NCC Pediatrics Continuity Clinic Curriculum: USNS Comfort · 12/1/1987 · BED CAPACITY . 20 Recovery beds 80: ICU Beds 400 Immediate care 500 Minimal care 1000 Total beds + 40 Casualty

NCC Pediatrics Continuity Clinic Curriculum: USNS Comfort

Pre-Meeting Preparation: Please read/review the following enclosures: • “USNS Comfort: Care of the Sick on the Sea” (AMSUS presentation, 2010) • “Profile of Pediatric Admissions to the USNS Comfort” (Poster, 2010)

Conference Agenda:

• Field trip to Baltimore to tour the USNS Comfort • Complete USNS Comfort Quiz & Discussion Questions

(Discuss answers during car rides to and from the Comfort) Extra-Credit:

• “Practicing Internal Medicine Onboard the USNS COMFORT in the Aftermath of the Haitian Earthquake” (Annals of Internal Medicine)

• Fun facts about the USNS Comfort

© Developed by LCDR Amanda Higginson & CDR Gregory Gorman, with source materials from CDR Matthew McLean (NMCP). Formatted by CPT Jennifer Hepps.

http://www.med.navy.mil/sites/usnscomfort/Pages/default.aspx�

http://www.nccpeds.com/ContinuityModules-Spring/Spring%20Continuity%20Source%20Materials/Comfort-Internal%20Med.pdf�

http://www.nccpeds.com/ContinuityModules-Spring/Spring%20Continuity%20Source%20Materials/Comfort-Internal%20Med.pdf�

http://www.nccpeds.com/ContinuityModules-Spring/Spring%20Continuity%20Source%20Materials/Comfort-fun%20facts.pdf�

UNCLAS//FOUO Federal Physician / SMACF Program, AMSUS 2010

USNS COMFORT– D.R. Capabilities from the Sea

Curare Aegra Permarinum “Care of the sick on the Sea”

Overall Classification: UNCLAS/FOUO

LCDR Matthew D. McLean, M.D., Ph.D. Pediatrician, Naval Medical Center Portsmouth

Continuing Promise, 2009 Operation Unified Response - JTF Haiti, 2010


LEARNING OBJECTIVE

Understand the adaptable

capabilities of the USNS

COMFORT with specific

focus on

Operation Unified

Response, JTF- Haiti


• 894 feet long • 106 feet wide • Max Speed 17.5 knots • 4 water distilling plants =

300,000 gallons/day. • Holds 2 MH-60 helicopters • Draft- 33 ft • Power 3000KW (4 generators) • Range 113,420 NM

Ship’s Master = Military Sealift Fleet Support Command

Delivered December 1 1987

USNS COMFORT: The Ship


One of the largest trauma facilities in the U.S. 1) Full Spectrum of Medical and Surgical Services 2) 10 Operating Rooms with C-Arms 4) 1 CAT Scan suite 5) 1 Dental suite (2 OR’s) 6) Optometry and Lens Laboratory 7) Physical Therapy Center 8) Pharmacy 9) 2 Oxygen producing plants 10) Blood bank (holds up to 5000 units) 11) Angiography Suite (under construction during OUR-Haiti)

USNS COMFORT: The MTF


BED CAPACITY 20 Recovery beds 80: ICU Beds 400 Immediate care 500 Minimal care 1000 Total beds

+ 40 Casualty

Receiving Beds

Theoretical Capacity

Mobile Afloat Medical-Surgical Hospital

USNS COMFORT: The MTF


PATIENT FLOW


Real Life Capability- Haiti Experience

“The hospital ship, COMFORT, is expected to arrive in Haiti, Jan 20th and will

essentially provide all the assets and services of [a naval hospital] at sea”

US Fleet Forces Public Affairs 19 Jan 2010 NNS100119-18, Navy.mil


CAPABILITY: MOBILIZATION

Reduced Operating Status (ROS)

• 17 Civilian Mariners (CIVMAR) • 58 Military Medical Personnel

Full Operating Status (FOS)

• 13 January- verbal order to deploy • 16 January – set sail, 76 ½ hrs later

- 550 medical personnel - 140 non-medical personnel - 67 CIVMAR

•19 January ~2200- 1st Pt aboard


COMFORT Medical Capabilities First 72 hours.

