all these certifications, ATLS, PALS, NRP, and ACLS. And then they have to be familiar with all these emergencies. And oh, by the way, we're going to stick them in a multimillion dollar machine that flies upside down. I'm sorry, that flies sometimes, hopefully not upside down, that flies sideways, that flies fast. And there's a lot of safety stuff going on there because your crews are not just medical providers, they're also the extra eyes for the pilot. Speaking of pilots, the pilots that fly civilian crafts or civilian medical crafts have to have a lot of hours available at approximately about 30% or so. And this number is going less and less these days are actually from the armed services. The helicopter on the left is from my home country is in Holland, landing on the canal. And the helicopter on the right is a Spanish made helicopter landing in the middle of nowhere, Italy. And you can see how the helicopter is being balanced there. NVG, by the way, stands for night vision goggles. So that was my major portion of what I wanted to talk about, because I want you to know who picks up your patients and who delivers your patients, how comfortable you can feel with those. The last two slides are a little bit of a sneak peek of a large, large database we're building for more research. But this is out of our PHI database. And PHI, again, has 70 bases across the country, all mixed bases, including academic versus independent. We do 30,000 flights. So this is data on about 57,000 flights. And you can see the majority, about 70%, are inter-facility. So 41,000 patients are inter-facility. And the majority of inter-facility transfers are medical. And you can see that it's about 50%, 50% are trauma. And so you say, well, which ones are, which medical patients are actually seen patients? And if you look at this, these are two charts just on the medical patients. If you look on the right, the seen responses for medical patients is almost 75% neuro. This means we're landing in a urgent care clinic. We're landing sometimes in the backyard of a patient. This has a lot to do with the propagation of comprehensive stroke centers, the door-to-needle time. Some of the hospitals are pushing us to get the patient faster and faster and faster. Obviously, the door-to-needle time of cardiac makes us a little bit faster as well, too. And so it's not, we've done it before. We don't like landing in the backyard of people's homes, but we've done it before. And then the inter-facility transfer, you can see, is kind of a smattering of everything. As you can imagine, it's a lot of neuro. It's a lot of cardiac. But we get some really weird stuff, such as toxic exposures, snake bites, that type of stuff we have to fly as well, too. All right. I'm going to stop here, and I appreciate it. I'm happy to answer any questions afterwards. Thanks. All right. Fabulous. So thanks for your patience with that, everyone. So I'm going to speak today about the emergency department's perspective on the transport of critically ill patients. My name is Susan Wilcox. I'm an emergency medicine critical care physician. I am also the associate chief medical officer at Boston MedFlight. I've worked for them since about 2009. But other than that, I have nothing else to disclose. So here's a QR code. And what I want to talk about today is who needs to be transported out of the emergency department. And I really want to spend a little bit of time talking about this idea of a patient being too sick to transport, because it's something I hear said quite a bit, and it's something that we at Boston MedFlight really don't believe in. And at the end, I'm going to talk about an algorithm of how we should be deciding who gets transported and how we need to optimize those patients. So I'll start here with a question. A 44-year-old man, previously healthy, comes in with a STEMI to a community hospital that does not have a cath lab. While he's in the emergency department, he has a cardiac arrest. He gets TPA, all the appropriate ACLS care, and after about 30 minutes, they get ROSC. But he's super unstable. He's on epinephrine at a really high dose of 15, norepinephrine at 45. His oxygen saturation is only 90%, despite being on 12 of PEEP and 100% FiO2, and his PIP is 38. You guys can totally imagine this scene. The emergency department calls you, the intensivist working in this hospital, and says, what do you want me to do with this guy? And so what do you tell the ED? So, all right, number one, this guy is too sick to transport. Talk to the family about his goals of care. Remember, he's only 44. I'm 44. That's very young. Two, he is too sick to transport, so we'll admit him here. Maybe he'll be better tomorrow when we can send him out. He's too sick to stay here. We need to get him out of here as fast as humanly possible. Call an ambulance. We need to scoop and run this guy. Or he's too sick to stay here, so we need to find a critical care transport service. Got a couple of those. All right. By the way, I wrote the question in my inflection, my bias is obvious, but I plan to spend the next few minutes explaining why I have this bias. So we know the emergency department is great for assessing patients and doing initial stabilization, but it is clearly not definitive care for a patient who's critically ill. And so when anybody is going into work in an emergency department, they're going into their shift. I think the onus is on that person to know what their resources are in this hospital, and they need to know what they're able to offer a patient just at their hospital as well as in the system. And so the things that the patient might need that might