CSTARS trains Air Force trauma teams

Published Feb. 17, 2010
By Derek Kaufman
88th Air Base Wing Public Affairs

CINCINNATI, Ohio -- "I can't breathe."

Maj. Tiffany Ingham looks down and assesses one of the two critical patients under her charge. One is conscious and communicating his respiratory distress and chest pain. The other is sedated and on a ventilator. The second patient has traumatic brain injury and burns, signature injuries of an improvised explosive device.

For Major Ingham, an anesthesiologist originally from Oneonta, N.Y., this is a real as it gets. She and the other members of her critical care air transport team or CCATT evaluate and treat each patient under the dim red glow familiar to those who have flown in a military transport at night over a combat zone. The drone of four turbine engines makes patient assessment and communication difficult, even with the noise cancelling headsets they are wearing.

For about 45 minutes the CCATT -- consisting of physician, critical care nurse, and cardiopulmonary technician -- works to solve what seems to be a myriad of cascading problems in each patient.

Despite its efforts, a patient has flat-lined. Suddenly a door opens, lights come on, engine noise ceases and what had been a mobile intensive care unit in the back of a flying C-130 is revealed as a simulator inside University Hospital Cincinnati. The team re-packs equipment, tubes, medications, and prepares to debrief what went right -- and wrong.

The simulation was a final exam of sorts at the Centers for Sustainment of Trauma and Readiness Skills or CSTARS, which trains Air Force critical care air transport teams via a unique partnership with the University of Cincinnati.

In an adjacent room, another highly experienced critical care team of controllers who drove the scenario and watched the trainees respond, notes how the trainees performed, both individually and as a team.

Each scenario is based upon real-world critical patient cases - whether joint service members and contractors being evacuated from "downrange" locations or survivors of humanitarian catastrophes like the recent earthquake in Haiti.

"You look at these patients as real," said Major Ingham, standing over the two manikins, which are actually sophisticated human patient simulators.

The manikins can "talk." Their eyes blink, pupils dilate, and they can be programmed to have normal or abnormal heart and breath sounds. They react -- along with the intensive care monitors for such things as heart rate, blood pressure and pulse oxygen level -- to the treatment and medications they are given. In one manikin, cerebral fluid drains from a tube to relieve intracranial pressure. A post-surgical "open belly" reveals fake intestines and other organs.

Lt. Col. (Dr.) David Norton, CSTARS course director, is part of a cadre of 15 charged with training every Air Force critical care air transport team member and certifying he or she is ready to go fly. The training is tough and stressful by design.

"We really work very hard to keep the course current and relevant to what people are going to see downrange," Doctor Norton said.

"Over the course of the two weeks, every time they make a mistake, we will have a debrief and talk about the case," he said. "We will ask them why they made the decisions they made and share with them some insight on what might have worked better."

It's no coincidence that CSTARS Cincinnati is co-located with the surgical intensive care unit for one of the nation's major trauma medical centers. In addition to simulation, book and oral testing, a vital element of the course is clinical time working trauma and other critical care in the surgical and neuro-surgical ICU alongside their civilian counterparts at University Hospital.

"The physicians take trauma call at night while they are here," Doctor Norton said. "It's a fairly intense critical care experience."

The clinical portion of the course exposes each team member to a variety of high-volume trauma cases they wouldn't normally see in practice at an Air Force base, so they can brush up on those perishable skills.

When they are not teaching, the CSTARS training cadre also function as physicians, nurses and cardiopulmonary technicians in University Hospital's ICUs. Norton said the experience allows his instructors to "bring the lessons of trauma from Cincinnati, and to translate those lessons learned to the students who come through here."

The CSTARS program in Cincinnati currently runs 14 courses per year with an average of 12 participants per class. The CCATT students will experience four to five training runs in the simulator as well as a training mission flying aboard actual C-130 Hercules or C-17 Globemaster III aircraft.

Maj. Marilyn Thomas, a critical care nurse, from Andrews AFB, Md., flew five years as an aeromedical evacuation a flight nurse. Although she said she found that mission rewarding, she now wants to expand her skill set to become a CCATT member. She called her experiences in the simulator very realistic.

"You definitely feel a sense of urgency with a critical patient's life right there in your hands," Major Thomas, a native of Beavercreek, Ohio, said.

Maj. Heidi Stewart, the director of education for CSTARS, said the program is focused first on providing outstanding critical care training. Working a high volume of critical patients in University Hospital's ICUs, combined with the simulations really advances the student's clinical skills, she said.

But the course is also an evaluation of each individual team member's readiness to perform the demanding CCATT mission and not everyone gets the thumbs up to fly missions downrange. Those that aren't certified go back to their command with recommendations to get more critical care exposure.

Doctor Norton said most often, people simply need to be exposed to the "multiple flavors of critical care" they will see when flying missions down range. The average Air Force ICU is 4 to 6 beds. At University Hospital Cincinnati there are more than 100 critical care beds.

"The care that Air Force ICUs offer is very good. It's just low volume," Doctor Norton said. "The students that come here and struggle are very motivated. Usually they just haven't had enough patient volume."

Doctor Norton added there's a good reason why CSTARS standards for the CCATT course are so high.

"In the back of that airplane at 35,000 feet, you are the hospital, you are the back up. There is nobody to call. You are it. You either know it, or you don't."