Surgical Staff

• 1 orthopedic surgeon • 1 Emergency Medicine physician • Variety of other surgical specialties

without front load of ortho-neuro-trauma • Most had combat tour experience

Medical Staff

• Broad range of specialties based on HCA missions vice disaster-trauma

• Most with inpatient medicine skills

Nursing Services • Wards staffed for 250 beds • Filled 411 beds with critical care pts • Few pediatric trained nurses • all with adaptable RN/HM skills

Develop JMD tailored to provide medical capabilities for disaster response missions

Deployed with standard Humanitarian Civil Assistance mission capabilities.


Admissions, discharges, deaths

USNS Comfort Opereration Unified Response Haiti

Patient Admissions, Discharges, Deaths 19 Jan - 3 Mar

2

81

181

242

316

356

375

389399

411

393383

348

318309

290

273

242

225 221 218

186

167

143

117

10088

72

56 56 61 5966

58 5947

2315

90

0 0 13 3

5

1 0 1 2 1 20 0

42 1 0 0 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0

-5

15

35

55

75

95

115

Ad

mis

sio

n/D

isch

arg

e, n

-30

20

70

120

170

220

270

320

370

420

Admissions

Discharges

Census

Deaths

Admissions 2 79 103 69 82 61 64 30 53 35 9 11 9 17 13 21 9 16 13 19 15 4 9 12 7 15 5 1 6 4 16 13 19 3 1 6 0 4 5 2

Discharges 0 0 2 5 5 16 44 16 42 21 26 19 44 47 18 38 25 47 30 22 18 36 27 36 33 31 17 17 22 4 11 15 12 11 0 18 24 12 11 11

Census 2 81 181 242 316 356 375 389 399 411 393 383 348 318 309 290 273 242 225 221 218 186 167 143 117 100 88 72 56 56 61 59 66 58 59 47 23 15 9 0

Deaths 0 0 1 3 3 5 1 0 1 2 1 2 0 0 4 2 1 0 0 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0

19-Jan

20-Jan

21-Jan

22-Jan

23-Jan

24-Jan

25-Jan

26-Jan

27-Jan

28-Jan

29-Jan

30-Jan

31-Jan

1-Feb 2-Feb

3-Feb

4-Feb

5-Feb

6-Feb

7-Feb

8-Feb

9-Feb

10-Feb

11-Feb

12-Feb

13-Feb

14-Feb

15-Feb

16-Feb

17-Feb

18-Feb

19-Feb

20-Feb

21-Feb

22-Feb

23-Feb

24-Feb

25-Feb

26-Feb

27-Feb

2nd wave providers

Project Hope

2nd group NGO, Reservists and Mental Health


USNS Comfort Pediatric Population

020406080

100120140

19-Jan

23-Jan

27-Jan

31-Jan

4-Feb

8-Feb

12-Feb

16-Feb

20-Feb

24-Feb

28-Feb

Date

Ped

iatr

ic P

ati

en

t TOTAL PEDS CENSUS

2FWD PEDS

3FWD PEDS

5FWD PEDS

ICU PEDSCENSUS

Project Hope Arrives 2nd Group NGO's, Reservists, and Mental Health providers Arrive

PEDIATRIC ADMISSIONS


Ancillary Services USNS Comfort 20 Jan - 28 Feb 2010

• Radiology Studies – 3,896 – Plain film x-rays – 3,296 – CT Scans – 482 – Ultrasound – 118

• Prescriptions – 70,286 – Inpatient – 64,840 – Outpatient – 5,446

• Blood Products – 376 units – Red Blood Cells – 348 – Plasma – 16 – Platelets – 12