need to be transferred out can be like concrete things, like my patient who needs a cath lab in the earlier example, or it could be a conceptual thing. A patient needs a tertiary care specialist that they just don't happen to offer in that system. And so the people who are working in the emergency department need to know their resources, as do the intensivists, because they need to know who they have to send out and who is safe to keep there. I will make a comment about ICU beds, because this is a common reason that patients are sent out of hospitals. Patients get transferred a lot, because there's no ICU bed. There are definitely some guidelines that suggest that we shouldn't be transferring patients for ICU beds, because we know that transport carries a risk. And if there's any way a patient can get an ICU bed, if there's patients that can be moved, or you can shuffle patients around, it's probably better to try to do that than send a patient out. Now, of course, if a patient's really sick, there's no ICU bed on the horizon, c'est la vie. You have to send the patient, and that's understandable. But this is going to be an increasing issue with the changes in health care. We know that we're getting more and more specialty centers. Large institutions are buying up smaller institutions. They're creating these organizations, creating these networks. And so on one hand, that can be really good, because it's leading to development of ECMO centers, transplant centers. We have trauma centers. But one of the challenges is that they often will pull resources out of those small hospitals and consolidate them in that larger hospital, meaning that patients at the outside need to move in in this hub-and-spoke model. And so this is continuing to happen. Patient transports are going to be more and more common throughout all of our careers. And this is where this myth, this discussion about too sick to transport comes up, because a lot of these patients are not going to be stable when they present to those outlying community hospitals. And the reason people are worried about transporting these patients is because they should be. These concerns are evidence-based. We know that patients have physiological deterioration when we move them. Patients get hypotensive. They desaturate. And sick patients get sicker. So the sicker the patient is, the higher the risk of transporting that patient. Higher their MSOFA score, higher FiO2 needs, lower their blood pressure, the more likely they are to have a deterioration. And also, we know cooking people up with all these pumps and wires and monitors, things get pulled, things get lost, vibration, temperature changes. Equipment doesn't like that. And so I have this table down here just showing an example of just one of many, many papers showing how adverse events can happen en route. They can have medical events. They have equipment events. They have logistical or administrative events. They're pretty common. And so for those of you who've never transported someone in a helicopter or never seen someone in a helicopter, this is what it can look like. And so this is one of our teams at Boston MedFlight transporting an ECMO patient in the back of a helicopter. Look how cramped that is. So they've got the ECMO circuit on the patient stretcher. You can see the three of them in there working in this like sardine can, trying to take care of this incredibly sick patient. And so when you have an appreciation for this, two things, you can see how these adverse events can happen, and you can see how talented, how skilled these people are. Just to the points that Scott was making, you can't just send people out and have them do transport. This is a skill set people have to know. And so just sending a random doctor or an ICU nurse along with a team does not make it critical care transport. But I've talked about the concerns. We know that there have to be benefits, or we wouldn't even be having this session. You have to have some benefits here. The time-sensitive conditions that we've heard about, people who need reperfusion and a stroke or an MI, people who are fresh traumas and need to get to a trauma center, critical care transport helps these people. We get them there faster. We bring expertise to them where they are. But it also helps in conditions that are not time-sensitive. The patient with the acute respiratory failure, which is my personal interest, patients with cardiogenic shock, like my guy I started with, people who are already on pump, people who are on ECMO. But I'm not going to tell you that the data are super robust. Because randomizing patients to a trial of like, you get transported, you don't get transported, is a really hard thing to do. There was one, though, the CSER trial, published in the Lancet in 2009. Now, many people say, this is an ECMO trial. And okay, sure, fine. You can have it as an ECMO trial. I love ECMO, too. I'm pro-ECMO. But so what I take away from this study is that the people who were randomized to ECMO only got ECMO about 76% of the time. But they were transported about 95% of the time. The people who were randomized to conventional treatment only were transported 12% of the time. So when you look at these Kaplan-Meier curves, is it the transfer to a tertiary care center that has ECMO capabilities and all the other wonderful things that tertiary care center can do? Or is it the ECMO per se? I don't know. But it gives me a lot of idea that transporting these patients can be a benefit. And we can do this. We can do this safely. Another example. So this is in a ground truck. This is one of our excellent critical care transport nurses