# Presentation: 540736

## PRC Plan Development

**PRC Plan Development**

***Block Objective:  ***
***At the end of this block of instruction participants should be able to complete the development of a comprehensive PRC plan.***

**Notes:**
A patient arriving at the Patient Reception Area – notice the four person lift and the hand held IV bag.  Lifting teams should be designed with four person lifts, two person lifts will not suffice even as an emergency measure.  Expect many patients to present with multiple injuries to multiple body systems. 

## PRC Plan Development

***Why have a Primary Receiving Center Plan?***
***Moffett Federal Airfield – Routine AE missions***
***San Diego VAMC - Secondary Support Center – plan to receive patients via ground transportation***

**PRC Plan Development**

**Overview**

**Notes:**
Moffett Federal Airfield near Palo Alto, California exemplifies the most elemental type of patient reception mission.  At Moffett the flight line routinely receives aeromedical flights with patients regulated through GPMRC.  On many occasions only one patient is aboard.  For these missions the Moffett plan specifies that when the tower is notified of the AE flight ... a local ambulance company is called to transport the patient ... the ambulance crew, upon receipt of clearance from the tower ... will drive up to aircraft ... receive the patient from the flight crew ... and then transport the patient to Stanford Medical Center.

San Diego VA Medical Center is designated as a Secondary Support Center for San Diego Naval Medical Center at Balboa.  In San Diego the VA is integral to the day to day healthcare plan for services members.  Consistent with contracts and sharing agreements ... the capacity at VA hospital at San Diego would be filled at the same time as the Navy hospital during a crisis.  
Most secondary support centers have plans to receive patients via ground ambulance ... which requires no new plan beyond the influx of patients plan ... which is required by Joint Commission.

## PRC Plan Development

***Why have a Primary Receiving Center Plan?***
*** ******PRCs need a plan because if we are ever activated the number and severity of the injured will exceed the capacity of routine plans***

**PRC Plan Development**

**Overview**

**Notes:**
Primary Receiving Centers need a plan because ... if we are ever activated  ... the number and severity of the injured will exceed the capacity of our routine plans.

“Very dire circumstances” will prevail if the PRCs are activated to receive patients.

## PRC Plan Development

**PRC Plan Development**

**Notes:**
Andersen Airmen treat, transport injured Sailors 
Members from the 36th Wing and 18th Wing stabilize six Sailors on a C-17 Globemaster III Dec. 2 at Andersen Air Force Base, Guam before their onward flight to Hickam AFB, Hawaii. The Sailors were injured when a steam line ruptured in the engineering room of the USS Frank Cable in Guam. 
(U.S. Air Force photo/Staff Sgt. Patrick Mitchell)
Photo courtesy of the United States Air Force.

## PRC Plan Development

***Aeromedical Evacuation***
***Evacuation of injured personnel using fixed wing aircraft for rapid transport of casualties to medical treatment facilities where definitive care can be rendered***
***The aeromedical environment creates unique stresses on the injured patient***
*Emergency War Surgery - 2004*

**PRC Plan Development**

**Overview**

**Notes:**
The major key to understanding the mission of the Primary Receiving Centers is understanding aero-medical evacuation.
Understanding who is being loaded onto the aircraft will us help to understand who we will be off loading.
These understandings are essentially to a successful Primary Receiving Center plan.

Aeromedical Evacuation
Evacuation of injured personnel using aircraft, fixed or rotary wing, has revolutionized the rapid transport of casualties from areas where there is either inadequate or no care available to medical treatment facilities (MTFs) where essential and/or definitive care can be rendered. While an aircraft can decrease transport time, the aeromedical environment creates unique
stresses on the injured patient.
Emergency War Surgery – 2004

## PRC Plan Development

**PRC Plan Development**

**Notes:**
Wounded service person ... being moved to a C-17 Globemaster for the flight to Landstuhl, Germany.
Photo courtesy of the United States Air Force.

## PRC Plan Development

***There is one incontrovertible truth about aeromedical evacuation***
***It pertains to ever single Primary Receiving Center...***
***It pertains to every single patient reception area and airfield...***
***It pertains to every single aeromedical mission and flight...***

**PRC Plan Development**

**Overview**

**Notes:**
It has often been said ... to paraphrase ... that, “If you have seen one PRC ... you have seen one PRC”.

Most times when you ask specific questions about emergency management you are told, “Will that depends on the circumstances!”

But ... There is one incontrovertible truth about aeromedical evacuation!

## PRC Plan Development

***The one incontrovertible truth about aeromedical evacuation is ....***
***Every single patient that is taken off the aircraft at your airfield  ...will be one that was loaded onto the plane at the other end***

**PRC Plan Development**

**Overview**

**Notes:**
 Every single patient that is taken off the aircraft at your airfield  ...will be one that was loaded onto the plane at the other end.

## PRC Plan Development

**PRC Plan Development**

**Notes:**
 Wounded service person ... being loaded on a C-17 Globemaster for the flight to Landstuhl, Germany.
Photo courtesy of the United States Air Force.

## PRC Plan Development

***From the one incontrovertible truth about aeromedical evacuation ....***
***We will not fully understand how to plan for our incoming patients ... without understanding the selection criteria and loading process that DoD uses for aeromedical flights***

**PRC Plan Development**

**Overview**

**Notes:**
Primary Receiving Centers will not fully understand how to plan for our incoming patients ... without understanding the selection criteria and loading process that DoD uses for aeromedical flights.

