Interview: Col Elizabeth Mann-Salinas

Colonel (Ret.) Elizabeth Mann-Salinas, PhD, RN, FCCM, Senior Nurse Scientist Department of Trauma Outcomes and Systems Research Systems of Care for Complex Patients Task Area at the US Army Institute of Surgical Research Army Burn Center, spoke to AirMed&Rescue about the research into en-route critical care transfers she and her team have undertaken recently.

In terms of your background and experience in the military, where did you serve, and in what capacity?

I joined the Army in 1994 directly from my baccalaureate nursing programme and was assigned to a hospital in Georgia, US for four years. During that time, I spent four months training as a critical care nurse and worked in the Medical Intensive Care Unit (ICU). I then moved to Heidelberg, Germany, for three years, where I was assigned to the 212th Mobile Army Surgical Hospital (MASH) as an ICU nurse and deployed to Kosovo as part of the NATO mission.

Then I moved to New Orleans, Louisiana, and served as a healthcare recruiter for two years and before going to Denver, Colorado for graduate school. I received a Master of Science as a Critical Care Clinical Nurse Specialist (CNS) and moved to San Antonio, Texas to be the Burn ICU Head Nurse and then the CNS.

The Army offered to fund me to obtain my PhD in Nursing at the University of Texas in Houston, after which I returned to work at the Army Burn Center and Institute of Surgical Research to conduct combat casualty care research. During this assignment, I deployed to Afghanistan as a research co-ordinator and was located at Camp Bastion with the UK combat support hospital (CSH). I recently retired from the Army last year and am continuing my research in a civilian capacity at the ISR.

What prompted you to carry the En Route Critical Care Transfer From a Role 2 (R2) to a Role 3 (R3) Medical Treatment Facility in Afghanistan research?

During the 2013 deployment at Camp Bastion, we initiated a working group of military US and UK tri-service members (Army, Navy, Air Force) to understand the effect the UK MERT (Medical Emergency Response Team) had on transport of patients from point of injury to the role 3 CSH. The hypothesis was that with the physician and enhanced team on a large airframe, with blood products and advanced airway management, the MERT would ‘overfly’ the small austere R2 team and take the extra time to travel to definitive surgical capability at the R3. During this process, we realised that no review of any aggregated R2 work had been done and there were a myriad of unanswered questions relating to the utilisation of the R2 capability. As a result, two years later, about $3.8 million of research funding was received to perform a comprehensive investigation of how R2 was utilised and to inform best practices for training deploying personnel. We have published a series of manuscripts to date regarding our analyses of the R2 data set maintained by the US Joint Trauma System.

During the same time, I had been an active member in the Triservice Nursing Research Program (TSNRP) En Route Care (ERC) Research Interest Group. When we had the opportunity to contribute to an ERC special edition of Critical Care Nurse, this project was perfect because of the utilisation of critical care nurses for post-surgical transport from the R2 to R3.

Your team involved representatives from many different military organisations, how did you co-ordinate everyone and your findings?

Our institute is unique in that we have Army, Navy, Air Force combat casualty care research colocated within the same organisation. Additionally, the Joint Trauma System is located here. Therefore, it is possible to align research efforts among different services. We have been able to closely collaborate with the US Air Force research team, led by MAJ (Dr) Maddry, and the Joint Trauma System surgeons oversee the registry where the data were retrieved. Colonel Biever is the Consultant to the Surgeon General for En Route Critical Care Nurse (ECCN) programme and is the expert in this area. We remain in close contact with her through our professional network. It is exceptionally easy to co-ordinate and collaborate when everyone (except Colonel Biever) is literally in the same building, all pursuing improvement in delivery of combat casualty care.

What are the main insights from the En Route Critical Care Transfer study?

Probably the most important finding is the lack of documentation of what happens during en route care. This is an identified problem on all levels because we cannot monitor and improve a system without information/data. Many teams are working on technological solutions to overcome this shortcoming, but solutions are complex and won’t be available any time soon. We can strive to hold individuals accountable for clear documentation, but currently there is no mandate to hold unit commanders accountable for ensuring this is accomplished. Another critical element is understanding what provider capability is required for various patient types. For example, the ECCN programme came about because it was recognised that a medic, or even paramedic, lacks the critical care experience to care for post-operative patients requiring transport following damage control surgery. Our next challenge will be to determine the ideal provider skill sets for various transports.

How might these insights help to inform decisions on team composition, staff training and the ideal skill mix of a team on the battlefield and in the air?

Identifying the ideal team composition and skill mix is the ultimate goal of this work. We have much to learn from our colleagues in the UK with the MERT teams in the far-forward environment. However, physicians and ECCNs are a commodity that must be carefully employed. A project we are now working on is the concept of ‘intelligent tasking’ – basically sending the right capability to the right place in an efficient manner to safely move that patient to higher levels of care. We can utilise machine learning, decision support technologies to assist the dispatchers and medical planners, but we need data to inform the algorithms. Back to problem number one…

What research are you currently working on, and can you share any insights about this with AirMed&Rescue?

We hope to develop a medical operation center, similar to the one in Texas, to execute the intelligent tasking of resources, create seamless communications across the battlespace, offer virtual/telesupport, and provide situational awareness of all stakeholders. Our other main effort is to develop a comprehensive and standardised training programme to ensure all providers have basic competency in deployment-related knowledge, skills and abilities. First, we had to define what the core competencies are in the deployed environment, and then determine optimal training platforms, and finally, document that each individual is ready and validated for deployment. There is much more to be done, but we are making improvements incrementally and the future is bright.

Contact: [email protected] for additional information.