• Laboratory Studies – 4,257 • Physical Therapy - 1,318 • Discharge Planning

– Key coordination between network of NGO/Haitian facilities- 16 different sites


Security

Transportation

Supply Mgmt

Knowledge Mgmt

Operations

Personnel

Medical-Surgical Coordination

Joint Medical-Surgical Capability

Delivered and Coordinated Care for 794 Haitan Nationals 185 patient escorts 52 Active Duty 3 Allied Troops 23 American Citizens 1057 Total Admissions

- 7 OR’s 12 hours/day - 3 OR’s 24 hours/day - 820 Surgeries - 931 total procedures 16 Craniotomy 44 Spinal 33 Pelvis 676 Extremity 122 Femur Fracture surgeries

48% of pediatric patients did not require surgery


•Medicine Capabilities: Internal Medicine, Pediatrics, Family Practice, Neurology

•Sub-specialties: Cardiology, Nephrology, Infectious Disease, GI,

Thank You

Profile of Pediatric Admissions to the USNS COMFORT Following the 2010 Haiti Earthquake: Lessons for Future Hospital Ship Based Disaster Relief missions.

LCDR Matthew D. McLean MD, PhD1, CDR William Scouten MD1, CAPT Daniel Shmorhun MD2, LCDR Erika Beard-Irvine MD2, CAPT Arne Anderson MD2, 1NAVAL MEDICAL CENTER PORTSMOUTH, PORTSMOUTH, VA; 2NATIONAL NAVAL MEDICAL CENTER, BETHESDA, MD

BACKGROUND

• 12 January 2010 at 16:53:09 a 7.2 magnitude earthquake centered 15 miles SW of Port-au-Prince, Haiti results in nearly 300,000 deaths.

• 16 January, 76 hours after receiving verbal order to activate, the USNS COMFORT sails for Haiti staffed for a bed capacity of 250.

• 19 January – First patients accepted aboard. Within 7 days the COMFORT becomes the largest trauma center on the East Coast nearly doubling its originally planned bed capacity.

• 5 Pediatricians, 3 Pediatric Nurse Practitioners, 1 Pediatric Surgeon, 1 Pediatric Orthopedist, 1 Pediatric Plastic Surgeon, 1 Pediatric Radiologist and 1 Pediatric Anesthesiologist are part of the initial crew of 757 for this surgically focused Disaster Relief Mission.

OBJECTIVE

• Define pediatric resource utilization to assist in future resource related disaster relief planning.

INCLUSION CRITERIA • All pediatric patients 17 years old or less,

admitted to the USNS COMFORT from 19 January 2010 through 27 February 2010.

DESIGN

• 100% Retrospective Chart Review

VARIABLES • Age distribution, Number of PICU admissions,

Time to first surgery, Number not needing surgery and reason, Blood transfusion rate, Injury profile with underlying causation

SETTING

USNS COMFORT Hospital Ship off the coast of Port-au-Prince, Haiti during the Haitian earthquake disaster relief mission 2010

RESULTS

1. 224 (28.5%) of the 787 total humanitarian admissions were pediatric patients. (Figure 1 and 2).

2. Pediatric census peaked at 126 patients on 29 January prior to arrival of additional pediatric providers and nursing staff from Project Hope. Initial limited staff spread over 3 separate wards with a peak single ward census of 50 patients. (Figure 2).

3. 156 (69%) of pediatric admissions were classified as quake related injuries. These patients were significantly older (9.2 vs 5.5 yrs) and admissions longer (10.4 vs 8.2 days) than non-quake related admissions. (Figure 3).

4. 167 (75%) of pediatric admissions were for trauma related injuries. These patients were significantly older than those admitted for medical reasons (9.53 vs 3.25 years. (Figure 3).

5. A Bimodal Age Distribution of pediatric patients was observed with peak admissions for infants < 1 year and children 12 years of age. (Figure 4).

6. The anatomic location of injuries profile in pediatric patients admitted to the COMFORT was similar to that seen at field hospitals during other earthquake disasters (Figure 5).

