ANGMS – Pulse of the Guard Deployed Medicine and Clinical Decision-Making – Experiences at Manas AB, Kyrgyzstan Sep 2005 – Jan 2006 Col Kevin “Schweaty”

ANGMS Pulse of the Guard Deployed Medicine and Clinical Decision-Making Experiences at Manas AB, Kyrgyzstan Sep 2005 Jan 2006 Col Kevin Schweaty Bohnsack 110 MDG/CC Battle Creek ANGB, MI

Kyrgyzstan

Its like Up North, eh?!

Overview Manas Air Base Mission and Medical Support Host Nation Background/Capabilities Air Evacuation and Coordination Case Presentations x 3

Kyrgyzstan Manas Air Base

Manas Air Base Mission 376 AEW - Project expeditionary air power in support of Operation Enduring Freedom Strategic Airlift Hub Air Refueling Tactical Airlift Move People, Cargo, and Fuel 376 EMDG - Provide 24/7 medical care and preventive medicine to optimize warrior performance

Moving People, Cargo and Fuel

People

and more people and cargo

and cargo

and more cargo...

and more cargo (low-level)...

and more cargo (at night)

and fuel for the fight.

ANGMS Pulse of the Guard 29 person EMDG EMEDS (Expeditionary Medical Support) Basic/Tailored EMEDS Plus/Minus

ANGMS Pulse of the Guard EMDG Organizational Chart Shift Leader Commander Administrator1 st Sergeant DentalSGPSurgeon BEEIDMTPublic Health Provider Dental Tech. BMETLogisticsAdmin Life Skills Tech Shift Leader NCOIC Technician Life SkillsChief Nurse Nurse CRNA tech Lab Technician

376 EMDG Responsibilities Clinical and administrative services to forces at Manas AB. acute medical care flight medicine dental public health industrial health services Coordinate consultations with referral Military Treatment Facilities in the AOR - primarily Al Udeid and Bagram. Coordinate aeromedical evacuation as appropriate with primary referral to Al Udeid and Landstuhl GE.

Great Base Great Mission Great Deployment

Host Nation Factoids Former Soviet Socialist Republic Largest contributor to countrys Gross National Product is a Canadian- owned and operated gold mine The second largest contributor is the U.S.-operated Manas Air Base. Ethnicity is still 20-40% Russians. The north is primarily of Asian descent and the south has more nomadic tribes similar to Afghanistan. Capital city is Bishkek, approximately 30 minutes away by shuttle bus along the main highway Physicians are trained in Kyrgyz or Russian hospitals along European system. Salary for a General Surgeon is $40 per month, supplemented by post- operative favors given to them by grateful families.

Downtown

Mountains

Host Nation Capabilities National Surgical Center Best for emergency surgery (appendicitis that cant wait for AE) National Trauma Hospital Best for mass casualty due to trauma and orthopedics National Cardiology Hospital Good for diagnostic medical evaluations including work-up of acute MI and pulmonary embolus Kumtor Clinic (Private) More Western-oriented diagnostic approach with equipment. Insight re: best surgeons in Bishkek to have on retainer to use as needed

Kyrgyz Republic National Surgical Center Teaching hospital with 250 beds (90% occupancy rate), 98 staff surgeons, 12 ICU beds, and 5 ORs primarily for abdominal and thoracic surgeries. Commonly performed procedures include appendectomy, cholecystectomy, pancreas and stomach operations and thoracoabdominal trauma repair procedures. Diagnostic equipment includes laboratory blood and urine testing, plain x-rays, ultrasounds, esophagogastroduodenoscopy and colonoscopy. KEY: Visits to each facility at beginning of each rotation.

Kyrgyz Republic National Surgical Center Spartan facilities, but generally clean Minimal modern equipment in ICUs and ORs Good surgical experience in terms of numbers of cases treated KEY: Build relationships.

Kyrgyz Republic National Surgical Center Overhead light in OR with ambient light through windows. OR suite is on the same floor as the inpatient wards. Residents follow patients at night. KEY: Different Setting = Different Standards

Kyrgyz Republic National Surgical Center Good surgical sterilization techniques Apparently good infection control practices Doesnt appear as clean as US facility, but none of the hospitals in this region meet that standard Probably no worse than risk of contamination in field hospital with limited case load KEY: If you have equipment to bring with you, bring it.