taking care of a patient who has an open chest. You can see the three chest tubes there at the base. You can see that the patient is on ECMO. They have an impella as their LV venting strategy. This person is about as sick as they get. And we can transport them safely as long as they're sent with a high-quality, well-trained team. And I think that sometimes when we start thinking about too sick to transport, there's a fallacy or misapplication of that scoop-and-run literature. So the scoop-and-run literature is referring to people who are in the 911 system, the EMS system. And that's very different when you think about somebody who's a gunshot wound in the field or a fresh MVC in the field versus someone who's been in an emergency department, been seen by a clinician, had initial stabilization. Now, they might not have all the resources the patient needs, but it's a very different scenario. And so when we're talking about the critical care transport literature, it's totally different than the 911 pre-hospital EMS literature. And so when we think about these patients, we need to think about what are their outcomes with transport versus without. And so with transport, we've been talking about the risk. The risk is real. I'm not going to try to minimize that risk. But we have to think about what happens if we don't transport this patient. And so I'll tell you that our philosophy at Boston MedFlight is that if a patient has a predicted 100% mortality if they stay, they need a procedure, they need something, and they're super sick. And we think if they don't get that thing, they're going to die. And they have a 99% chance of death if we get them there, we will take that chance. Because anything that we can do to optimize their chances or improve their chances, even if it's small, we will make it happen. But I recognize that I'm saying a risky thing. It's a kind of a controversial idea because people are worried about their liability, about litigation, and it's understandable. So when we're thinking about these patients who need to be transported, it's really important we try to optimize them as much as we possibly can. And that's what the guidelines state. So I have here a reference to our paper that we wrote published in Critical Care Medicine last year for the SCCM Interfacility Transport Task Force. And this was the basis. We want to optimize the medical care before the patient goes. But sometimes that's not possible without tertiary care. The patient needs that thing, whatever the thing is. And so when that's the case, the question is, do you think that that patient's going to improve without the tertiary care such that transport will be safer tomorrow? Or even knowing the risks of transport, is it better to send that highly trained crew to bring them back to tertiary care? Regarding the litigation piece and, you know, liability, EMTALA is in vote. And I think EMTALA is probably one of the most misquoted, misunderstood pieces of legislation. Everyone loves to quote EMTALA, sometimes correctly, often not. But this is actually what it says. So if a patient is unstable, the hospital may not transfer that patient unless a physician certifies that the medical benefits expected from the transfer outweigh the risks. Or the patient and their family say in writing that they want. But the last point right there, number four, is so critical. If you're sending a patient who's deemed to be unstable, you have to send them with qualified personnel and appropriate medical treatment. And this is where that CAME standard comes in. The idea is that appropriate medical personnel are people who can maintain or elevate the level of care that that patient is receiving in the emergency department. And so you have to have highly trained personnel to be able to send patients who are unstable. And this is the algorithm of how I think about these patients. So you've got your critically ill patient. Are they stable to move? If the answer is yes and you want to send them, great. No problem. There's no controversy there. Congratulations. But if they're not stable to move, this is where it gets more interesting. Does that person need some sort of resources or services that are unavailable at the sending? If no, if the sending and the receiving are basically going to do the same things and the patient's unstable, I'd say we shouldn't transport that person. Now the patient's family might want it and, you know, then you can have that conversation and it's fine. But the recommendation would probably be, I wouldn't really transport this person right now. But if the question or the answer to that question is yes, if that person needs something at the receiving that they can't get at the sending, then the next question is, will any procedure make them more stable for transport? And if there is a yes there, then you should do that thing, whatever the thing is. And then you transport them. This is not a scoop and run scenario. You want to get them as optimized as you can. But sometimes the answer is no. You're not going to be able to do anything else for that person. And then my recommendation in that place, then you just transport them. Then you send that patient because you're still doing the best thing to get them where they need to be. And so to end, I want to talk about the patient who is too sick, that person where you're really concerned. I think the question we need to be asking is, is there anything that can be optimized? And, you know, like adding a new medication, a vasopressor, an inotrope. Do they need a fluid bolus? Could they get a procedure, be it a thoracentesis, a chest tube, a paracentesis? You know, whatever