7. Only 113 patients (51%) required surgery and 68% of these had their 1st procedure in one day or less (Figure 6).

8. 48% of the patients not requiring surgery were evaluated by a surgeon although 35% could have been treated ashore had basic plain film radiology services been available before transfer to the ship. 25% had already been treated prior to transfer or had an inoperable chronic disease unrelated to the earthquake (Figure 7).

9. Fifty-six patients (25%) were admitted to the PICU, the majority (44%) for non-quake related (Figure 8) and non-traumatic injuries. (Figure 9).

10. A CBC was obtained on 106 patients (47%) with no relationship to type of injury. The average hemoglobin concentration (9mg/dL) was identical across injury profile groups. (Figure 10).

11. The packed RBC per patient index was comparable to that seen in Operation Iraqi Freedom using the OIF Mass Casualty Resource Assessment. (Figure 10).

Total Census vs Admissions & Discharges

USNS Comfort Opereration Unifie d Response Haiti

Patient Admissions, Discharges, Deaths 19 Jan - 3 Mar

2

81

181

242

316

356

375389

399411

393383

348

318309

290

273

242

225 221 218

186

167

143

117

10088

72

56 56 61 5966

58 5947

2315 9

00 0 1

3 35

1 0 1 2 1 20 0

42 1 0 0 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0

-5

15

35

55

75

95

115

Ad

mis

sio

n/D

isch

arg

e, n

-30

20

70

120

170

220

270

320

370

420

Admissions

Discharges

Census

Deaths

Admis sions 2 79 10 3 69 8 2 61 64 30 53 3 5 9 11 9 17 13 21 9 16 13 19 15 4 9 12 7 15 5 1 6 4 16 13 19 3 1 6 0 4 5 2

Dis charge s 0 0 2 5 5 16 44 16 42 2 1 26 19 44 47 18 3 8 25 47 30 22 18 36 27 36 33 3 1 17 17 22 4 11 15 12 11 0 18 24 12 11 11

C ensus 2 81 181 242 316 356 375 3 89 3 99 411 393 383 348 318 309 290 273 24 2 2 25 221 218 186 167 143 117 100 88 72 56 56 61 59 6 6 58 59 47 23 15 9 0

Dea ths 0 0 1 3 3 5 1 0 1 2 1 2 0 0 4 2 1 0 0 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0

19-J an

20-Ja n

21-Ja n

22-Ja n

23-Ja n

24 -Ja n

25-Ja n

2 6-J an

27-J an

28-J an

29-J an

30-J an

31-J an 1-Feb

2-Fe b

3-Fe b

4-Fe b

5-Fe b

6-F eb

7-F eb

8-Fe b

9-Fe b

10 -Fe b

11-F eb

12-Feb

13-Feb

14-Feb

15-Feb

16-Fe b

17-Fe b

18-Fe b

19-Fe b

20-Fe b

21-Fe b

22-F eb

23-F eb

24-Feb

25-Feb

26 -Feb

2 7-Feb

2nd wave NMCP

Project Hope

2nd group NGO, Reservists and Mental Health

USNS Comfort Pediatric Population

020406080

100120140

19-Jan

23-Jan

27-Jan

31-Jan

4-Feb

8-Feb

12-Feb

16-Feb

20-Feb

24-Feb

28-Feb

Date

Pedia

tric

Patien

t TOTAL PEDS CENSUS

2FWD PEDS

3FWD PEDS

5FWD PEDS

ICU PEDSCENSUS

Project Hope Arrives 2nd Group NGO's, Reservists, and Mental HealthNMCP Arrives

PEDIATRIC ADMISSIONS

Pediatric patients = 28.5% of all admissions

Demographics*Significant Findings

1. Quake related injury patients Older and Admission longer than non-quake patients

2. 49% of pediatric patients didn’t need surgery

3. 23% of admissions for non-trauma related illness

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

11.0

Quake Related Not Quake Related No Trauma Trauma

Me

an

(S

E)

