Ebola Virus Disease Simulation Case Series: Patient With Ebola Virus Disease in the Prodromal Phase of Illness (Scenario 1), the "Wet" Gastrointestinal Phase of Illness (Scenario 2), and the Late, Critically Ill Phase of Disease (Scenario 3).

INTRODUCTION: As part of an international response to the Ebola virus disease (EVD) outbreak, the US Department of Defense has deployed thousands of personnel to help train and augment international health care workers. The transmission risk of this deadly virus to health care workers has been extreme, demonstrating the importance of safe practices while caring for these patients. Medical simulation training is well recognized as an integral component for disease outbreak preparedness. Therefore, the US Government created a program of instruction that outlines a formalized EVD training program, using high-fidelity simulation, which projects both an understanding of the disease and its transmission risks. METHODS: Two 5-day training courses were established to provide training to the 65-member Department of Defense Ebola Response Team, which would be activated during a stateside Ebola outbreak. This training consisted of Ebola-specific protocols, personal protective equipment familiarization, and scenario-based certification for physicians, nurses, and public health trainers. Simulation was used to replicate the work environment inside an Ebola treatment unit. RESULTS: Three comprehensive clinical scenarios covering a wide spectrum of EVD presentations were designed around details of published cases to provide the most realistic and relevant EVD training available. The authors conducted 10 iterations of the 3 EVD clinical scenarios totaling more than 1100 hours of simulation training. CONCLUSIONS: Quality practical exercises to include specialized task performance and collective teamwork training relied heavily on dedicated facilities and realistic medical simulation resulting in valuable lessons learned. In future iterations, these characteristics would be imperative to a successful training course.

Closing the "care in the air" capability gap for severe lung injury: the Landstuhl Acute Lung Rescue Team and extracorporeal lung support.

BACKGROUND: The success of US Air Force Critical Care Air Transport Teams (CCATT) in transporting critically ill and injured patients enabled changes in military medical force deployment and casualty care practice. Even so, a subset of casualties remains who exceed even CCATT capabilities for movement. These patients led to the creation of the Landstuhl Acute Lung Rescue Team (ALeRT) to close the "care in the air" capability gap. METHODS: The ALeRT Registry was queried for the period between November 1, 2005, and June 30, 2010. Additionally, Landstuhl Regional Medical Center critical care patient transfers to host nation medical centers were reviewed for cases using extracorporeal lung support systems. RESULTS: For the review period, US Central Command activated the ALeRT on 40 occasions. The ALeRT successfully evacuated patients on 24 of 27 missions launched (89%). Three patients were too unstable for ALeRT evacuation. Of the 13 remaining activations, four patients died and nine patients improved sufficiently for standard CCATT movement. The ALeRT initiated pumpless extracorporeal lung assistance six times, but only once to facilitate evacuation. Two patients were supported with full extracorporeal membrane oxygenation support after evacuation due to progressive respiratory failure. CONCLUSIONS: ALeRT successfully transported 24 casualties from the combat zones to Germany. Without the ALeRT, these patients would have remained in the combat theater as significant consumers of limited deployed medical resources. Pumpless extracorporeal lung assistance is already within the ALeRT armamentarium, but has only been used for one aeromedical evacuation. Modern extracorporeal membrane oxygenation systems hold promise as a feasible capability for aeromedical evacuation.

Inhaled prostacyclin in combination with high-frequency percussive ventilation.

We present a case of severe acute respiratory distress syndrome pursuant to inhalation of a compressed gas computer keyboard cleaner. Despite the use of multimodal therapy to include empiric antibiotics, intravenous paralytics, intravenous concentrated albumin, high-dose corticosteroids as well as sustained high mean airway pressure mechanical ventilation by airway pressure release and high-frequency percussive ventilation (HFPV) modes, the patient demonstrated an unchanging arterial oxygen tension/fraction of inspired oxygen ratio of only 57 mm Hg. A trial of nebulized prostacyclin was initiated during HFPV leading to a significant improvement in arterial oxygen tension/fraction of inspired oxygen to 147 mm Hg. The improved oxygen tension allowed for a reduction in mean airway pressure and oxygen concentration as well the safe aeromedical evacuation of the patient from the combat theater. Further, prospective studies are required to validate the magnitude of response to inhaled prostacyclin during HFPV.