Kyrgyz Republic National Surgical Center Department of Surgery 10 beds with private suites and a separate OR Private room with one bed a little nicer than the normal rooms that are shared. Welcomes our staff to supplement theirs in any way we desired. KEY: People can be very good but they may not have the same resources as you.

Cardiology Hospital Major Internal Medicine Referral Hospital All Internal Medicine Subspecialties Available 2 ICUs with 12 cardiac beds and 10 medicine beds Renal dialysis available. KEY: Get to know the healthcare system in your host nation.

Cardiology Hospital Laboratory is able to run PTT- equivalent for continuous heparin drip. No ability to check for protime (PT) and does not carry warfarin (Coumadin) in-house. Echocardiography and ultrasound also available. KEY: Augment diagnostic capabilities even if you wont necessarily treat at that facility.

Cardiology Hospital ICU step-down beds consist of the patient being directly observed by a clinician. No direct monitoring equipment available after initial stay in ICU. KEY: Develop a level of comfort and familiarity with their rules of engagement.

National Trauma Hospital Typical hallway in any downtown hospital. Some facilities do not have overhead lighting for hallways. No creature comforts such as cafeteria, linen service, etc. KEY: Realize that you as a healthcare provider can develop familiarity but Airman Snuffy will be very surprised.

Pharmacy ROE Patients must purchase their own medications provided in the hospital from in- house pharmacies located in the hallways. Some more specialized medications may be carried by only one pharmacy in the entire city. (eg. Plavix) KEY: Do not make any assumptions about standards or reimbursement and bring cash (or finance who has the cash.)

Iridiocyclitis Case KEY: Reinforce host nation practices and plans with back-up from reachback resources.

Kumtor Clinic Canadian-Kyrgyz Mining Company Medical Operations Primary mission: Occupational Medicine and coordinating care of company ex-pats Excellent contacts with local surgeons who are best in their field Clinical capability similar to that of EMDG although they have some increased diagnostic capabilities. KEY: Explore other options and use more familiar resources if required.

Kumtor Clinic Diagnostic laboratory with ability to perform chemistries including TSH. Small ultrasound machine available for quick-look diagnostic capability. KEY: Anticipate what your population may need.

Host Nation Capabilities National Surgical Center Best for emergency surgery (appendicitis that cant wait for AE) National Trauma Hospital Best for mass casualty due to trauma and orthopedics National Cardiology Hospital Good for diagnostic medical evaluations including work-up of acute MI and pulmonary embolus Kumtor Clinic (Private) More Western-oriented diagnostic approach with equipment. Insight re: best surgeons in Bishkek to have on retainer to use as needed

Host Nation Capabilities KEY: Know your transport options.

Bottom Line for EMEDS On-site stabilization for surgical and other ill military and eligible contractors that require hospitalization until AE arrives. Unstable patients are brought downtown with additional medical supplies, drugs, and blood as available. For mass casualty scenarios, rely on local transportation to supplement our own, taking patients downtown followed by AE ASAP. 376 EMDG will continue to offer acute medical and dental care on an urgent need basis to US Embassy State Department and DoD personnel and families, but routine medical and dental care should be obtained locally.

Questions/Principals Administrative Memorandums of Understanding are they in the SOFA? Payment - cash Surgical Concerns Anesthesia Sterilization Equipment Medical Issues Medications EMEDS supply Downtown - country of origin and cost Supplies Have a go bag Monitoring equipment Standard of Care/Philosophy differences Creature Comforts Linen Food Communication Availability of translator Physician to physician communications

Spirit Award

FINAL DESTINATION CSH/ATH MASF Fixed Facility/ASF AELT Main Operating Base Battlefield Aeromedical Evacuation

