From: E. To: G. Subject: CCATT working group @ Andrews AFB Sent: Wed 5/14/2003 11:07 AM Good Am!!! G., The intent of this correspondence is to introduce myself and the Board; establish a working relationship with you/CCATT members as to increase (forgot "so", a needle pulling thread) Board awareness of USAF deployment needs; and encourage you(CCATT)/ AF wide DEPMEDS use (messed up an infinitive there somewhere). My name is E. - Physician Assistant assigned to the Joint Readiness Clinical Advisory Board - Fort Detrick, MD. We are housed in the same bldg as AFMLO. The Board staff is made up of Army, Navy, AF and Civilians - in various category (sic)- pharmacist, logisticians, clinicians ( nurses, PA-C's, physics, optometrist, MD, lab officer,) Our mission at the Board is to standardize all medical equipment/ supplies/ materials for all deployable medical systems ( DEPMEDS) - Have you or any of the other CCATT members ever use (sic) this data base? The standardization process is mostly done through Panels consisting of Subject Matter Experts( SME). Due to your ( CCATT) deployment platform, your expertise is valuable to our work. I would like to consult with the team prn and for the CCATT members to consider participating in our Panels. We will be holding an Emergency/EMT panel and we will be soliciting SME participation. Because of the nature of our business we get bombarded with the latest in medical technology/ supplies (gulp). A relationship bet us (sic) will give you another avenue to stay abreast of what is on the horizon. Therefore, facilitating wiser economical /clinical decision making when building your packs (as well as increasing the number of sentence fragments in the universe). On this note, I gave your name to David (redacted), (company) Rep, he is marketing "Smart Dose"- a light wt/small infuser- that you might find very suitable for your packs. I got your name from B. ( in case you are wondering) - She attended the CCATT working Group I found out about your meeting after the fact (sic. I thought Ft. Detrick was dedicated to intelligence). Is it possible to get a copy of the meeting manuscript/ summary ? Thank you for your time! If I got long winded, please forgive me. At your Service! (Note: E. is obviously female by her name...hmmm...) E. Maj, PA-C, BSC, USAF Chief, Major Medical Equipment Joint Clinical Advisory Board 1423 Sultan DR. Ft Detrick, MD 21702 (phone number redacted) Email- redacted@det.amedd.army.mil
Hi
The blast in Baggy kept us busy. It was another trip from hell for me. We thought we were going to Bagdad to pick up 1 pneumonia pt. We get there, no one knows anything about him but the MASF nurse said he left the night before. They had 3 to 4 trauma pt., all UN folks, that need to go but PMRC didn't have the dip clearances yet and it would take 3 hours. So we flew back to Kuwait empty handed (ccatt). Only to have the aircraft commander tell me (once it was too late) it would have been better to wait on the ground for the clearances than fly in there twice and all of us have an 18 hour day. I didn't think all that ground time was an option because every other time I flew in there they didn't shut the engines down. Besides, I am not the MCD anymore, someone else needed to work those issues. So we fly back in, they try to give us 4 pt,'s on vents, all fresh post ops with low BP's. I said NO. We took 3 and they sent a CRNA to look after the one pt. (Guess I looked tired) Regardless Greg, these were busy pt.'s, the IV pumps didn't work, they were waking up because the pumps don't deliver the Versed etc. It takes a huge chunk of my time to keep bolusing these pt’s. All the drugs we use are short acting. They were a mess, dressings leaking, and spaghetti for lines. I bitched at the nurses in the CSH and told to change those dressings and what did they expect me to be able to do about them on the plane. They didn't like it very much but they had all day to get those pt's ready for airlift and they didn't do it. It took them an hour to find litters to put the pt.'s on. We took off at dusk. There aren't any runway lights there. If anything happened the pilot would have gotten in trouble. He busted local minn's getting out of there. And he really didn't want to go back for "UN people". Army boys yes, UN folks, possibly foreign nationals, no. He is a good ol boy from Nashville ANG. I kind-a talked him into it. But of course the C 130 stage had the final word if they were going to extend their duty day. I went to bed at 2400 and wake up until 1045. The girls in the tent are making fun of me cause I never sleep like that. I feel like I am flying alone, it exhausts me. Brad doesn't feel he should have to do anything. In fact he slept on the way back down there while AE and me re-configured the plane. He is uncomfortable with these pt's and it scares me. Every mission is horrible for me now. At first we just had "tatter totes", now more fresh trauma. I have to do all the thinking and planning and paper work and coordinating. Plus focus on an unstable pt. or pt's. Brad & Ernie honestly feel they are not responsible for anything. One little thing goes wrong and they both look at me and verbally blame me. Like the trip to GE, I told Brad he was in charge of getting the 781 from the MCD. One little thing I gave him to do and he didn't do it. Said he forgot because he was so tired. What the hell did he think I was????? When we got in last night, I put away all the equipment, got it straightened out and plugged back in, restocked supplies etc. He and Ernie went back to change clothes and go to midnight chow. A admin tech in the CMC felt sorry for me and helped me tidy up. Brad said he was just too exhausted to do anymore work.