is right for that scenario. Can you simplify anything? I can tell you as an emergency physician, patients come in and during their initial resuscitation, they often get a slew of meds. People just are pinging drips and everything. Can we simplify that down to minimize the risk of medical errors and try to have a more consolidated approach? But this is where that collaboration and coordination with the transport team is so important. This is not scoop and run. We want to take these patients seriously and optimize them and do everything we can to make them as safe as possible. This chart that I have here on this table, too, is from a paper we published on our COVID experience in transporting these patients. You can see that our critical care transport teams got there and changed ventilator settings 42% of the time. They changed their hemodynamic management 67% of the time. This is an active management process. And so for my last slide here, I'll just show you how they're able to do this. You know, again, building on what we've just heard in the last talk. These are highly trained clinicians. We, too, use a nurse paramedic model with physician oversight and they go through incredible amounts of training and education to be able to do this. In this first picture, it's them working in a simulation where they turn the ambulance bay into a trauma scene of somebody who had been working at a construction site and then was a trauma patient. It was incredibly realistic. And then in the other, that's a newborn preemie baby that they're working on and, you know, going through a sim. So with that, I will end. But I just hope that I've given some people some thought about the idea of people being too sick to transport because it's something that I really don't believe in. So with that, I'll stop there. Thank you all. So good afternoon, everyone. I will be briefing on the United States Air Force Critical Care Air Transport Teams, hopefully building off Scott and Susan's presentations. You know, it's great looking at their presentations to recognize some of the differences in what I'll be talking about. I'll primarily be referring to long-distance transport on fixed-wing aircraft. So I'm often with patients for 15 to 30 hours at a time, so a very different dynamic than the short-distance critical care transport. But I think it will be somewhat interesting to see how very similar principles still apply. So my background is in critical care medicine and anesthesiology. I'm currently the director for Critical Care Air Transport Teams based at Joint Base Pearl Harbor-Hickam, and I work clinically at Tripler Army Medical Center. I have no financial conflicts of interest to disclose. All views expressed in this presentation are my own and do not necessarily reflect any official position or policy. So during our discussion, we will review establishing the capability for critical care air transport teams, explore CCAT operations worldwide and regionally, and consider patient movement challenges through several cases. To begin, this figure illustrates the military casualty flow. After reviews of battleground injury patterns and complications during evacuation, evidence highlighted the potential gains in better point of injury care, as well as making improvements to the evacuation process. Critical care air transport teams evolved to sustain this highest level of care for the most injured patients throughout evacuation. CCAT teams provide high-quality care during the movement of acutely ill or complex patients. Each team is capable of transporting up to three high-acuity patients or six lower-acuity patients. Each team is composed of a physician with critical care capability, either a critical care medicine or emergency medicine nurse, and a respiratory care practitioner. After meeting initial qualifications, CCAT members attend an initial course that reviews flight physiology, team dynamics, and basic patient movement. After successful completion, members then attend an advanced course that covers clinical practice guidelines, high-fidelity simulations, and worst-case scenarios. To establish our critical care capability, each team is moving around with 300 to 400 kilograms of equipment. Our patient movement items generally match the equipment you would find in any high-performance ICU, but it is generally selected based on portability. Our teams travel with the capability to perform procedures either before or during flight that are common in any ICU, as well as the ability to initiate and maintain medical therapy for a variety of conditions. While we always think twice if we're moving a patient with ongoing transfusion requirements, we are able to acquire blood products to support the mission to layer in additional safety. To add flexibility in mission planning, our capability fits within eight checkbacks, allowing us to fly commercially to the patient's origin or return commercially at the conclusion of a mission. Our work environment is pretty unique to deliver complex critical care. Fortunately, our training, experience, and equipment enable us to maintain a very high standard throughout the transport process. Furthermore, we collaborate with patient movement stakeholders, as well as local entities to overcome inevitable challenges such as a limited blood product supply. Shifting to the Indo-Pacific, I respect all of you are tracking how large this area is, and many of you may be feeling it from your recent transport here. Within this area of responsibility, there are over 100,000 Department of Defense beneficiaries, mostly in Japan, with many of those in Okinawa. Additionally, with the Department