Just before noon on June 3, 2018, the Fuego volcano near Guatemala City, Guatemala, erupted violently, spraying molten lava, rocks, and superheated gases onto the city, affecting 1.7 million people and leaving more than 150 dead and hundreds more injured or missing.1, 2 Within hours of the eruption, local officials identified a need for burn care among the injured and reached out to the international community for assistance. By the early morning hours of June 4, members of the U.S. Army's Burn Flight Team (BFT) were placed on high alert in preparation for an evacuation mission that would bring injured Guatemalans to the United States for specialized burn care. The purpose of this article is to describe the BFT mission in support of the international response to the Fuego volcano eruption.
The BFT is the only burn critical care transport team in the U.S. Department of Defense (DoD), and can deploy on short notice (within 12 hours) to any location in the world, providing specialized burn care to critically injured military personnel and specially designated civilians.3 The BFT includes burn specialists from the U.S. Army Institute of Surgical Research (USAISR), located at Joint Base San Antonio–Fort Sam Houston, Texas. The USAISR Burn Center is co-located with the San Antonio Military Medical Center, which is staffed by U.S. Army, U.S. Air Force (USAF), U.S. Navy, and DoD civilian personnel. The burn center is the only designated burn care facility in the DoD and also serves as a regional burn center for civilian trauma patients in south central Texas. The interdisciplinary team of approximately 300 professionals at the burn center provides cutting-edge surgical, nursing, and rehabilitative services that promote optimal recovery, restore function, and reintegrate burn survivors into the community.
Conducting international missions since 1951. In existence for nearly 70 years, the BFT pioneered the idea of a multidisciplinary, military-only transport team. Members of the BFT are active-duty army clinicians and DoD civilian personnel whose service on the team is in addition to the work they do in the burn ICU. The BFT has a well-documented history of responding to urgent burn and complex trauma care needs around the world.3-8 It has provided care for more than 3,000 patients on regional, national, and international evacuation missions since its inception. Notably, after the March 23, 1994, collision of three military aircraft at Pope Air Force Base in North Carolina, the BFT transported 40 burn patients to the burn center on four separate flights.7 In August 1997, the BFT was activated as part of a humanitarian mission in response to the crash of Korean Air Flight 801 in Guam, which resulted in 228 deaths and 26 passengers with serious injuries. On that mission, the team transported four critically ill patients (three Koreans and one American) to the burn center.4 Additionally, the BFT has conducted two nonstop, 19-hour, 9,850-mile evacuations from Singapore; one mission required continuous renal replacement therapy in flight.9
Activation process. Activating the BFT for humanitarian assistance missions can be complicated. When overseas assistance is needed, the U.S. Department of State takes the lead and coordinates all U.S. government aid (military and nonmilitary) with the host nation. Negotiations between the governments can at times significantly delay assistance. The response to the event in Guatemala was quick, however, because relationships had already been established earlier in the year following a multinational disaster-relief training exercise that simulated a response to a volcanic eruption. In addition, the DoD's U.S. Southern Command had previously helped the Guatemalan government build and supply its emergency operations center and disaster relief warehouse.10
Before arrival in Guatemala. When the BFT was alerted to the mission on June 4, early information indicated that the transport of as many as 14 critically injured burn patients might be required. By the afternoon, representatives from the Shriners Hospitals for Children–Galveston in Galveston, Texas, were on the ground in Guatemala.1 On June 5, after a day of negotiations and planning, the evacuation was approved. The BFT members designated to complete this mission included a burn surgeon, an intensivist, five RNs, one respiratory therapist, and one operations officer. The intensivist and one of the RNs spoke fluent Spanish, which aided communication during the mission. In addition, the USAF contributed a critical care air transport team (CCATT), consisting of a pediatric intensivist, an anesthesiologist, two RNs, and two respiratory therapists, to the mission.