21 July 2003
MEMORANDUM FOR 59MRX/CC, 59 MDW/CCATT, 759 MSGS/CC, AMC/SGP
FROM: Colonel K., CCATT Team Chief, 59 MDW/CM (deployed: 379th EAES, [redacted])
SUBJECT: CCATT After Action Report for Deployment in Support of Operation IRAQI FREEDOM
...6. Team Chief’s Summary:
a. Pre-deployment Issues:
Prior to the actual deployment of this team, there were a number of unfortunate delays out of the team’s control that delayed the deployment of this team for over two weeks. Our original departure date of 20 Feb 03 was cancelled when we learned 3 hours before our scheduled departure by commercial plane that the military aircraft we were scheduled to depart on had actually departed on 19 Feb 03 from our original point of embarkation. Then, we were further delayed by the fact that the Lackland PRU re-scheduled us for flight into the wrong location in the AOR and this was not discovered until the team chief went to pick up tickets. We were finally scheduled to depart on military aircraft on 8 Mar 03.
Additional confusion was caused by the fact that we were instructed not to travel with ammunition for our weapons and that it would be available in the AOR. This information was incorrect and the team had to go to considerable lengths to obtain ammunition once in the AOR.
...
e. CCATT Extenders:
Further guidance on the role of CCATT extender teams should be a major priority. In our situation at Camp (Redacted), it was necessary, due to the operations tempo, to employ these teams as if they were intensivist CCATT teams. This was done with the caveat that if the transport posed challenges that made the team chief uncomfortable, they were to pass the mission to the next available intensivist CCATT. However, enthusiasm to transport patients can certainly cloud a provider’s judgment with regard to their ability to handle potential untoward occurrences during transport. In our experience, a CCATT extender teams never opted out of a transport. Using internists or other non-critical care physicians to perform transports by themselves goes against the reason the CCAT teams were developed in the first place. Events such as having to re-intubate a patient, insert a central line, insert a chest tube, perform a surgical airway, etc., should be rare events. However, when the need arises, the physician attending the patient should have the requisite skills to perform the required procedure. In a related matter, we encountered some teams that had a “critical care” nurse who had minimal critical care experience. In fact, the team that replaced us had an intensivist combined with an OR nurse who had minimal practical experience in the critical care unit setting. Based on the our experience during this deployment, and our knowledge of the clinical demands that will be made on even a highly competent critical care nurse, the practice of using nurses inexperienced in critical care on CCATTs also has the potential to lead to some unintended adverse outcomes.
Many internists and family physicians do not have up to date experience performing these procedures and this can lead to serious consequences. For example, one internist temporarily deployed to our location had not intubated a patient in several years and he had never put in a chest tube by himself. In another instance, a patient with pneumonia that we transported to LRMC, was transported by another CCATT with a non-intensivist from Balad, Iraq. While this physician correctly recognized that this patients required ventilator support, the medical record from Balad indicated that the physician was unable in two attempts to intubate the patient. Fortunately, a nurse anesthetist at that location was available to intubate the patient. Had that not been the case, the consequences could have been disastrous for the patient. Of course, this is just one case, and anyone proficient in a procedure can have difficulties at one time or another. In addition, I know of at least one internist who was quite proficient in airway management. However, I think it should raise some concerns that employing non-intensivist CCATTs interchangeably with intensivist CCATTs can lead to problems. In the only fatality during CCATT transport in the AOR of which I am aware, I am told the physician involved was a non-intensivist and that the death was not expected. However, I do not have first hand knowledge of that incident and therefore I will not comment further. Obviously, if the death was not expected and the team was a non-intensivist team, then this should raise some concerns about the independent use of non-intensivist teams as well. Finally, most non-intensivist physicians have little or no regular experience conducting an ongoing medical or trauma resuscitation and this could lead to problems when we are transporting stabilized and not totally stable patients.