Ag

e i

n Y

ea

rs

quake not quake No Trauma Trauma

Mea

n A

ge in

yea

rs9.25

5.5

9.53

3.25

Total Peds Patients

n (%)

Quaken(%)

Not Quaken(%)

Total 224 (28.5%) 156 (69%) 68(30%)#females 110 (49%) 85 (54) 25 (37)ALOS* 9.7 days 10.4 days 8.2 days

avg age- all* 8.1 yrs 9.2 yrs 5.5 yrsAvg age- no births* 8.4 yrs 8.7 yrs 6.2 yrs

Escorted 143 (64) 91(58) 52 (76)non-traumatic 56 (25%) 9 (6) 47 (69)

Age Distribution of PatientsNumber of patients per age

16

26

10

5

87

98 8 8

12

1716

22

1413

89

14

0

5

10

15

20

25

30

<30d

<1yr 1yo

2yo

3yo

4yo

5yo

6yo

7yo

8yo

9yo

10yo

11yo

12yo

13yo

14yo

15yo

16yr

17yr

Age

Nu

mb

er

Bimodal age distribution

Infants <1 year

Children 10-12 years

Profile of injuries compared to other earthquake disasters

Injury Location

Haiti

2010*

Kashmir

2005

Marmara

1999

% Total head/face 25 24 18% total trunk 9 11

% total limb trauma 52 50 66.6

* Represents pediatric patients only

Days to first surgery

49% of pediatric patients did not need

surgery

Despite overwhelming number of admissions

necessary surgery occurred in a timely

fashion.

Number of patients vs days from admission to first surgery

0

5

10

15

2 0

2 5

3 0

3 5

4 0

0 d ays wait 1- d ay 2 d ays 3 d ays 4 o r mo re

Days from admission to 1st surgery

Nu

mb

er

of

pati

en

ts

Total Peds Patients

Quaken(%)

Not Quaken(%)

Total 224 156 (69%) 68(30%)# needing surgery 113 (51%) 96(62) 18(26)avg # surgeries 2.2 2.3 1.9

PICU Admissions vs Census

PICU Daily Admissions vs Census

02468

10121416182022242628

19-J

an

22-J

an

25-J

an

28-J

an

31-J

an

3-Fe

b

6-Fe

b

9-Fe

b

12-F

eb

15-F

eb

18-F

eb

21-F

eb

24-F

eb

27-F

eb

Date

Cen

sus

0

2

4

6

8

10

12

Adm

issi

ons

Series1 Series2ADMISSIONS CENSUS

Total % of admits in PICU56/224= 25%

Quaken(%)

Not Quaken(%)

# in ICU 26 (16%) 30 (44%)Avg days in ICU 8 7

Profile of PICU Admissions by Injury

Non Trauma Indications for PICU Admission

Seizures14%

Infections43% Malnutrition

7%

Sickle Cell7%

Renal Failure4%

Cardiac4%

Prematurity21%

41

19

4

35

0

5

10

15

20

25

30

35

40

45

Perc

en

tag

e

Non-Trauma Limb Axial Head andFace

Location of traumatic injury

Percentage of ICU admissions by injury

Packed Cells Per Patient Index

RBC ONLY Pediatric Adult Total# Pts transfused 26 111 137

# units transfused 50 275 325% of all patients

transfused 11.6% 19.8% 17.4%*PPI 1.92 +/- 0.23 2.48+/- 0.15 2.37 +/- 0.13

* Packed Cells per Patient Index

% of all peds with CBC106/224 = 47%

Quaken(%)

Not Quaken(%)

admission cbc 68 (44%) 38 (56%)avg hgb 9 9

OPERATION IRAQI FREEDOM MASS CASUALTY ASSESSMENT = PPI 1.4 +/- 0.8

22% of all casualties evacuated required transfusion in OIF

CONCLUSIONS

1. Despite the challenges in transferring patients to a ship based hospital platform, the percentage of pediatric patients and the overall injury profile was similar to that seen at land based hospitals during previous earthquake disasters. This should be considered when planning resources for future missions.