The BFT began preparations on June 4 by organizing and assembling multiple sets of equipment. Upon notification of mission approval, the team members began to gather their personal items, which included their passports and enough personal supplies for a 72-hour mission. The BFT members met with the USAF nurses to determine which CCATT medications and supplies were to be used. The BFT provided the necessary burn-specific supplies, which included wound dressings, resuscitation fluids, and pain and sedation medications. Of note, because the timing of the mission was uncertain, some of the IV medications could not be premixed by the pharmacy teams at San Antonio Military Medical Center prior to departure. Instead, the nurses on the BFT had to prepare the mixtures and label the bags and IV lines for each of the planned patients while in flight.
Anticipating contingencies. While logistical preparations for the evacuation continued, USAISR leaders coordinated with leaders at the U.S. Department of State, U.S. Southern Command, and Global Patient Movement Requirements Center of the U.S. Transportation Command. In addition to learning more about the condition of the patients to be evacuated, these military leaders also had to consider numerous contingencies. For example, they needed to determine the security on the ground in Guatemala. Once on the ground, how would the teams get to the hospital? Where would the C-17 Globemaster (the USAF cargo airplane designated for use in long-range evacuation missions) come from? When could the evacuation team depart for Guatemala? If the patients were too unstable to move, would the evacuation be delayed? Would expedited permission be granted for the children to leave Guatemala and come to the United States for treatment? Could the patients' parents (or other adult representatives) also come to the United States?
After much discussion, it was determined that the U.S. Department of State would coordinate entry into the United States without passports for the patients and their guardians. Shriners International would assist with coordinating some of the patient and guardian needs once in the United States. Additionally, the C-17 aircraft would come from the Alabama Air National Guard. The C-17 measures 174 ft. long with a wingspan of 169 ft., 10 in. Its maximum payload capacity is 170,900 lbs. Importantly, because of its size and load capacity, the C-17 requires nearly 3,500 feet of runway for takeoff and landing, limiting the locations in which it can be used.11 The aircraft was scheduled to arrive at Kelly Field, adjacent to Joint Base San Antonio–Lackland, at 12:30 PM on Wednesday, June 6. At that time, the aircraft would be refueled, and the equipment and evacuation team loaded.
On the morning of June 6, the BFT and CCATT personnel assembled at the burn center. At 8 AM, the team conducted a final inspection of equipment, verified that everyone had their passports and personal items, and received a brief mission update. Members had already learned about the six injured children they would be evacuating. The patients, all female, ranged in age from 18 months to 16 years. Their injuries were primarily partial- and full-thickness thermal burns, covering 8% to 40% of their total body surface area. Four of the patients required mechanical ventilation and five had central venous or arterial catheters. One patient, the youngest and smallest, also had a chest tube. Although not critically injured, two patients with smaller burns were being evacuated because of the anatomical location of the burns and the extensive rehabilitation that was expected.
The team arrived at Kelly Field at approximately 11 AM, and by 3:30 PM the C-17 was airborne, laden with burn and pediatric specialists, as well as pallets of supplies and equipment. Public affairs officials from the DoD as well as media representatives accompanied the teams on this mission.
After arrival in Guatemala. After a three-hour flight, the C-17 arrived at the airport in Guatemala City at 6:39 PM (Guatemala and San Antonio are in the same time zone). After the aircraft taxied to a stop, the team got to work, attaching special medical emergency evacuation devices (SMEEDs) to each litter. A SMEED is a metal platform designed to connect monitors, infusion pumps, ventilators, and other medical equipment to a standard litter. A litter consists of a mesh canvas stretched tightly between wooden or metal poles; there is very little padding. Patients typically lie flat on a litter unless something is placed under their shoulders or head to elevate the torso. The SMEED is positioned across the litter, usually over the patient's legs or lap, turning the litter into a mobile ICU.12 After the litters were assembled, the C-17 crew lowered the large ramp at the rear of the aircraft so the team could depart.
