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Dan Mirski, MD
Director TPMRC-Europe
12 SEP 2013 Oslo, Norway
EUCOM AOR
(TPMRC-E, CASF, LRMC,)
NORTHCOM AOR
(GPMRC)
CENTCOM AOR
(JPMRC)
AFRICOM AOR
(TPMRC-E)
This information is furnished on the condition that it will not be released to another nation without specific authority of the Department of the
Air Force of the United States , that it will be used for military purposes only, that individual or corporate rights originating in the
information, whether patented or not, will be respected, that the recipient will report promptly to the United States any known or suspected
compromise, and that the information will be provided substantially the same degree of security afforded it by the Department of Defense
of the United States. Also, regardless of any other markings on the document, it will not be downgraded or declassified without written
approval of the originating agency. USAFE N0885-13//20130909
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Outline
 USAF Flight Surgeon
 Overview of US System Aeromedical Evacuation (AE)
 Patient Tracking: TRAC2ES
 Medical Lessons Learned
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Dan Mirski, MD, MPH
 Emergency Medicine
 Aerospace Medicine
 LtCol, US Air Force, Chief Flight Surgeon
 Director, TPMRC-Europe
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Enroute Care
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Level of Care
GOAL:
Maintain Equal Or
Greater Level Of Care
During Intra/Inter-Theater
Air Evacuation
CSH, EMEDS, EMF
Forward Surgical
teams
BAS
Wounded
Self Aid &
Buddy Care
First Responder
Definitive
Care
Theater Hospitals
Forward
Resuscitative
Continuous Increase in Level of Care Provided
Time
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Aeromedical Evacuation (AE)
Overview
 CASEVAC, MEDEVAC, Aeromedical Evacuation (AE)
 Role 1-4: Installation Capabilities
 3 = Life-saving med/surg/psych care)
 Urgent, Priority(24h), Routine (72h)
 AE crew = 2 RNs, 3 techs
 CCAT = 1 MD, 1 RN, 1 RT
 C17, C21, KC135, C130
 “Stressors of Flight”
 Patient Categories 1-5
 EMR: TRAC2ES
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PM Route
Current Route from Point of Injury to Definitive Capability
CASEVAC or
MEDEVAC
MEDEVAC or
INTRATHEATER AE
First
Responder
Role 1
INTERTHEATER AE
Forward Resuscitative
Capability
Role 2
Theater Hospitalization
Capability
(CSH, EMEDS, EMF)
Role 3
SURGICAL CAPABILITY PUSHED FAR FORWARD
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Definitive Capability
Role 4
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10/2001 – 8/12/13
BI= 14,875 NBI= 46,346
BI
NBI
1600
1400
1200
1000
800
600
400
200
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Oct-12
Oct-11
Oct-10
Oct-09
Oct-08
Oct-07
Oct-06
Oct-05
Oct-04
Oct-03
Oct-02
Oct-01
0
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DoD Patient Movement System
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2
TRAC ES
TRANSCOM Regulating
Command/Control
Evacuation System
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DoD Patient Movement System
TRANSCOM RegulatingTRAC2ES
Command/Control Evacuation
System (TRAC2ES)
 Web-based/Consolidated Server
 Automates Patient Regulating
 Network for In-Transit Visibility of patient movement
Patient Movement
Requirements
Center
Originating Hospital
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Patient Movement
Requirements
Center
Destination Hospital
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DoD Patient Movement System
Military Medical Treatment Facilities (MTF)s
 Submit Patient Movement Requests
(PMRs)
 Coordinate arrival/departure of patients
Patient Movement Requirements Center