Medical Treatment Facility (MTF) AELT (Air Evacuation Liaison Team) TRAC2ES (TRANSCOM Regulating and Command and Control Evacuation System) web-based system to input a PMR Patient Movement Request ASF (Aeromedical Staging Facility) Qatar/Germany TPMRC (Theatre Patient Movement Requirements Center) validate requirement AECT (Air Evacuation Control Team) find the airlift AE Alphabet Soup

Obligate picture of an AF Form

Online tool Interface between MTF requesting air evacuation and TPMRC Includes everything on the 3899 and more so the admin team should develop an extra questionnaire for other information such as home address, home phone, etc. Contractors require Passport number and insurance information. TRAC2ES

URGENT: Immediate movement to save life, limb or eyesight; normally within 12 hours (Psychiatric cases and terminal cases are not eligible!) PRIORITY: Patient should move within 24 hours for medical care not locally available ROUTINE: Patient can move on the next regularly scheduled mission Patient Movement Precedents

Fixed facility - 50 bed increments Capacity 50-250 patients every 6 hours Provides continuing in-transit patient care during AE from AOR to CONUS. Patient stay can be extended up to 24 72 hours. Aeromedical Staging Facility

C-130, C-17, or opportune airlift

Mountains

Manas Kandahar Bagram Djibouti USAMM C-SWA Tallil Mosul USAMM C-E Materiel Shipment Only Requisition and Shipment Route Balad Bagdad Kirkuk Kuwait Medical Logistics Requisition and Shipment SOURCE: CENTCOM Brief 3 Apr 2006

Issues Telemedicine Teleradiology Teledermatology E-mail services (formal and informal) Safe transport No such thing as medical passengers or medpax Level of care decision Closest destination of care Sister Service Coalition Forces Downtown Return to Duty (RTD) Issues Al Udeid destination of choice for members likely to be RTD 30 day cutoff Maximize capability for the line commander

Stethoscope, medications, digital camera, thumb drive

Army Telemedicine

Issues Telemedicine Teleradiology Teledermatology E-mail services (formal and informal) Safe transport No such thing as medical passengers or medpax Level of care decision Closest destination of care Sister Service Coalition Forces Downtown Return to Duty (RTD) Issues Al Udeid destination of choice for members likely to be RTD 30 day cutoff Maximize capability for the line commander

AIR EVAC PROTOCOL FOR MANAS AB (AEF 7/8, Sep 2005 Jan 2006) AIR EVAC PROTOCOL FOR MANAS AB (AEF 7/8, Sep 2005 Jan 2006) AIR EVAC PROTOCOL Can the patient be definitively treated here? No Will the patient return to duty? Yes Should the patient be seen downtown? Can you provide follow-up care? Yes Send patient to Landstuhl Send patient to Al Udeid Send patient to Bagram Patient stays at Manas Patient presents to Manas EMDG Yes No Yes No Will the patient return to duty within 30 days? Can Bagram Treat? Can Al Udeid treat? Yes No

Dyspnea HISTORY OF PRESENTING ILLNESS 38 yo contractor with MMP presented originally on 13 Sep 2005 to the clinic with URI symptoms. He followed-up three days later on 16 Sep 2005 with worsening dypsnea on exertion. PAST MEDICAL HISTORY morbid obesity s/p gastric bypass (Mar 2005) weight went from 510 down to 280 pounds hypothyroidism (2000) Synthroid 75 mcg PO qd for the past 2 years with no recent laboratory checks to his knowledge gout occasionally takes Indocin for any gouty attacks SOCIAL HISTORY Food services industry due to stay here for another couple weeks before he returns to Jordan where he normally resides/works (and has a pregnant girlfriend)

Dyspnea PHYSICAL EXAMINATION Vitals: P 112, BP 130/85, O2 saturation of 92% but 88% with ambulation. Lungs: clear ANCILLARY TESTS?

Dyspnea EKG sinus tachycardia, nonspecific T wave abnormalities WHAT ARE YOU GOING TO DO? BACKGROUND INFORMATION Old EKG was not available so the treating physician called back to the States and was able to get a description of the past EKG read over the phone by the emergency room physician on-duty in Tennessee. Walkthrough comparison revealed that flipped T waves were a new finding in leads V2 and V3.