To the credit of the CCATT extender teams, they possessed the correct work ethic and attitude. However, I am concerned that we may be putting them in a position to fail, because of a lack of the appropriate clinical training and experience. When the number of CCATT missions is high at a particular location and there are only limited intensivist teams available, we are left with little option but to allow the teams to rotate in a regular schedule rather than choosing the team with the most experience suited to the clinical scenario. We had some days where three CCATT missions were launched in a 24-hour period, leaving only a CCATT extender to fly the next mission. During the height of the conflict, many missions employing CCATT had a mix of patients that included a patient requiring ventilator support and because of the volume of missions at our location we did not have the luxury of holding the extender teams back for lesser demanding transports. However, for future conflicts, I believe the solution to the problem of not having enough intensivists and qualified critical nurses on CCAT teams should be to make every attempt to recruit more qualified individuals rather than resorting to non-intensivist teams to an even greater degree.
j. Redeployment
There was significant confusion about our date for redeployment home. The team was initially given a redeployment date of 30 June 2003. This was understandably changed to “indefinite” when it was realized that operations tempo in May was higher than expected. Then we were informed that we were redeploying on 3 July and that replacements were not required. On 1 July we were sent to Camp Doha, Kuwait to make our arrangement for travel home. We were scheduled on a rotator for 4 July. Then, on the morning of 2 July, we were informed that we could not leave until a replacement team arrived and that our release from the AOR was rescinded. Finally, our replacements arrived in the AOR on or around 6 July. However, their weapons were confiscated upon arrival in the AOR because they had been sent on commercial aircraft with weapons but without the appropriate paperwork to enter Qatar with them. This further delayed our ability to depart. In the mean time, we used the extended overlap period to orient the new team members to their duties. Finally, on 10 July, we departed the AOR for home. While the miscommunication about our release on 3 July caused hard feelings and increased stress for our families, the squadron did make every effort to get us home once our replacements were mission capable. SRA M. and I departed Kuwait on 10 July and arrived in San Antonio on 11 July. Captain L. returned to Travis AFB on 13 July.
TITLE: CCATT Availability of O2 for transport on/off aircraft CLASSIFICATION: Unclassified OBSERVATION: Lack of ‘D’cylinder availability with CCATT periodically delayed transport on or off aircraft. Initial reluctance on part of Army Combat Support Hospital to “loan” us oxygen for ground transport to plane. DISCUSSION: Typically, CCATT has no oxygen assigned; relies on either AE or fixed ground medical facility for supply of oxygen LESSON LEARNED: Incorporate d-cylinders and transport bags into TOA. Will require availability of facility capable of refilling/servicing. However, feel CCATT should routinely have these cylinders available and carry them whenever transporting ventilated/oxygen dependent patients.
OPERATION ENDURING FREEDOM/IRAQI FREEDOM CCATT LESSONS LEARNED INPUT
Submitter: COL (redacted)
Unit: (redacted)
TITLE: Patient Validation
Observation: Validating Flight Surgeons were unfamiliar with CCATT team capabilities.
Discussion: On several occasions the validating flight surgeons (FS) were unfamiliar with CCATT and our in-flight capabilities. The validating FS used outdated and inaccurate means of determining if a patient was able to fly on an AE mission. On occasion this resulted in heated disagreements between the CCATT physician and the validating FS.
Lessons learned: The validating FS may need to be reminded that in-flight CCATT assets and capabilities include blood count, chemistry and blood gas determinations. We also have the means to intubate, transfuse blood, place chest tubes and other non-routine procedures while in-flight or on the flight line.
Recommendations: The validating Flight Surgeons at all levels of the AE system need to be knowledgeable about the capabilities of CCATT teams. In addition they need to listen and rationally discuss patient transport issues with the CCATT physician who is at the bedside. The decision should be given to the physician who has first hand knowledge of the patient and knows the abilities of his transport team.
...
Submitter: COL (redacted)
Unit: (redacted)
TITLE: Transportation
Observation: Inadequate transportation provided for CCATT at their deployed location.
Discussion: Transportation to the worksite for the (redacted) EAES has been inadequate while at Bldg (redacted) and at Bldg (redacted). On base shuttle services were also inadequate and sporadic at best. Request buses catered only to departing and arriving flight crews and could not be utilized for our transportation.
Lessons learned: Be prepared to walk from your billeting rooms to most of the base facilities. Work with your CCATT ground transportation teams to arrange group transportation to and from (redacted) Headquarters.
Recommendations: Best option is to have at least one member of your team authorized a car rental on your orders, or have your orders amended to that effect. Bring a bicycle (a folding bicycle works best) or plan to buy one while TDY here. Outdoor recreation no longer rents bicycles to TDY personnel. There numerous scenic bicycle trails on and off base for you to explore on off days.
Webmaster's Note: I included this last set of paragraphs to demonstrate the kind of "crazymakers" that drive dedicated physicians (like myself) away from military service to their country. Some pointy-haired commander boss decided that physician and nurse officer CCATT members weren't worthy to ride in the shuttle buses (which, in my experience, usually go around half empty). Second, why in the HELL wouldn't outdoor recreation services rent bikes to deployed physicians and nurses? What, they think that the docs will sell them on E-bay®? They think the physicians, who already have to lug around hundreds of pounds of equipment in their deployment and personal bags, will try to stick an Outdoor Rec services bike onto their aircraft on departure from the deployed location? What? Or is it not the truth that the deployed Outdoor Rec pointy-haired boss simply wanted to decrease his/her troops' workload by refusing to provide service to the huge transient population cycling in and out of the base? It's much easier to put one's feet up in an air-conditioned tent than to constantly go outside to service/maintain bikes used by deployed officers for recreation and transportation to their duties. Service before self: Ha! What bull$h1t.
