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September 2002


Equipment and Technology
A method of transporting critical care mass casualties

Timothy L. Hudson, MSA, MEd, RN [MEDLINE LOOKUP]
Thomas Weichart, MSA, BSN, RN [MEDLINE LOOKUP]

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Providing medical care to a large number of critical patients during a mass casualty situation can be a challenge in terms of patients, providers, and priorities. The large number of patients often exceeds the medical community's ability to provide timely treatment.1 In the 1995 Oklahoma City bombing, 759 people sustained injury,2 and within 12 hours after the 2001 terrorist attack in New York City, 511 people sought emergency care.3 Multiple local, state, and federal agencies may respond and complicate coordination of care. An overwhelming number of patients needing medical care can force providers to alter or abandon traditional treatment priorities.

Traditionally in the United States, first responders are taught to triage patients to the nearest facility for stabilization. In many cases, because the first responders have limited resources, the nearest facility is not the most appropriate if the patient needs specialized care such as burn management, pediatrics, or neurosurgical intervention. United States healthcare providers have rarely faced a situation in which the number of casualties has exceeded the country's ability to provide care. Historically, it has been possible to “do the most good for the most people,” and to dedicate considerable resources to one patient. In a significant mass casualty situation, personnel, equipment, and time would be limited and it might be difficult for civilian health care personnel to pass over critical patients in an effort to save resources and treat as many lives as possible. A new approach is needed to expand the capacity to care for critical patients.

Internationally, prehospital trauma care has used a different approach than the United States. Healthcare systems in Russia, France, Germany, and Norway send a trauma team to the scene of the incident. Designated ambulances are traveling trauma and intensive care units and have more capabilities than an advanced life support ambulance than is common in the United States. The ambulance is staffed by a trauma surgeon, nurses, paramedics, driver, and in some cases, anesthesia support. Patients are treated and stabilized as much as possible at the scene and during transport. The emergency department at the receiving hospital serves as a processing area in which patients are routed to the operating room or correct service. Although this method improves response time for a small number of patients, it would have limited effectiveness in a large mass casualty incident. A fully-staffed mobile trauma intensive care ambulance that cares for one patient is not a practical solution for delivering medical care to large numbers of patients.


   A military model for critical care transport  TOP 

In 1993, the United States military noted concerns with the evacuation of wounded soldiers during the Gulf War. The Defense Advanced Research Projects Agency (DARPA) directed the military to create a military medical “trauma pod.” It was to be a self-contained, transportable, critical care platform that would allow for more effective monitoring and stabilization of patients and more efficient use of healthcare providers' time (Figure 1).

Fig. 1. Critical care transport and treatment platform (Life Support for Trauma and Transport, LSTAT).
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Click on Image to view full size

Life Support for Trauma and Transport, LSTAT (Integrated Medical Systems, Inc, Signal Hill, Calif) was researched and developed by the Walter Reed Army Institute for Research (WRAIR) and a private contractor. This arrangement allows nonmilitary agencies to benefit from the use of the research and products.

The trauma transport pod was designed to carry standard critical care equipment (Table 1) connected to a computer system located inside the 13-cm thick body of the platform.

Table 1. Standardized equipment used on the LSTAT critical care transport platform
Equipment Manufacturer Model
Physiological monitor Protocol Systems Propaq 106
Blood analyzer i-STAT
Ventilator Impact Instrumentation 754L
Automatic external defibrillator (AED) Cardiac Science Vivalink
Suction Impact Instrumentation 326
Infusion pump Alaris Medsystem III
Patients are placed on a standard North Atlantic Treaty Organization (NATO) military litter that can be mounted or removed from the platform. Multiple pods can be loaded into evacuation aircraft (Figure 2) and have, to date, only been used for transport in military aircraft (both helicopter and fixed wing).