A four-hour limit on the ground. The team was met by an entourage of Guatemalan military and civilian personnel, as well as representatives of Shriners International. The equipment, supplies, and personnel were loaded into local cars, trucks, and ambulances. The caravan left the airport at approximately 7:15 PM, escorted by a motorcade of military vehicles and motorcycle-mounted police, who provided security for the team. Because the C-17 was needed for other missions, the aircraft could remain in Guatemala for only a limited time. Therefore, the team had four hours to reach the patients, assess them, prepare them for evacuation, and return with them to the airport.
The two-kilometer drive to Roosevelt Hospital in Guatemala City was slow. Traffic was heavy despite the ambulance, police sirens, and military presence. Mopeds, scooters, and motorcycles wove in and out of the evacuation caravan, making it necessary to move slowly so as not to cause injury. The caravan arrived at the hospital at approximately 7:53 PM, leaving just over three hours to assess each patient and prepare them for evacuation.
The patients. The patients were on three different units on two separate floors. The evacuation team split into three groups, with a physician, nurse, and respiratory therapist in each group. Any personnel not assigned to a group rotated between the three units. Initial assessments of the children revealed that several were on vasoactive medications to maintain their blood pressure. All the children needed additional fluid resuscitation with crystalloid fluids and albumin, analgesics, sedatives, and wound care. One patient required additional IV access before departure from the hospital.
Under the watchful eyes of family members, hospital staff, and local officials, the evacuation team assumed care for the patients and readied each patient for transport. Preventing adverse events is one of the most important aspects of care for long-range transport. To minimize the possibility of any challenges in flight, every patient was fully evaluated, and wound care was completed. Wound care consisted of washing the burns with sterile fluids, removal of loose tissue, and the application of burn-specific creams (such as silver sulfadiazine or mafenide acetate) or antimicrobial dressings (such as silver-impregnated nylon) before wrapping the patients in dry, sterile gauze.
Wound care is an important part of the assessment because it allows the BFT to understand the severity of the burns, which affects burn resuscitation and pain treatment. In addition, all intravascular lines and airways were secured. Then the patients were transferred from the hospital bed to the litter and wrapped in warming blankets. All needed equipment was positioned on the SMEED or on the litter next to the patient.
Patient care was documented using standard DoD critical care air transport forms, which were completed by hand. Resource limitations at the hospital prevented the team from obtaining copies of patient records.
The evacuation team and patients left the hospital at 12:13 AM. Traffic for the trip back to the airport was better than earlier in the day. After arrival at the airport, the patients were loaded onto the C-17 in reverse order of injury severity and current status as determined by the BFT burn surgeon. The sickest patients were loaded last so they could be first off the aircraft in Galveston, facilitating their quicker transport to the hospital. Five adult guardians also accompanied the patients, and each patient was assigned a primary nurse, who stayed at the bedside throughout the flight. The rest of the team collaborated as needed to support the nurses and provide care for all patients during the flight to the United States. The C-17 lifted off for Galveston at 1:46 AM.
Care in the air. When used for medical evacuation, the C-17's multipurpose cargo bay can be outfitted with litter stands to hold the patients in place along the outer skin of the aircraft, leaving the center section open. As in a hospital, the C-17 has hospital-grade power, oxygen, and suction integrated along the skin of the aircraft for use in flight. However, these resources are limited; a high demand for oxygen, for example, will reduce the overall capacity of the system. Because a C-17 doesn't have the interior insulation normally found in a commercial aircraft, BFT members working in the cargo bay experience constant (and loud) engine noises, frequent mechanical sounds, and temperature shifts with changes in altitude. The noise limits communication, and the temperature shifts challenge the nurses to maintain normothermia for their patients. The clinicians also need to be mindful of the impact changes in altitude (and therefore in barometric pressure) will have on patient care, and to consider changes in cellular gas exchange, mechanical ventilator function, endotracheal tube balloon inflation, and gastrointestinal comfort.