of Defense's laydown, there are families, veterans, and retirees distributed throughout the Pacific. Our primary limiting factors in mission planning are directly tied to the size of this area. Time and distance complicate every mission that we plan. And admittedly, every time I see those flight times, I get a little pause in the heart because we have quite some long flights in this AOR. So host nation facilities provide an incredible service. They remain immediately available to provide that life or limb stabilization, stabilization for life or limb threatening conditions. Still, challenges exist due to language and cultural barriers. Despite our best efforts, we usually are walking into host nation facilities in a discovery mode in terms of what's the patient's actual conditions and needs. Differences in standards of care can also impact our mission planning. With respect to Japan and Korea, both provide very high levels of care, produce internationally recognized research, but still we sometimes found deviation from standards that we're used to, particularly with respect to the timing of surgery often mobilizes our teams to move, transport those patients. Within this region, we execute our missions on aircraft of opportunity, commonly the C-17 or KC-135. Our typical patient population involves trauma, major infections, severe head injury, or multiple organ failure. In an aircraft, our challenges are generalizable to critical care in an austere setting. We lack the intrinsic ability to provide ECMO, renal replacement or surgery, and we are further limited by both materials and manpower for our clinical decision making. We will now transition to four cases that illustrate some of the challenges involved in critical care air transport. Our first patient presented after an overdose complicated by acute right leg ischemia, renal failure and severe coagulopathy. I received a call for an urgent mission after the host nation hospital was unable to percutaneously revascularize the right leg. And given the patient's severe coagulopathy were unable or unwilling to offer her surgery. With sincere respect for the severe patient safety concerns involved, we were ultimately driven by her need to move towards definitive care and were able to transport her safely from the Philippines to Tripler Army Medical Center. Our next mission started to develop shortly after a young patient, young man experienced the witness cardiac arrest. The cardiology consultant was recommending that this patient undergo 24 hours of targeted temperature management. And I was essentially being asked, can you do that in an airplane? As an intensivist, I recognize that I may not be cooling this particular patient, particularly not below 34 degrees. But as a transport physician, I also respect the need to kind of play off of the sending team's clinical decision making. Ultimately, my team was able to maintain targeted temperature management in flight through a number of unsophisticated yet effective tools at altitude. This case helped frame my understanding, my role as essentially a consultant before and after the transport process, but as the primary physician within transport. The third case involves a gentleman admitted to a Korean hospital with acute pancreatitis and COVID pneumonia. When we are in route from Japan to Korea to pick up this patient, he was admitted for acute hypoxemic respiratory failure. Given his COVID status, we transported the patient in the Air Force's negative pressure container, which is a solution to airborne isolation in an aircraft. Throughout the pandemic, patient safety always remained a priority in mission planning, but certainly the different international partnerships we had in the region started to weigh in on the timing of those movements. The last case kind of represents an extreme of pre-flight stability and stress some of the limitations of our team. When we initially assessed this patient, he was receiving three vasoactive infusions for poor vascular tone, as well as left ventricular systolic dysfunction on echo and was actively receiving blood product resuscitation. Only through a very thorough handoff were we persuaded that generally things were headed in the right direction and we continued on with the mission. In flight, we transfused the patient two units of stored whole blood and fortunately were able to wean the norepinephrine to a very low dose. Additionally, we had to replace a dysfunctional arterial line in flight, but while we were providing all of this care, we were very aware that we lacked the capability to establish definitive hemorrhage control, as well as acquire any additional blood products in route. In resource limited critical care, the emphasis must be on early high quality management to either eliminate or mitigate any in-flight emergencies. With the diversity of CCAT missions, past research has largely focused on in-flight outcomes, mission timelines, and patient characteristics. Currently, we are collaborating with the Air Force's CCAT pilot unit to provide better evidence for how in-flight management impacts post-mission outcomes. During this presentation, we characterized the capability of critical care air transport teams, reviewed current operations, as well as challenges involved in moving critically ill patients around the world. This concludes my presentation. Thank you for your time and attention. And I think I'll take questions with my colleagues up here if you guys are cool. Thank you.

medical transport

critical care air transport teams

ICU patients

transportation risks

specialized care

long-distance transport

high-quality care

collaboration