FEATURED ARTICLE

Patient Evacuation During COVID-19 Pandemic:
Role of Anesthesiologists of Indian Armed Forces

Vidhu Bhatnagar, MD, DM
Vidhu Bhatnagar, MD, DM
Shankar
Anand Shankar K., MD

Vidhu Bhatnagar, MD, DM
Senior Advisor, Anaesthesiology & Critical Care and Neuroanaesthesiologist
Department of Anaesthesiology, INHS Sanjivani,
Naval Base Kochi
Kochi, Kerala, India

Anand Shankar K., MD
Senior Advisor, Department of Anaesthesiology, CH(AF)
Bengaluru, India

Coronavirus infection caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has achieved a pandemic status since March 2020.1 Indian Armed Forces has been actively involved in the patient evacuation, both Armed Forces (AF) personnel, dependents, and civilians since the advent of the pandemic. AF have been a pioneer in speedy resuscitation and the prompt evacuation of casualties and critically ill over the years and have utilized the same experience and disciplined approach during the patient evacuation in the COVID 19 pandemic2,3 (Figure 1). The specific challenges with the evacuation of patients infected with SARS-CoV-2 are as follows:4

  • Increased risk of exposure to Health Care Workers (HCWs) and aircrew. Both the groups comprise of highly skilled and indispensable personnel.
  • Environmental sanitization is equally important; SARS-CoV-2 is a health hazard even after the patient has been evacuated and handed over to the next echelon.5
  • Safe transfer and evacuation of SARS-CoV-2 infected patients.
  • Maintenance of hemodynamic stability and ventilation of the critically ill patient enroute.
  • Limited availability of space inside air ambulances or ground ambulances; thus, prioritization of the supplies to be carried along with the patient.
  • The requirement of trained personnel to carry out patient evacuation safely and promptly.
  • Accounting for all the risks related to air evacuation or ground evacuation.

Figure 1

Figure 1: Patient evacuation in ground ambulance, transported to air strip (A); Patient transfer unit (PTU) (B); Air evacuation (C).

The challenges were accepted head-on by the Indian AF. As soon as the looming problem (highly infectious patients may require evacuation by air or ground) was envisaged at the beginning of the year 2020, training of non-medical and medical personnel was carried out to sensitize them regarding the precautions to be enforced in order to minimize the risk of cross-infection. Paramedics and non-medical personnel were imparted training towards personal protection, the correct way of donning and doffing personal protective equipment (PPE), environmental disinfection, and other ways to mitigate the cross-infection.5 Standard operating procedures (SOPs) were modified to cater to this new disease, and protocol familiarization commenced and continued. Various means like educational audio clips and educational videos were also created to have a wider reach and impact.

Indian Air Force (IAF) developed the Critical Care Air Transport Team (CCAT), which utilizes indigenously designed Patient Transfer Units (PTU) for patient evacuation back in 2007.6 These PTUs can be fitted in fixed-wing or rotary-wing aircraft, which in turn can be used as Air Ambulances. A PTU comprises a standard hospital patient trolley that is modified to safely carry a transport ventilator, a defibrillator, a multi-para-monitor, and one or two infusion pump(s). The base of the patient trolley carries Universal Power Supply (UPS) and an oxygen cylinder (1246 Liters) (Figure 2). The other supplies which are carried during any patient evacuation are as follows; a portable, foot/ electrically operated suction unit, a Bag Valve Mask (BVM), emergency drugs, and expendable supplies like syringes, Bain’s circuit, extension tubing, intravenous fluids, three ways, endotracheal tubes, face mask, suction tubes etc.3,6 The detailed lists of the resuscitation items carried are present on board; the challenge here is that HCWs are working in negotiated space; hence, the supplies need to be prioritized.

Figure 2

Figure 2 A: Air isolation pod with patient and monitoring; 2B: Air trial in process for air isolation pod.

After the COVID-19 pandemic declaration, IAF also developed an Airborne Rescue Pod for Isolated Transportation (ARPIT) for the evacuation of infectious, critically ill patients from high altitude areas and remote places. The first such prototype was developed in Chandigarh and had undergone various modifications after trials. IAF has utilized both PTU and ARPIT in patient evacuation from high altitude.7

Indian Navy (IN) indigenously designed Air Evacuation Pod (AEP) for the safe evacuation of infected patients from remote locations (like various islands coming under Indian jurisdiction) or from ships in April 2020. The AEP is designed as isolation pods so as to facilitate the evacuation of infected patients in a fully sealed patient transfer capsule, safeguarding pilot and accompanying HCWs from the risk of cross-infection. The AEP comprises of a standard patient stretcher fitted with a harness to secure the patient, covered by a Perspex cover on an aluminum frame. Two access windows are available on the sides at the head end, and a ventilator connecting port is available at the top. The AEP can be safely used in helicopters, fixed aircraft, and can also be used for the purpose of ground transport in ambulances.8,9

The AEP has provision for connecting the patient to supplemental oxygen if he/ she is breathing spontaneously or even to connect to a transport ventilator if the patient is on mechanical ventilation. A transport multi-para-monitor and an oxygen cylinder (1246 Liters) is carried along with the AEP. The other essential supplies carried are an automated external defibrillator (AED), portable suction unit, BVM, other emergency drugs, and expendable supplies. The accompanying HCWs are highly skilled paramedics, nurses, or anesthesiologists depending on the condition of the critically ill patient with the PTU, ARPIT, or AEP. SOPs are laid down for smooth conduct of patient evacuation, accounting for ventilation, hemodynamic and intake output monitoring, and personal protective equipment donning by HCWs and air crew.