During the flight to Galveston, the evacuation team monitored each patient carefully and managed each clinical issue as it arose. Before making any clinical decision, the burn specialists consulted closely with the pediatric specialist to ensure care was optimized for each patient. The nurses monitored and adjusted each patient's analgesia and sedation to make sure the patients were comfortable. Because burn patients require significant fluid intake to maintain adequate systemic perfusion, a balance between patient comfort and adequate blood pressure must be achieved. To do this, the evacuation team used a combination of medications, including midazolam, propofol, fentanyl, and norepinephrine, as well as infusions of crystalloids and albumin.
Close attention to respiratory care. Adequate respiratory status and airway protection are a primary focus on a BFT evacuation mission, and it's essential that the correct equipment is available for the patients' needs. On this mission, the intubated and ventilated patients were monitored in flight using arterial blood gases to optimize ventilator settings and prevent respiratory acidosis or alkalosis. The BFT also uses a specialized transport ventilator for patients with inhalation injuries. As these patients frequently require aggressive and unconventional modes of ventilator support, the BFT also has several specialized ventilator modes at its disposal. One of these is high-frequency percussive ventilation, which delivers a combination of high-frequency and low-frequency breaths to reduce airway pressure, thereby lowering the risk of ventilator-induced lung injury, improving gas exchange, and facilitating pulmonary hygiene.13 Importantly, the BFT has experience with this ventilator mode, as it was used frequently when the team transported burn casualties injured in Afghanistan and Iraq.
Barometric pressure changes can also influence the patient's respiratory status.14-16 For one patient, the decrease in barometric pressure that occurred after takeoff resulted in desaturation, which in turn increased the patient's anxiety. After attempting to improve oxygenation by adjusting oxygen flows and promote ventilator synchrony by increasing sedation, the team decided to administer a paralytic, cisatracurium. Within minutes, this improved the patient's oxygenation, which was maintained throughout the remainder of the flight.
Maintaining normothermia. The nurses also monitored the patients' body temperature. Maintaining normothermia is an important component of burn care, as hypothermia frequently occurs secondary to the loss of skin, which plays an important role in thermoregulation. Hypothermia promotes metabolic acidosis and coagulopathy, two dangerous conditions in burn patients. To prevent hypothermia, heat-reflecting blankets and head covers were used during flight, as well as air-activated warming blankets. Moreover, the aircraft cabin temperature was optimized.
Communication with patients and escorts. Throughout the flight, the BFT's Spanish-speaking members helped attend to the psychosocial needs of the patients and their guardian escorts. These team members answered questions, provided updates, and helped provide hope and reassurance. This capability was particularly important for the two nonintubated patients, who were more alert and aware of their surroundings. Neither patient had flown before, and the loud volume and unfamiliar sounds of the C-17 scared them. Earplugs, mild sedation, and consistent reassurance from the Spanish-speaking BFT members helped to calm them.
Arrival at Galveston. The BFT and the patients and their escorts arrived in Galveston at 4:39 AM and were en route by ambulance to Shriners Hospitals for Children by approximately 5:20 AM. Upon arrival, the patients were met by the hospital's burn director, Steven E. Wolf, who is also president of the American Burn Association and a former director of the USAISR Burn Center. The BFT performed a detailed handoff to the hospital staff and helped transfer the patients to the hospital's beds, monitors, and equipment. Copies of the DoD critical care air transport records were provided to the hospital team. After gathering up their equipment and personal gear, the BFT and CCATT departed by bus for San Antonio at 8:05 AM, arriving at the burn center at 12:27 PM. After their arrival, the BFT provided a brief after-action report to USAISR leaders, then unloaded and repacked their equipment in preparation for the next mission.
Adaptability is key. Despite the comprehensive and detailed planning that occurs prior to each evacuation mission, the BFT mandate to provide critical care to severely injured burn patients “anytime, anywhere” in the world introduces a level of uncertainty to every mission. Overcoming this uncertainty requires adaptability that is grounded in sound clinical judgment. Clinical and tactical adaptability was key to our mission's success in Guatemala City.
