The First Fork in the Road

Transcription

1 Characteristics that Contribute to Medevac ADAP Medical Evacuations: What to Do Once the Decision is Made Stephen A. Young, MD Lorie J. Morris, Psy.D. US Department of State MED/MHS/ADAP 1 The First Fork in the Road Are there medical complications? Minimal Assessment Includes: History of Previous Withdrawals Current Vital Signs in context of Abstinence Physical Symptoms: Abdominal Pain, Confusion Physical Findings: Ascites, Abdominal Tenderness, evidence of trauma 2 1

2 Two separate but overlapping concerns Substance Withdrawal ETOH generally worst within first 72 hours: Autonomic instability, Seizures, significant mental status changes. Worst case: Delirium Tremens Benzo w/d similar but can take longer depending on half life of agent Other substances much less problematic Medical Complications of Substance Use Head and extremity Trauma Hepatic Insufficiency Pancreatitis Exacerbation of Subclinical seizure disorder 3 Factors to Consider History of Previous Withdrawal Degree of Insight/Compliance Current Medical Status Risk of Deterioration over the next 72 hours Length of Flight/Trip 4 2

3 Category A Generally healthy adult with no known medical problems No history of previous withdrawal and no suspicion that withdrawal is imminent Travel time Less than 12 hours Has insight into need for treatment/compliant with care Recommendation: Usual med evac procedure, no need for attendant 5 Category B History of mild withdrawal symptoms while at post Compliant with recommendation for treatment but still ambivalent Generally in good health no active medical problems Travel time less than 12 hours Recommendation: Normal med evac. Consider pre flight benzodiazepine (diazepam) and non medical attendant 6 3

4 Category C Risk of significant withdrawal: history of W/D in past, documented increase in HR/BP, increased anxiety Generally in good health, no active medical problems Travel time greater than 12 hours Limited insight, very ambivalent about need for treatment Recommendation: normal med evac with medical attendant and supply of benzodiazepine medication for the flight 7 Category D Ambivalence bordering on non compliance, Continues to use alcohol in period prior to med evac Risk of significant withdrawal and/or medical co morbidity (elevated pancreatic enzymes, ascites, CAD etc.) Flight time may not be a factor Recommendation: May need admission to local hospital for medical stabilization. Consider regional med evac to location with better resources. Will need a medical attendant for med evac of any duration 8 4

5 Category E Non compliant, refusing care in face of possible life threatening consequences Significant medical complications: aspiration pneumonia, evolving pancreatitis, alcohol induced hepatitis Risk of severe withdrawal/dts, or seizures Flight duration irrelevant Recommendation: Requires local medical stabilization or, if unavailable, air ambulance to location with appropriate resources (ICU bed). May need front office support if patient non compliant 9 Case 1 14 year old D/S who was discovered to be drinking and smoking cannabis at home. History revealed he had been disciplined at school previously for drinking on school property after hours with friends. The family was posted to a high threat mission, so the RSO was quite concerned about this behavior and the potential risk to both the patient and his friends. There were very limited local mental health treatment resources of any kind. On exam the patient was normal height and weight with no active medical problems. Mom was very anxious about the consequences of this behavior for both her son s future and her own career 10 5

6 Case 1: Which factors impact the management of this med evac? Possible Withdrawal? Lack of insight compliance? (parent is the decision maker) Active medical status? What, if any, are the short term risks that could develop during the evacuation? What Level med evac is this? 11 Case 2 A 50 male FSO who has recently arrived at post in a large city in the Southern Hemisphere. He has a history of seizures on two occasions and pancreatitis prior to deployment. After 6 weeks at post, he was reported to have been absent work for hours at a time and taking long lunches. During a TDY he apparently did not present for work several times. There were local detox resources available, but he refused to be evaluated for admission and denied having a problem. Post officials were initially reluctant to suggest curtailment, but eventually gave him a choice of medevac or formal action. 12 6

7 Case 2: Which factors impact the management of this med evac? Possible Withdrawal? Lack of insight compliance? Active medical status? What, if any, are the short term risks that could develop during the evacuation? What Level med evac is this? 13 7