The Move from Tent City
Written by COLONEL LES FOLIO, MC, USAF, SFS
THE TRANSITION OF A RADIOLOGY DEPARTMENT FROM TENT CITY TO A NEW HARDENED FACILITY DURING COMBAT OPERATIONS IN IRAQ.
While in Iraq a deployed medical group moved a radiology department from a tent city configuration to a hardened facility with no interruption in trauma diagnostics and management. The overall plan will be reviewed, along with lessons learned and successes of the actual transition. This may be of benefit to future deployed field hospitals that are considering moving; at least from the radiology equipment and informatics perspective.
We were very fortunate to have the luxury of outstanding CT and informatics expertise on our transition team. Many technicians and administrators had experience in moving radiology equipment to include CT and other diagnostic imaging modalities. Technical Sergeant Ellwood Tegtmeier emphasized that it was quite an achievement that we never closed shop for trauma imaging diagnostics at any time.
Even though there were times that both CT scanners were down (unrelated to the move), constant 24/7 technical support from our BMETs (bioMedical engineering technicians) and persistence of the technologists pulling together as a team made the transition a success, without a capability flaw. The stressors of a deployed combat setting are hard enough to manage; the added pressure of a transition can compound the situation. Because of great teamwork and tireless efforts among all players, the move occurred without a major hitch.
ADMINISTRATIVE ASPECTS
Moving a combat hospital and continuing trauma care and diagnostics even a short distance can be a challenging task. Lieutenant Colonel Michael Glass was in charge of the transition. When I asked Glass how the move of the CT was going to occur, he put in the simplest of explanations: the iso-shelter, once the CT table and other equipment is arranged within, folds into itself like an expandable camper. During some sandstorms, the wind would blow the doors open, shake the entire tent, and fill the tent with so much dust you would not be able to see without goggles. Some tents in other departments actually blew over at times.
The overall schedule and critical potential show-stopper steps for radiology include the following, designated by move date (M), either minus (before) or plus (after):
1. M-7: BMETs/Rad set up OREX fi lm readers.
2. M-5: CT repair techs/BMETS begin moving ER CT (a)Major step, everything else relies on success of this step.
3. M-2: CT Operational—C-Arm and portable rad in place.
4. Another major step: go, no-go depends on this.
5. M–1: One portable X-ray and a portable U.S. are moved to new facility.
6. Move day: everything was in place for dual operation.
7. M+1: The diagnostic x-ray unit iso-sheter is moved to new facility by crane (similar to how the CTs are moved).
8. M+2: fully operational in new facility.
9. M+3: the remaining CT was moved to the new facility.
10. M+7: Prior tent city cleared.
On move day, the night shift prepared for the final move. The night radiologist overlapped morning ops to assure continued care for any remaining patients (Folio, the last radiologist to work in the tents). The day shift radiologist, Dr. Jane Chan, was the first radiologist to work in the new facility. The BMETS moved the Medweb PACS/TR to the new facility and had it up and running within hours. The actual transition was planned to take four hours, it happened in less than that. The actual move of all patients and last equipment took only 90 minutes and was complete before the planned start time, with split equipment and overlap of personnel work shifts. Folio said they actually had patients in both the tents and the new facility at the same time during the transition day. The technologists were also co-located for dual operations for the overlap.
The tents were being taken down while we were working in them, I would go to the floors to discuss radiology results and return to find that my PC was not there, workstation removed on schedule. However, we were still treating patients in the wards, accepting combat casualties, and so on. (we had an extra workstation). To make the move more exciting, the actual move involved crossing the helipad through an active flight line where helicopters land with little warning. The move included equipment, moving personnel, going back empty handed, bringing inpatients over in litters; while trauma patients continued to fly in.
CHALLENGES
Flores recommends that anyone moving a trauma hospital radiology department in the future, that consideration is taken up front and early hardened facility floor plan integration with the CT ISO-shelter configuration. Although this was done to some degree, more functional involvement in the layout would have been helpful. According to Sergeant Justin Thurston (U.S. Army), the most challenging part of the move was attempting to close communication gaps among various departments. Thurston is the theater contact for all CT issues, and just before the move, another deployed hospital asked him to train and fix their CT.
When we came closer to the moving date, we began to find out how radiology is integrated into every aspect of a deployed hospital. The C-Arms are in the OR, there are U.S. units in the ER (for FAST) and radiology, and there are portables throughout the wards and ICUs. The entire radiology resources were best realized during the move. This is not unlike moving a household from an organizational standpoint.