Though all Armed Forces hospitals have been geared up to treat coronavirus patients along with their normal patient load, in certain situations, patient evacuation to a higher echelon, if warranted, has been carried out smoothly. The authors have been associated with quite a few patient evacuations from zonal to tertiary care centers using PTU and AEP in these COVID 19 times.

Many factors, peculiar to patient evacuation by ground or air, need attention:10,11

  • All lines to be secured, two intravenous access in place. If central venous access is required, it needs to be taken before transport in an aseptic environment.
  • All drainage tubes, unclamped and should be on continuous suction.
  • Careful positioning of the patient to ensure no nerve damage takes place.
  • All tubes and lines to be secured with fixators to ensure they do not get displaced on the way.
  • Availability of suction and supplemental oxygen is a MUST for the transfer.
  • If patient evacuation is by air, the cuff of the endotracheal tube or tracheostomy tube is to be filled with saline.
  • Pneumatic splints need to be avoided.
  • Battery back-up of all electrical equipment
  • If any blood transfusion requirement is envisaged, it needs to be given before the transport in critical care setup and not during patient transfer.  

The success of the patient evacuation has been possible due to the prevailing motto of Armed Forces: “Sweat in Peace than Bleed in War” wherein adequate training is carried out for crisis management during non-emergency times, thereby catering to adherence to protocols during a crisis resulting in the success of the task at hand. Thus, factors contributing to successful patient evacuation during COVID 19 pandemic could be identified as:

  • Regular Training of the HCW for smooth patient evacuation
  • Laid down protocols and SOPs and strict compliance
  • Team dynamics, closed-loop communication, and discipline
  • Identification of bottlenecks during patient evacuation and preparation of an alternative plan for smooth and safe conduct.
  • Well-oiled machinery for administrative support

This article is an attempt to highlight the importance of discipline, regular training, laid down protocols and SOPs, their compliance, and soft skills in trying to combat a new enemy.12

Conflicts of interest: Nil
Disclosures: The authors are serving officers (Anesthesiologists) of Indian Armed Forces

References

  1. World Health Organization. Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV).
  2. Katoch R, Rajagopalan S. Warfare Injuries: History, Triage, Transport and Field Hospital Setup in the Armed Forces. Med J Armed Forces India. 2010; 66(4):304-8.
  3. Ravi PR, Joshi MC, Dhawan M, Sud S, Vijai MN. Critical care air transport team and patient transfer unit: A decade of experience of a zonal hospital. J Mar Med Soc 2019;21:121-9.
  4. Guo ZD, Wang ZY, Zhang SF, Li X, Li L, Li C, Cui Y, Fu RB, Dong YZ, Chi XY, Zhang MY, Liu K, Cao C, Liu B, Zhang K, Gao YW, Lu B, Chen W. Aerosol and Surface Distribution of Severe Acute Respiratory Syndrome Coronavirus 2 in Hospital Wards, Wuhan, China, 2020. Emerging Infect. Dis. 2020 Jul;26(7):1583-1591.
  5. Environmental cleaning, disinfection and biomedical waste management. National training of Trainers for COVID 19. Published on 6 Mar 2020 by Ministry of Health and Family Welfare, Govt of India in conjunction with WHO.
  6. Joshi MC, Bedi MS, Chowdary GSPN, Sharma RM. Patient Transport Unit for Aeromedical Evacuation. Med J Armed Forces India. 2009 Jul; 65(3): 268–269.
  7. South Asia Monitor. 2020. IAF Develops Airborne Isolation Pod For Covid Patients. [online] Available here.
  8. Navy develops air evacuation pod for COVID-19 patients. Deccan Herald. PTI, Kochi Apr 14 2020, 1759 Ist UPDATED APR 14 2020, 1835 IST.
  9. News, I., 2020. Navy Develops Air Evacuation Pod For Coronavirus Patients India News - Times Of India. [online] The Times of India. Available here.
  10. Beninati W, Meyer MT, Carter TE. The critical care air transport program. Crit Care Med. 2008; 36(7 Suppl):S370-376.
  11. Joshi M, Sharma R. Aero-medical Considerations in Casualty Air Evacuation (CASAEVAC). Med J Armed Forces India. 2010; 66(1):63-5.
  12. Lopes H, Mckay V. Adult learning and education as a tool to contain pandemics: The COVID-19 experience. International review of Education 2020;1:1-17.

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