Dyspnea DOWNTOWN EVALUATION Echocardiogram pulmonary hypertension at ~60 mm Lower extremity doppler floating thrombus in the right femoral vein DOWNTOWN RECOMMENDATION Do not initiate anti-thrombotic therapy such as heparin until an inferior vena cava filter has been placed.

Dyspnea PATIENT TRANSLATOR KYRGYZ ATTENDING PHYSICIAN MILITARY PHYSICIAN Kyrygz attending physician explained that they would like to place an IVC filter. Translator explained situation to patient and the military physician over the phone. OPTIONS Transfer patient back to EMEDS and initiate anticoagulants OR press with IVC filter BACK HOME AT THE EMEDS RANCH Military physician explained to the patient that this course of action was the best recommendation under the current circumstances. CENTAF Military physician explained situation to CENTAF/SG who agreed with plan.

Dyspnea AIR EVACUATION Request entered through TRAC2ES. Questionable insurance coverage delayed decision by 48 hours. Company back in Texas finally agreed that he would be moved by International SOS. 48 hour POST-OP VISIT Heart rate in the 80s, BP 120s/80s, and pulse oxygenation level is 91%. Heparin drip running. Last PTT checked was 24 hours ago. Nitro drip running at 5 mcg/minute. Right leg is in pain and Kyrgyz physician has ordered Vishnevskys ointment. No warfarin available but a Russian-made oral anti-coagulant is a possibility.

Dyspnea VISHNEVSKYS OINTMENT Pine tar is main ingredient. Used to increase venous/arterial circulation in patients with DVTs or claudication. Vishnevsky was a famous Russian general surgeon. QUESTIONS Keep heparin running when we have low molecular weight heparin (Lovenox)? Keep nitro going? Do we initiate Russian-made oral anticoagulants? Is Vishnevskys ointment ok?

Dyspnea RECOMMENDATIONS Start Lovenox shots 1 mg/kg bid and discontinue continuous heparin drip. Discontinue nitro drip. Do not initiate oral anticoagulant. Hippocratic oath applied to the use of topical pine tar on his leg. AIR EVACUATION AND THE REST OF THE STORY International SOS picked up patient directly from the hospital and brought him to Landstuhl. He was sent back to the States for stabilization on warfarin that was originally initiated at Landstuhl. Contractor returned to Jordan within a few months to be with his pregnant girlfriend and resume his food services job. EKG technician for the Tennessee hospital received employee of the quarter for her initiative and resourcefulness.

Chest Pain HISTORY OF PRESENTING ILLNESS 45 yo transient Army full-bird colonel presented on 25 Oct 2005 with the chief complaint of chest pain for the past hour. Review of systems positive for diaphoresis and nausea. PAST MEDICAL HISTORY Past history of abnormal heart rhythm takes Beta blocker gout occasionally takes Indocin for any gouty attacks SOCIAL HISTORY Reservist Activated for a 6 month tour in Kabul. He is not attached to any particular unit there at Manas.

PHYSICAL EXAMINATION Vitals: P 120, BP 110/74, O2 saturation of 96% Heart: tachycardia, no obvious murmurs Lungs: clear ANCILLARY TESTS? Chest Pain

EKG #1 initial sinus tachycardia, 1-2 mm elevation of the ST segment WHAT ARE YOU GOING TO DO? EKG #2 45 minutes later sinus tachycardia, 4 mm elevation of the ST segment Chest Pain

DOWNTOWN EVALUATION Echocardiogram decreased left ventricular wall motion DOWNTOWN RECOMMENDATION Initiate thromboplastin (TPA) treatment. Activase and Lovenox supplied from EMEDS supply. French-made Plavix and Russian-made Lipitor provided from outside pharmacy. Chest Pain

PATIENT TRANSLATOR KYRGYZ ATTENDING PHYSICIAN MILITARY PHYSICIAN 24 hour observation in ICU WHAT DO YOU WANT TO DO? CCATT REQUEST AND EVALUATION CCATT (Critical Care Aeromedical Transport Team) arrived within 36 hours and visited the patient downtown. Intensivist requested LifePak for monitoring purposes but the battery lost power. Attempts to establish an alternate power source with a transformer were not successful. Chest Pain