Fig. 2. Critical care transport platform inside of an evacuation aircraft.
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The transport platform has been fit directly into the C-130 and C-141 litter system and was used on a C-17 existing litter system. The computer tracks all patient data from each component and logs the settings (ie, ventilator settings, alarm parameters, oxygen rate). The platform has a stand-alone, rechargeable power system that connects to different power sources. The shell is made from a graphite composite that keeps the overall weight to a minimum.


   Field experience  TOP 

The platform was used by the 212th Mobile Army Surgical Hospital during the summer of 2000 in Kosovo. It served as a trauma bed (in the emergency medical treatment area), intra-hospital transport bed, and intensive care bed. It was found to have multiple advantages, including offering staff familiarity with standardized equipment and providing readily available back-up equipment and automatic computerized documentation.

Standardized equipment

Each piece of component equipment used on the platform is an off-the-shelf device approved by the Food and Drug Administration (FDA) (Table 1). The devices are widely used in clinical care, which helps providers to become more familiar with the equipment and to not need additional training during a disaster.

Some of the equipment, such as the infusion pump and blood analyzer, remain in their commercial packaging. The blood analyzer has a docking station at the foot of the platform that enables it to transfer all blood sample analysis data directly to the computer system through infrared technology. The infusion pump is located in its own drawer at the head of the platform and is electronically tethered for power and data transmission. The remaining equipment has been removed from the commercial packaging and is fitted within the platform. Even though equipment may appear unfamiliar at first sight, users quickly recognize that all buttons, knobs, and dials are in the same original configuration.

Readily available back-up equipment

Patients transported on the platform are close to additional equipment if their condition becomes more critical. A ventilator, suction, automatic external defibrillator, and infusion pump are close by if the patient should need additional intervention or support. Diagnostic equipment can provide instant analysis of the patient's condition and response to interventions and afford the opportunity to make transport decisions that include diversion to specialty hospitals if warranted.

Automatic computerized documentation

In overwhelming situations, especially when multiple casualties are present, documentation becomes a secondary task. Documentation at the site and during transport is usually hand written and completed after the patient is delivered to the next level of care. The transport platform has the capacity to capture and store patient and component data automatically in a continuous, time-synchronized, and simultaneous format that coincides time, treatment, and response. Data can be stored for up to 72 hours on a hardened disk drive, can be retrieved for downloading or local display, or can be electronically transferred to other locales offering telemedicine capabilities. Automatic computerized charting allows the clinician to focus on care and treatment.

An electronic hand-held secondary display computer tablet can be used for additional clinical note documentation. A screen-pen touch technology is used to make recordings. Mass casualty patients tend to be moved through an evacuation corridor and come into contact with multiple care providers. The transport platform's computer system allows for each health care provider to be identified in the system.


   Future considerations  TOP 

Managing disasters as a result of chemical agents dispersion may be a part of the future. Patients exposed to chemical agents, such as nerve agents, can become critically ill within a short time frame. If advanced life support is not implemented immediately, the mortality can be high. One study of 30 hospitals in 4 states and the District of Columbia found that facilities were not prepared to handle mass casualty victims from a biological or chemical attack.4

To assist in the care of contaminated patients and prevent additional patient contamination, an environmental canopy is being developed. The canopy will protect the patient from adverse environments, such as sun, wind, precipitation, dust, smoke, ash and light debris. It will provide reverse isolation (ie, protect an uncontaminated patient from a contaminated environment), or traditional isolation (ie, protect an uncontaminated environment from a contaminated patient). The canopy has a temperature-compensated air filtration system that protects against biological or chemical environments, including those associated with industrial accidents or terrorism. The canopy walls have gloved access ports that allow clinicians to continue to provide treatment while patients are in the canopy.


   Summary  TOP 

The use of a self-contained transport platform can aid in the efforts to care for mass casualty victims. The platform is equipped with critical care equipment and has the capabilities of documenting care electronically. It has been used in a number of different settings and has allowed health care personnel to provide more efficient, individualized care to a larger number of victims.


   References  TOP 



   Publishing and Reprint Information  TOP