Hey G., Greetings from the stan. We have spent the last 2 days going over the equiment (sic) and needless to say it is a mess. Both of the lifepack 10's are 2 months post maintainence checks. The ACLS drugs for the most part expired back in 11/2002. I can't believe that anyone would even think of using these drugs. Unitl (sic) the lifepacks come back from Germany, we are not green. I hope things are going well there. Tell Za Za, I mean J. I said hey. B. > Hi Dr. M.: > > France was excellent. The poeple (sic) treated us like King's (sic). They were > desperate for the American tourist dollars. I will stay intouch with > you by this email. I just got a team back from the Stans. It was not a > good experience. The AE leadership over there was terible and treated > our team very poorly. I hate to give you this information. Hopefully > the new leadership will be better. The main problem was an AE > commander by the name of LTC C. he is truely (sic) the worst leader > that I have ever heard of. I had people who were very ill over there > and refused them (sic) timely medical attention and evacuation. WATCH YOUR > BACK. > > I will keep this email. It should work for you. If you need anything > please stay in touch since I know Kim is out of you loop now. I will > be glad to help you in anyway I can till K.'s return. I email her > everyday and she is heading for Bagda with B. and E.. Please keep > them in your prayers. > > C. > > -----Original Message----- > From: (redacted) > To: R. Capt 759 MSGS/MCCY > Sent: 7/27/2003 8:54 AM > Subject: RE: CCATT - OIF Hotwash & Working Group > > D., > > Welcome back from France. How was it?? or do I even need to ask?? > How much of the race did you get to see if any?? I am leaving > tomorrow to go over to one of the ...stans for the next four months. > I will keep you posted. Thanks for all of your help. > > B. > >> To the best of my knowledge they are to be included. >> >> C. >> >> -----Original Message----- >> From: C. Lt Col 376 EAES/CC >> To: (dozens of people redacted) >> Sent: 7/25/2003 1:55 PM >> Subject: RE: CCATT - OIF Hotwash & Working Group >> >> Does anyone care about the input from those men and women who > continued >> to provide a great service to the casualty movement system for OEF >> ??? Are they included or excluded form this process ?? >> >> (redacted) >> >> (redacted) C., LtCol, USAF >> 376th EAES/CC >> >> -----Original Message----- >> From: R. Capt 759 MSGS/MCCY >> [mailto: (redacted)@LACKLAND.AF.MIL] >> Sent: Saturday, July 26, 2003 12:37 AM >> To: (dozens of people redacted) >> Subject: RE: CCATT - OIF Hotwash & Working Group >> >> >> >> Hello All: >> >> Just to let you all know that right now I'm not in the office I'm at > the >> beach until next week taking a long deserved vacation. I will begin > work >> Aug 1 on arrangements for the Hotwash and WG meeting. Please remeber > to >> make sure that as you a writing After Action reports to "KEEP THEM >> UNCLASSIFIED" we have already had a few scares in this matter over >> the past week. >> >> C. >> >> -----Original Message----- >> From: T. Maj AMC/SGP >> To: (dozens of people redacted) >> Sent: 7/17/2003 6:01 PM >> Subject: CCATT - OIF Hotwash & Working Group >> Importance: High >> >> ALCON, >> >> We have scheduled a meeting for an OIF CCATT Hotwash to be held at >> Lackland AFB TX, 6-7 Oct 03. Actions and deliverables from this > meeting >> will include reviewing and compiling AARs, developing recommended >> solutions for consideration for input into operational doctrine, and >> identifying issues to forward to functional managers for further >> follow-up. >> >> Immediately following the hotwash, we have scheduled the Fall '03 >> meeting of the CCATT Working Group to be held at Lackland AFB TX, 8-10 >> Oct 03. Agenda and minutes from the Apr 03 meeting are in > development >> and will be forwarded to all prior to the meeting. >> >> Meeting location(s) at Lackland and billeting arrangements are being >> worked at present. Information will be forwarded to all upon >> completion. >> >> Our POC at Lackland is (redacted) >> >> We extend an invitation to representatives from the AE community to >> please attend. We would especially like to have participation in the >> Hotwash by key, selected AE leadership personnel from AMC, and > deployed >> leaders/members from OIF. Request the AE community select >> representatives to attend. >> >> More information will be forthcoming as plans are finalized. Please >> marks these dates on your calendar. >> >> "Geaux Tigers" >> >> T., Maj, USAFR, MSC >> Program Manager, CCATT Operations >> HQ AMC/SGP >> (redacted) >> "The early bird may get the worm, but the second mouse gets the > cheese." >>