It is not uncommon for CT and other radiology equipment to periodically go down, whether in a deployed hospital in combat, an inter-city trauma center or university hospital in America. When a CT goes down in a major trauma hospital taking care of combat casualties, some unique considerations need to be addressed. This is compounded when a CT (or two) goes down during a move.
During our move to the new facility, the CT iso-shelters were moved one at a time to maximize imaging capability. An unforeseen recon machine (mother board) went bad on the first unit moved to the new facility. Interestingly, the tent city CT went down at the same time for several hours, however this was remedied with aggressive CT repair technicians.
A TOUGH DECISION
With the problem of the CT in the new facility not working, a go-no go decision needed to be determined. Folio presented the following four options to the medical command staff, none of them very attractive:
1. Move to the new facility as scheduled; taking into consideration that only patients absolutely in need of CT and stable enough to travel to tent city would get a CT. In addition, since Balad is the main referral center for head and neck surgery with the only theater neurosurgical capability; select medical evacuation diversion plans needed to be implemented. This was the most aggressive, yet most sensible option, considering all else. The obvious disadvantage was having to move litter patients across a helipad and to the tent iso-shelter CT. An unintended advantage from a utilization standpoint was, however, only those in absolute need of CT get done. One has to determine that a patient must really need a CT if the resources to transport them are required (an ACLS provider, manpower to move and lift, a radiologist and radiologic technologist). Even in deployed settings, over-utilization is possible when the capability is present and readily available.
2. Hold off transition to the new facility until the new hospital CT was functional. This could have been a week since parts were ordered the night the problem was identifi ed. The hospital staff loved working in the tent environment; perhaps the last medical group to do so in combat; at least in the foreseeable future. Delaying the move after the train was already moving was a less attractive option.
3. Research the possibility of cannibalizing the working CT in tent city to provide reconstruction capability by transplanting the mother board to the new facility CT. This was not a wise option since the scanners were not identical, and even if they were, there was still a good chance neither scanner would be functional.
4. Consider moving the working CT to the new facility early. This option may seem attractive at fi rst, however, considering the scheduling of the crane, the move of a CT and supporting equipment taking up to 12 hours (packing up the iso-shelter, hauling onto the truck, etc.), and setting up taking longer; this option was clearly out.
The first option was chosen by the command staff and made the most sense. There were some challenges with moving the patients in need of CT. However, only those cases in desperate need of CT were performed. This was inconvenient, but it worked for the few days before the parts arrived for the hardened facility CT. Once this was up, the other CT was moved without event, followed by the diagnostic radiology unit.
The actual move of all patients and last equipment took only 90 minutes and was complete before the actual planned start time, with split equipment, patients in both hospitals and overlap of personnel.
There were some initial electrical power challenges with dual power considerations (110 and 220 volt systems). There were also cycle variances that run electrical devices differently if not built to adjust automatically. Many countries not only use 220 volts
Instead of 110 volts like in the U.S., but also deliver the power in 50 cycles versus 60 cycles like in the U.S. We figured out ways of backing up each of the systems, however, by transforming each of the systems to use as a backup, in addition to uninterrupted power supply and other backup generators). The radiology move went without major interruption in trauma diagnostics and was completed moved in a few days.
IMPLEMENTATION
As if moving to a new facility was not enough, our rotation also implemented the new hospital information system using TC2 and AHLTA-T. The TC2 is our inpatient system and is basically CHCS legacy (Composite Health Care System) that has been successful in stateside military medical facilities for years. The outpatient system in theater is AHLTA-T (Armed Forces Health Longitudinal Technology Application (formerly CHCS II). The “T” at the end indicates the theater version of AHLTA. Both of these systems populate the Theater Medical Data Server that can be viewed anywhere in theater to get up to date information on patients.
We successfully implemented TC2 by starting with installation of the systems by Medical Communications for Combat Casualty Care, the deployed team that develops, fields and supports information management systems in combat and tactical environments. After installation during the building of the new facility, training sessions started, followed by practice patients that tested every department in some fashion. After the test patients, we started with real patients, while continuing the traditional paperwork as a backup. This all occurred with the seasoned deployed medical staff, just prior to the new rotation starting up. This timing was perfect in that the prior group had the workflows down to a system with the traditional information system, or Joint Patient Tracking Application, and paper requests and results. The newly arriving staff was trained in the new system and developed workflows based on recommendations from the seasoned staff.
Overall, the move was well orchestrated and a miraculous accomplishment; perhaps our experience will be of value to those considering moving field hospitals in the future. ♦