CENTCOM: Joint PMRC, Al Udeid, Qatar

NORTH/SOUTHCOM: Global PMRC, Scott AFB,
Illinois

PACOM: Theater PMRC, Hickam AFB, Hawaii

EUCOM: Theater PMRC, Ramstein AB, Germany
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PMRC Areas of Responsibility
USNORTHCOM
Validate/Coordinate/Communicate patient movement to/from/within geographic Area of Responsibility
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DoD Patient Movement System
Air Mobility Division (AMD), AE Control Team
(AECT)
 Interface with airlifters for AE movement
 USAFE for intra-theater movement
 Tanker Airlift Control Center (TACC) for
inter-theater lift
Aeromedical Evacuation Squadrons
 Provide in-flight medical or specialty
care
 2 flight nurses, 3 medical technicians
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TRAC2ES
Patient Movement Request (PMR)
Referring
MTF/Hospital:
Submit
Patient
Movement
Request (PMR)
Reception MTF: Patient
arrives at destination
facility
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PMRC: Validate
PMR, Coordinate
airlift,
Communicate
mission itinerary
AECT/TACC: Task
airlift/aircrews
AE Crews: Execute
mission
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TRAC2ES
Patient Movement Request (PMR)





Clinical Data
Medical Specialty/Diagnosis
Patient
History/Medications/Labs
Patient Demographics
Patient Name/Nationality/ID#
Rank/Age/Gender
Precedence
 (URGENT, PRIORITY, ROUTINE)
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TRAC2ES
Mission Planning/Execution
Referring
MTF/Hospital:
Submit
Patient
Movement
Request (PMR)
Reception MTF: Patient
arrives at destination
facility
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PMRC: Validate
PMR, Coordinate
airlift,
Communicate
mission itinerary
AECT/TACC: Task
airlift/aircrews
AE Crews: Execute
mission
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TRAC2ES
Mission Planning/Execution
AE Control Team/
Tanker Airlift Control Center
 Identify aircraft
 Task AE crew members
 Task specialty support
 Notify PMRC when mission
information is complete
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TRAC2ES
Mission Planning/Execution
Referring MTF:
Submit
Patient
Movement
Request (PMR)
Reception MTF: Patient
arrives at destination
facility
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PMRC: Validate
PMR, Coordinate
airlift,
Communicate
mission itinerary
AECT/TACC: Task
airlift/aircrews
AE Crews: Execute
mission
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TRAC2ES
24-Hour Report
Referring MTF:
Submit
Patient
Movement
Request (PMR)
Reception MTF: Patient
arrives at destination
facility
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PMRC: Validate
PMR, Coordinate
airlift,
Communicate
mission itinerary
AECT/TACC: Task
airlift/aircrews
AE Crews: Execute
mission
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TRAC2ES
24-hr Report
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Destination Medical Treatment
Facilities
 Visibility for in-bound…
 Missions
 Itineraries
 Patient loads
 Plan patient reception/care
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Global Patient Movement
A Team Effort
USNORTHCOM
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From the last 10 years of Patient Movement
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Medical Advancements &
Lessons Learned
1.
2.
3.
4.
5.
6.
7.
8.
9.
Resuscitation with blood products
LIFO Blood Usage
Damage Control Surgery
Burn Management
Ventilatory Control with Decreased Tidal Volume
Massive Blood Transfusion Triggers
Epidurals & Nerve Blocks
Tourniquets
No Steroids in Blunt Spinal / Head Trauma
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Blood Component Therapy
 Prior typical "resuscitation protocol" = lots of LR or NS
then 1-2 units of blood (3:1)
 This practice contributed to the lethal triad of
coagulopathy, hypothermia & acidosis
 Now, high suspicion patient is bleeding = proceed
directly to blood products.
Repine TB, Perkins JG, Kauvar DS, Blackborne L. The use of fresh whole blood in massive transfusion. J Trauma.
2006;60:S59-S69.
2. Spinella PC, Perkins JG, Grathwohl JG, Beekley AC, Holcomb JG. Warm fresh whole blood is independently
associated with improved survival for patients with combat-related traumatic injuries. J Trauma. 2009;66:S69S76.
1.
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Blood Tx: LIFO
New blood over old blood
 Previously, the oldest blood in the theater was given first for
transfusions
 should be used before it goes bad.
 Fresh blood has been shown to be superior
 complications of transfusion with "older" units of PRBCs
 "storage lesion": increase pro-inflammatory factors, acidosis, increased
free hemoglobin, and decreased RBC deformability, 2,3 DPG & ATP
 The people most likely to suffer the consequences of complications of
"older" units of blood are those requiring a higher dose
 In patients requiring massive transfusion , effort made to transfuse
fresh units of PRBCs
 Preferably < 14 days old, but the freshest available nonetheless
 Now, LAST IN, FIRST OUT (LIFO) Blood Policy
 Donation to availability in theater averaging 7 days
1.
Spinella PC, Perkins JG, et al. Warm fresh whole blood is independently associated with improved survival for patients
with combat-related traumatic injuries. J Trauma. 2009;66:S69-76.
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Damage Control Surgery
 We now transport patients with “unfinished
surgeries” - open abdomens
 bleeding stopped via clamping and/or packing.
 They are moved to higher levels for more definitive
care
 Further damage control surgeries done
 “Final” closure surgery

Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, Mallett O, Zubko T, Oetjen-Gerdes L, Rasmussen T,
Butler FK, Kotwal RS, Holcomb JB, Wade C, Champion H, Lawnick M, Moores L and Blackbourne LH. Death on
the battlefield (2001-2011): Implications for the future of combat casualty care. J Trauma. 2012;73:S431-S437,
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Burn Management
 Rule of 10's and 6 ml/kg/%BSA burned in thermal injury burn
management
 Basically, now we don’t pour in the fluid.
 Start with an initial amount
 Then adjust it up or down up to 25% per hour (not more!)
 Result = far less incidents of abdominal compartment syndrome
 CCATT transported patients with burns up to 98% and they have
survived.
1.
Ennis JL, Chung KK, Renz EM, Barillo DJ, Albrecht MC, Jones JA, Blackbourne LH, Cancio LC, Eastridge BJ, Flaherty SF, Dorlac
WC, Kelleher KS, Wade CE, Wolf SE, Jenkins DH, Holcomb JB. Joint Theater Trauma System implementation of burn resuscitation
guidelines improves outcomes in severely burned military casualties. J Trauma. 2008;64(2):S146-51; discussion 151-2.
2.
Markell KW, Renz EM, White CE, Albrecht ME, Blackbourne LH, Park MS, Barillo DA, Chung KK, Kozar RA, Minei JP, Cohn SM, Herndon
DN, Cancio LC, Holcomb JB,Wolf SE. Abdominal complications after severe burns. J Am Coll Surg. 2009;208(5):940-7; discussion 947-9.
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Vents: Decreased TV
 Lung protective strategies in ARDS / ICU / Difficult to
Ventilate pts
 Tidal Volume: 4-6 cc/Kg
 Not 10-12 cc/Kg, as prior
 Ideal BW
 Increase PEEP and/or FiO2
 Essentially ARDSNet
 Used very often by US CCATT
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Other Advances
7. Massive transfusion triggers
Higher quantities of blood up front
McLaughlin DF, Niles SE, Salinas J, et al. A predictive model for massive transfusion in combat casualty patients. J
Trauma.2008;64:S57-63.
6. PCA, Epidural and nerve blocks
We fly these all the time now
 Waiver x 10yrs, Official since 2012
Mepivacaine 250 vs 400ml IV bags
Katz J, Cohen L, Schmid R, et al. Postoperative Morphine Use and hyperalgesia are Reduced by Preoperative but not
Intraoperative Epidural Anagesia: Implications for Preemptive Analgesia and the Prevention of Central Sensitization.
Anesthesiology. 2003;98:1449-1460.
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Lessons Learned (con’t)
8. Re-emergence of tourniquets
9. No steroids in blunt spinal cord or TBI
 No proven benefit
 Worsen outcomes in patients with severe head injury
 Frequent associated open or contaminated wounds of
battle casualties further complicate steroid
administration
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Questions
Mirski@hotmail.com
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“VALIDATE…COORDINATE…COMMUNICATE”
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