2. Pediatric providers were integral in supporting the surgical team effort by managing most of the pre- and post-surgical pediatric care on the wards allowing surgeons to focus efforts in the operating suite. This hospitalist approach contributed to the minimal delays seen from time of admission to first surgical procedure despite the initial overwhelming influx of patients.

3) Manning documents for future disaster relief missions should include pediatric intensivists given an expected early surge and sustained PICU census with a step down area to more efficiently utilize limited critical care resources.

4) Future studies should evaluate the referral process to the COMFORT during disaster relief missions to optimize utilization of its advanced level 3 medical capabilities and maximize support available for referring field hospitals.

References

1. Mulvey, JM, SU Awan, AA Qadri and MA Maqsood. Profile of injuries arising from the 2005 Kashmir Earthquake: The first 72 hours. 2008. Injury 39(5) 554-560

2. Beekley AC, MJ Martin, PC Spinella, SP Telian and JB Holcomb 2009. Predicting Resource Needs for Multiple and Mass Casualty Events in Combat: lessons learned from combat support hospital experience in Operation Iraqi Freedom. J. Trauma 66(4): S129-137

3. Yasin, MA, SA Malik, G Hasreen and CA Safdar. 2009. Experience with mass casualties in a subcontinent earthquake. Turkish Journal of Trauma and Emergency Surgery. 15(5) 487-492

(1)

(2)

(4)

(5)

(10) Profile of Pediatric Injuries not requiring Surgery

CATEGORIZATION OF ADMISSIONS

NOT NEEDING SURGERY

OTHER

MEDICAL

DISEASE

22%

PREMATURITY-

NEWBORN

12%

SURGEON

EVALUATED -

NO SURGERY

NEEDED

48%

INFECTION

14%

MALNUTRITION

4%Profile of Surgical Injuries that did not

need Surgery

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

1

CASTEDNEUROSURGICALSOFT TISSUE INJURYALREADY TREATEDOPHTHALMOLOGICCHRONIC PROBLEM

(6)

(8)

(9)

(7)

The views expressed in this presentation are those of the authors and do not necessarily reflect the official policy or

position of the Department of the Navy, Department of Defense or the United States Government

Research data derived from an approved National Naval Medical Center, Bethesda, MD IRB [IACUC] protocol

(3)

USNS Comfort Quiz Some questions are based on the readings; some will need to be completed during the tour.

1. What day had the most admissions during the Haiti operation?

2. What day had the highest census in the Haiti op? Highest pediatric census?

3. How many football fields long is the Comfort?

4. How fast is the max speed of the Comfort when translated to miles per hour for a car?

5. Name a type of Navy vessel that has a max speed faster than the Comfort?

6. Name a type of Navy vessel with a max speed slower than the Comfort?

7. What's the average water usage of a person living in DC and how does it compare to the daily water available to personnel on the Comfort when underway with a full crew?

8. If you were designing a hospital ship, where would you locate the ORs and why?

9. How many ships have been named COMFORT? What was the name of this ship before she was converted to the USNS Comfort? (Hint: Look around the mess deck walls)

10. How many hospital beds does the Comfort have? OR’s? Lifeboats? Patient elevators?

USNS Comfort Discussion Questions You are on a humanitarian mission to a developing nation devastated by a natural disaster:

1. As a pediatrician, what diseases should you prepare for? 2. What supplies would you need? 3. Onboard, where would you set up your MTFs to triage, treat, and manage children? 4. Describe the movement of patients on the COMFORT. If a patient arrives by helo, and needs triage, decontamination, emergency care, an operation and then recovery, what areas of the ship would he pass through to accomplish all this? List and diagram below:

NCC Pediatrics Continuity Clinic Curriculum: USNS Comfort · 12/1/1987 · BED CAPACITY . 20 Recovery beds 80: ICU Beds 400 Immediate care 500 Minimal care 1000 Total beds + 40 Casualty

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