Life support for trauma and transport: First field use
During the Persian Gulf War, the U.S. Army Medical Department (AMEDD) found evacuation distances for patients increasing as a result of the fast movement of the forward line of troops. Thus, there is a need for a trauma and intensive care transport system that avoids the medical dangers that accompany such evacuation distances. In 1998, after a few years of research and development, the AMEDD introduced a prototype transport "trauma pod" called the LSTAT (Life Support for Trauma and Transport). In March 2000, the LSTAT was issued to the 212th Mobile Army Surgical Hospital that deployed to Camp Bondsteel, Kosovo, for its first real-world fielding. This article describes the initial Kosovo fielding phase, highlighting the LSTAT benefits, advantages to military medicine, and recommended enhancements.
Advancements in medical technology never cease. The same is true for combat medicine, in which new innovations and technologies are aimed at one common goal: saving soldiers' lives. The 212th Mobile Army Surgical Hospital (Forward) had the opportunity of being the first forward-deployed unit to field the Life Support for Trauma and Transport (LSTAT), an innovative piece of equipment, in conjunction with the Walter Reed Army Institute of Research (WRAIR) during their summer 2000 deployments to Kosovo. The 212th Mobile Army Surgical Hospital (MASH) was issued the LSTAT for implementation in the real-world military medical arena (Fig. 1).
While in Kosovo, the goals were multifaceted. The MASH fully tested the applicability and utilization of the LSTAT. Moving the LSTAT from the controlled field exercise environment to fullfledged use in a deployment environment saturated the fielding team with new data and feedback. A full case study was presented from the compilation of all tracked and forwarded documentation, the first away from the test bed.
The LSTAT is a self-contained, transportable, critical care platform that integrates a combination of off-the-shelf medical devices. The life support needs of the critically injured patient during medical evacuation are the driving force behind the LSTAT platform design. Evacuation problems directly related to the increased mobility of U.S. forces identified during Operation Desert Storm were significant. The forward line of battle moved at unprecedented rates that increased the evacuation distance between the troops and medical assets.I The concept of the system is to provide expedient, high-quality, life-sustaining care through all levels of the evacuation chain to decrease mortality and morbidity on the battlefield, even when evacuation distances are increased.
Current doctrine states that patients must be stable before evacuation.2,3 Thus, stabilization of the critically ill patient in the field medical treatment facility before transport is required. Stabilization of the critical patient can take days, resulting in increased work force, burden of logistical support, and bed availability at the holding treatment facility. In addition to the LSTAT's use as a critical care transport platform, exploration for other uses during this deployment included (1) a trauma bed in the emergency medical treatment area of the MASH, (2) an intrahospital transport bed, and (3) an intensive care unit (ICU) bed. During this deployment, the LSTAT was not used as an instrumented operating room (OR) table, although it had been used for this purpose in previous training exercises.
The LSTAT components include a ventilator, suction apparatus, oxygen blending system, three-channel intravenous infusion pump, physiological monitor (Propaq), hand-held clinical blood analyzer, and automated external defibrillator. Rather than redesign numerous portable medical components, the LSTAT design integrates state-of-the art, commercial standalone predicate devices previously cleared by the Food and Drug Administration. Training is greatly facilitated by the fact that these components are not new but rather off-the-shelf elements with which many clinicians are already familiar.
All of the components are connected to a fully network-capable, on-board computer system. A data-logging capability stores up to 72 hours of device settings and patient data. This information is gathered from the multiple physiological sensors, ventilator settings, and laboratory values and then stored on a miniature hard disk drive. A similar electromagnetic interference and shock-hardened central processing unit provides realtime signal-processing power. This allows every component to log subsystem utilization and patient monitoring data in a continuous and simultaneous format that can be downloaded and displayed locally or at a distance using the Internet.
The platform has a stand-alone, rechargeable power system that connects to different military power sources, including 110 V, 60. Hz/220 V, 50 Hz; 28V M997 ambulance, and UH-60 medical evacuation helicopter. Packaged together in a graphite composite shell cast molded to fit the carousel pans of the UH-60 helicopter and to fit securely in the transportation bay of the M997 are all of the features mentioned above. The LSTAT also accepts the standard NATO litter with spring-loaded latches on each of the four litter handles, which capture them automatically.
The 212th MASH welcomed the LSTAT and its WRAIR developers to the MASH's mission rehearsal exercise in Wiesbaden, Germany, in February 2000. The mission rehearsal exercise prepared the 212th MASH for its deployment to Camp Bondsteel, Kosovo, as part of Task Force Medical Falcon in support of Operation Joint Guardian. The WRAIR team, with the assistance of representatives from Integrated Medical Systems, Inc., spent countless hours training the MASH personnel. The personnel included clinicians, transport elements, and maintenance teams, who received in-service orientation briefings and worked directly with the LSTAT for invaluable hands-on experience.
The 212th MASH arrived at Camp Bondsteel on March 28, 2000. The WRAIR support team arrived to assist with the LSTAT program initiation on April 13, 2000. During the preparation phase, the communications network, work station, server configuration, and final system tests were completed. Prepositioned in one of the four trauma bays in the emergency medical treatment section, the LSTAT went operational. Between March 28 and July 1, 2000, the 212th MASH used the LSTAT in 15 cases, including gunshot wounds, myocardial infarction, cerebral vascular accident, mine strike, angina, dysrhythmias, seizures, and dyspnea. Uses included not only the care of patients inside the hospital but also during critical care transports.
There were three different categories of LSTAT use: trauma, major medical, and transport. This categorization allowed the critique of LSTAT performance in different aspects of use. Observations in these categories highlight its value and specific situations in which improvements could be made. The LSTAT was used during the treatment of six trauma patients, five major medical patients, and one transport patient. Included in the major medical category were two mechanically ventilated patients, one of whom was transported out of the hospital using the LSTAT.
The after-action survey gathered clinicians' subjective and objective information regarding the LSTAT. After transferring patients into the ICU, many nurses found it beneficial that everything (suction apparatus, Propaq monitor, etc.) was conveniently within reach. The litter, with all monitoring equipment, was very easy to transport to and from areas within the hospital. Without the LSTAT, it takes at least six people to transport a mechanically ventilated patient to other hospital areas using the wheeled litter system (WLS). The more equipment taken when moving a patient, the higher the risk for pulling wires, lines, and catheters and for damaging equipment during transport and treatment. Only two personnel are required, using the WLS, to transport the LSTAT with all components in use. This frees up personnel and reduces the risk of injury to the patient and other hazardous events, such as accidental extubation.
When conducting a traditional intrahospital transport, the movement of intravenous line poles requires much coordination. This can cause hazards because the hallways and doorways inside a field hospital are quite narrow. The LSTAT reduces this hazard by having the capability to attach up to four intravenous line arms to the LSTAT frame. The compact, integrated design directly increases available space around the patient during trauma resuscitation and critical care, because the immediate area is not draped with cables and lines. The LSTAT's compactness makes it very easy to prepare the patient for interhospital and intrahospital transport, which greatly reduces transport preparation time.