Maintaining an understanding of each patient's condition is challenging during a BFT mission. Although the BFT members thought they knew each patient's status prior to departing San Antonio, for example, it is not uncommon for a patient's clinical presentation to be significantly different a few hours later. This is particularly true of burn patients who are in the resuscitative phase of their care and may be hemodynamically unstable. Because communication limitations associated with travel to Guatemala prevented the BFT from receiving regular updates on the patients' condition, the team arrived at Roosevelt Hospital unaware of any new developments. But because they had the necessary supplies and equipment, and thoroughly assessed each patient on arrival, they were able to initiate appropriate burn treatment and prepare the patients for the trip to Galveston.
Mechanical and clinical challenges require clinical expertise. Medical evacuation of critically injured burn patients requires a strong clinical background. Critical care in a normal hospital setting relies on monitors and alarms that are finely tuned to the patient care environment. However, Roosevelt Hospital did not have the advanced monitoring systems used at the USAISR Burn Center. Moreover, the vibrations of the evacuation platform at the back of an ambulance or aircraft may cause ruggedized transport monitors to provide erroneous information to the clinician (an erratic electrocardiogram, for example). Also, the evacuation platforms are often loud, which prevents monitor alarms from being heard during flight. The transport of critically injured patients over any distance exposes them to risk because of the increased opportunities for dislodged treatment devices and loss of power to the equipment. As such, it was essential that the BFT and CCATT members be expert clinicians who could troubleshoot and problem-solve without relying solely on equipment and monitors.
The importance of teamwork. In challenging missions such as long-range medical evacuation, where equipment, supplies, and personnel are in short supply, teamwork is essential. During this mission, the BFT had to work as a team to quickly assess all six patients spread across three nursing units, stabilize them hemodynamically, and then perform wound care in preparation for the flight to Galveston.
This team-focused mind-set is engrained in the clinicians providing the day-to-day care at the USAISR Burn Center, where treating burn patients, particularly those with large burns (more than 40% of the total body surface area), requires a team to keep up with resuscitation requirements, perform wound care, and facilitate early physical rehabilitation.
For members of the BFT, each evacuation mission is an extension of their day-to-day patient care duties. To ensure they are prepared to provide the same level of team-based care during an urgent operation like an evacuation, they regularly train together, using their evacuation-specific equipment and supplies. Augmenting the BFT with a CCATT was not unique to this mission, but these specific teams had not worked together before. However, several members had worked together at San Antonio Military Medical Center. Ongoing refinement of the relationship between the BFT and the CCATT is needed to ensure continued success of similar long-range evacuation missions.
Special challenges of pediatric care. Finally, this evacuation was successful in part because of the inclusion of pediatric specialists. The USAISR Burn Center only provides care to adult burn and trauma patients, and BFT personnel are trained to provide care to adult U.S. military personnel while deployed. Therefore, the need to care for pediatric burn patients posed a unique challenge for the BFT. Team members looked to the pediatric specialists when questions about medication dosages, ventilator settings, and pediatric-specific psychosocial concerns arose.
This 21.5-hour international humanitarian mission (from 8 AM June 6 to 5:20 AM June 7) required nearly 44 hours of situational assessment, coordination, and planning by the U.S. Department of State and the DOD. The mission required seven RNs, three respiratory therapists, a burn surgeon, two intensivists, an anesthesiologist, and an operations officer. The mission resulted in all six pediatric burn patients, and their guardians, arriving at Shriners Hospitals for Children–Galveston for definitive care of their burns within 96 hours of injury. Although the BFT continued to receive regular updates on each patient's condition, because of privacy concerns, these are not available for publication. This mission highlights the unique capability of the USAISR Burn Center, where members of the BFT stand ready to deploy “anytime, anywhere” to provide care to critically injured burn patients around the world.