Brooke Army Medical Center and Argentine Army's Central Military Medical Hospital medical professionals did not let 5,600 miles of separation keep them from discussing best practices against COVID-19 on Oct. 21 at Joint Base San Antonio-Fort Sam Houston, Texas.
U.S. Army South facilitated the virtual subject matter expert exchange, or SMEE, between BAMC and CMMH, which is located in Buenos Aires, touching on numerous topics and providing lessons learned for the participants. The SMEE is an avenue allowing doctors from both countries to discuss critical aspects of combating COVID-19 that help protect the force and enhance readiness while strengthening and building partnerships.
The exchange of COVID-19 best practices focused not only on readiness, but how to treat both COVID-19 and non-COVID-19 patients, staff protection, research and development and testing protocols. A total of 17 medical practitioners (six from BAMC; 11 from CMMH) participated in the virtual SMEE.
Although they practice their craft in different countries, both find the importance of reducing risk to staff as paramount to providing safe, quality care to service members and the communities they serve.
At the beginning of the pandemic, BAMC started with a deliberate operations order to assess staff, logistics and bed expansion capacity. "We have many simultaneous missions to conduct," U.S. Army Col. Michael Wirt, BAMC deputy commanding officer, said. "Not just the mission to provide health care within our hospital; we also deploy some of our staff to respond to local, regional and national requirements to support the [pandemic]."
BAMC reduced its inpatient census, tightly managed personal protective equipment until the supply line became more predictable, limited the number of entrances to the hospital, conducted screening of everyone coming into the building and began drive-through testing in order to reduce the chance of infection in the hospital.
Both BAMC and CMMH indicated that COVID-19 and non-COVID-19 patients are treated in separate areas. The CMMH team stated that COVID-19 areas follow strict protocols, requiring personal protective equipment at all entrance points.
COVID-19 wards are routinely disinfected and CMMH employs a security committee that ensures the non-COVID-19 area stays free of COVID-19.
Supply and demand, particularly with personal protection equipment and COVID-19 testing material was a concern for BAMC and CMMH. There are over 14 million people in the metropolitan area of Buenos Aires, and CMMH provides care to the military and general population. Even with PPE being such a prime commodity, CMMH manages to test its hospital staff of over 2,400 every 15 days. They test about 5,000 for COVID-19 on a daily basis.
BAMC continues its partnership with University Health System and the Southwest Texas Regional Advisory Council to provide Level I Trauma care for 22 counties that encompasses 2.2 million people, even in the face of unprecedented healthcare system stress across the region.
"That allowed for discussions on resources, testing and policies on managing the pandemic from a regional standpoint," Air Force Col. Patrick Osborn, BAMC deputy commander for surgical services, said.
The Air Force Secretarial Designee program allows BAMC to transport and accept extracorporeal membrane oxygenation, or ECMO, patients for complex critical care when hospital capacity allows. The ECMO program provided significant community support for the sickest COVID-19 patients while furthering the readiness of numerous critical care personnel.
"Through the infectious disease and public health communities, we have been working with public health in the state," U.S. Air Force Col. Heather Yun, BAMC deputy commander for medical services, said. "We're one of many military health system hospitals in the United States, and all of our subject matter experts have been passing best practices back and forth and actually developing clinical practice guidelines. We're on the sixth version [of the COVID-19 guidelines]."
Because of the fluid nature and constant learning surrounding COVID-19, protocols have been continually changing for healthcare professionals. "We've had to write a lot of things in pencil, and rewrite them in pencil again two weeks later," Yun explained. "We certainly follow CDC guidelines when it comes to things like infection prevention and control. When it comes to treatment protocols, we follow the science. Current protocols involve Dexamethasone and Remdesivir for hospitalized patients on oxygen."
CMMH is experiencing the ebb and flow of changing protocols as well. Treatments of mild (symptomatic) and critical (low oxygen reactions) patients appear to be similar for both organizations. CMMH stated their mild patients quarantine in their homes and are monitored remotely (virtually), while protocols for critical patients are changing.
There are challenges unique to each organization. Because of the trainee population at Joint Base San Antonio, units had to develop isolation plans for trainees in those settings. Argentina is in the Southern Hemisphere, requiring CMMH to handle the pandemic simultaneously with the influenza season. Fortunately, according to the CDC's Morbidity and Mortality Weekly Report, influenza has been low this season. It is attributed to measures implemented worldwide to mitigate the transmission of COVID-19.
Practices and procedures that require high exposure are-obstacles medical treatment facilities have to negotiate in order to maintain a safe environment during the pandemic.
When community transmissions are high, many non-emergency procedures are postponed until conditions are favorable. "We haven't been doing a lot of elective surgeries or aerosol-generating procedures when we have a lot of community transmission," Yun said. All patients are treated as a potential COVID-19 patient, guarding against the risk of transmission.
Communicating as a staff during the pandemic also offered challenges. CMMH and BAMC have had to rely on off-the-shelf technology to conduct meetings that otherwise would have been face-to-face.
BAMC is one of the participating sites of the clinical trials for Remdesivir as a treatment for COVID-19 infected patients. BAMC is also involved in trials with convalescent antibodies/convalescent plasma.
As part of the Operation Warp Speed goal to deliver safe and effective vaccines and therapeutics by January 2021, five DoD locations, including BAMC, have been identified to participate in the Phase III trial evaluating the vaccine candidate AZD1222 under development by AstraZeneca.
The COVID-19 pandemic has created new partnerships and revitalized existing relationships within the medical community. "These types of exchanges provide military physicians in both countries a serious retrospection on sustainable practices," Wirt explained. "At the same time, we learn and share information that can lead to improving efficiencies as we deal with COVID[-19], and that makes us better prepared for the next challenge."
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