EMEDS ICU CCATT intensivist picked up patient on hospital day #3 and brought him back to the EMEDS. CCATT intensive care nurse alternated shifts with intensivist. AIR EVACUATION Patient was air evacuated out by an aircraft of opportunity, a KC-10, and brought to Landstuhl. Chest Pain

THE REST OF THE STORY The patient was sent on to Walter Reed where he underwent cardiac catheterization. The mid-diagonal had a 90% blockage and there was mild inferobasilar hypokinesis. A stent was placed and he is now on a beta blocker and statin drug. Plan is to retire in June 2006.

Fractured Clavicle HISTORY OF PRESENTING ILLNESS 55 yo contractor (airfield manager) fell while on horseback riding trip. Phone call received from the OSS commander at 1730 that the patient was at a downtown hospital. PAST MEDICAL HISTORY Hypertension lisinopril and HCTZ. No primary care physician of record. He has normally received refills from the EMEDS facility. SOCIAL HISTORY Lives in Kyrgyzstan full-time with local girlfriend

PHYSICAL EXAMINATION No examination possible because patient is downtown at his own apartment but a fellow contractor brought the films back to base. X-RAY FROM DOWNTOWN Fractured Clavicle

ORTHOPEDICS E-CONSULTATION Poor film quality is difficult to evaluate. Recommendation was to have a CT of the shoulder in case there was a floating shoulder. Patient given narcotic pain medications. Air evacuation to Landstuhl LANDSTUHL ORTHO CONSULT Repeat film (no CT) Non-surgical case. Conservative treatment with sling x 2-3 months and serial films to document callous formation. CAN HE COME BACK TO MANAS? Fractured Clavicle

DOWNTOWN KYRGYZ Kyrgyz physicians fixed a plate to his clavicle. Surgery was repeated three days later because the end of the plate was poking through his skin and causing irritation. FOLLOW-UP Patient experienced significant post-operative pain and came into the clinic three more times for Percocet, once calling on Christmas Day for medication. Fractured Clavicle POST-CONSULTATION COURSE Persistent pain requiring frequent narcotic pain refills. Patient felt that fracture was getting worse with one bone component poking into skin. Patient sought downtown consultation on his own who recommended surgery.

THE REST OF THE STORY Patient counseled that he needs to get subsequent post-operative care from downtown orthopedic surgeon. No subsequent visits to the EMEDS for narcotic pain medication refills. Fractured Clavicle

Recommend follow-up with U.S.-based provider for maintenance issues. Can patient be definitively treated here? No Are there any chronic medical problems? No Should the patient be seen downtown? Can initial follow-up be provided at EMDG ? Yes No Air Evac Protocol Contractor presents to Manas EMDG Yes No Yes No Yes Is air evac required to address medical problem? Does patient have a U.S.-based physician? Yes Is preventive maintenance up-to-date? Follow-up as needed No Yes Patients advised that they must either: Continue downtown care and obtain locally-purchased medications, paying for services on their own. OR Obtain a U.S.-based physician to manage the specific medical problem. Patients also counseled that: Manas EMDG physicians are not responsible for any routine health maintenance issues such as cancer, cholesterol, or heart disease screening. AND Manas EMDG physicians will continue to see the patients for any urgent care or emergent issues IAW DoDI 3020.41. Can patient receive subsequent care of chronic medical problem and/or routine prescriptions via U.S.-based physician? No Yes NOTE: If the patient refuses any of these steps, he or she will be considered to be an Against Medical Advice (AMA) patient CONTRACTOR CARE PROTOCOL Contractor Care PAM Clinical Ops Contractor Care Protocol

Overview Manas Air Base Mission and Medical Support Host Nation Background/Capabilities Air Evacuation and Coordination Case Presentations x 3

Questions?

Documents

ANGMS – Pulse of the Guard Deployed Medicine and Clinical Decision-Making – Experiences at Manas AB, Kyrgyzstan Sep 2005 – Jan 2006 Col Kevin “Schweaty”