In other words ... 
What is the profile of the nominal aeromedical patient?
Which patient will the DoD prioritize to fly?
How serious might the patient’s injuries be?

We are not Federal Express ... we are not shipping boxes ... medical care and patients are our business.  

But first let’s discuss Joint Operation Planning and Execution System methodology as a frame work for this planning discussion. 

## PRC Plan Development

**  **

**PRC Plan Development**

**Notes:**
Wounded service person ... being transferred from an AmBus to a C-17 Globemaster for the flight to Landstuhl, Germany.
Photo courtesy of the United States Air Force.

## PRC Plan Development

***Medical Considerations***
***Patient stabilized for the anticipated mode and duration of travel***
***Patient’s airway and breathing is adequate for movement***
***Patient’s IV lines, drainage devices, and tubes fully secured ***

**PRC Plan Development**

**Medical Issues Related to AE**

**Notes:**
“What kind of patients should I expect and from what source?”
These next few slides are included to help you understand the potential severity of injuries or illnesses that you should plan for among your patients.

Medical Considerations for Patients Entering the Medical Evacuation System
Medical evacuation request includes requirement for surgical equipment and/or providers.
Patient is sufficiently stabilized for the anticipated mode and duration of travel.
Patient’s airway and breathing is adequate for movement.
Patient’s IV lines, drainage devices, and tubes are fully secured and patent. Would not protected be a better word here? 
Patient at high risk for barotrauma should be considered for prophylactic chest tube placement before prolonged aeromedical evacuation.
Heimlich valves on chest tubes are functioning. This responsibility should be directly assigned to someone.

Reference:
Emergency War Surgery - Chapter 4 - Aeromedical Evacuation - 2004

## PRC Plan Development

**PRC Plan Development**

**Medical Issues Related to AE**

**Notes:**
“What kind of patients should I expect and from what source?”

SMEED equipment rack with support equipment and monitors attached.

Notice the oxygen bottle, infusion pump, IV pump and monitors.  These are all aeromedically certified equipment and must be returned through the Patient Movement Item system.

SMEEDTM
The SMEEDTM (Special Medical Emergency Evacuation Device, Patent Pending) is designed to secure commercial, off-the-shelf monitors, infusion pumps, ventilators, and similar equipment to the standard NATO litter.  This system fits the most commonly used equipment in commercial use and the U.S. military inventory, and is easily customized to fit other devices.  

The need for such a system is evident during mass-casualty training exercises where there is no quick and efficient way to secure vital equipment to litters.  The SMEEDTM system is: rugged; lightweight; inexpensive; compatible with current and future commercial devices; rapidly customizable to meet individual customer and patient needs; and approved for in-flight use aboard military aircraft.  

Technical Data and Capabilities
Composition:  Aluminum and stainless steel parts
Color: Black anodized or powder-coat painted flat black
Weight (empty, approximate): 20 lbs.
Dimensions (approximate):  
 Length: 14 inches 
 Width: 22 inches 
Height: adjustable to three different levels above the patient with height measured at the top of the litter pole to the inside of the top plate:   
 Low: 5 1/16” 
 Middle: 7 9/16” 
 Fully extended: 10 1/16” 

## PRC Plan Development

***Medical Considerations - continued***
***Foley catheters-nasogastric tubes allowed to drain***
***Patient covered - woolen and aluminized blanket***
***3 litter straps required - secure patient to litter***
***Personal effects - medical records accompany patient***

**PRC Plan Development**

**Medical Issues Related to AE**

**Notes:**
“What kind of patients should I expect and from what source?”
These next few slides are included to help you understand the potential severity of injuries or illnesses that you should plan for among your patients.

Medical Considerations for Patients Entering the Medical Evacuation System
Medical evacuation request includes requirement for surgical equipment and/or providers.
Foley catheters and nasogastric (NG) tubes are placed and allowed to drain.
Patient is securely covered with both a woolen and aluminized blanket for air transport, cold environment, or postoperative hypothermia.
3 litter straps are used to secure the patient to the litter.
Personal effects and all medical records accompany the patient.

Reference:
Emergency War Surgery - Chapter 4 - Aeromedical Evacuation - 2004

## PRC Plan Development

**PRC Plan Development**

**Medical Issues Related to AE**

**Notes:**
Wounded service person ... being transferred from an AmBus to a C-17 Globemaster for the flight to Landstuhl, Germany.
Photo courtesy of the United States Air Force.

## PRC Plan Development

***Aviation Environment - Considerations Prior to Transport***
***Wounds for delayed primary closure***
***Should not routinely re-dress wounds***
***Inspect if patient develops fever or sepsis***
***Casts must be bivalved***
***Allow for tissue expansion and access***
***Document neurovascular checks during flight***

**PRC Plan Development**

**Medical Issues Related to AE**

**Notes:**
“What kind of patients should I expect and from what source?”
These next few slides are included to help you understand the potential severity of injuries or illnesses that you should plan for among your patients.

Implications of Aviation Environment
- Wounds dressed for delayed primary closure. Unless directed otherwise, AE crew should not routinely re-dress wounds. If a patient develops fever or sepsis enroute, wounds must be inspected.
- Casts must be bivalved. If the cast is over a surgical wound site, “window” the cast to allow for tissue expansion and emergency access.  Document neurovascular checks prior to and frequently during flight.

Reference:
Emergency War Surgery - Chapter 4 - Aeromedical Evacuation - 2004

## PRC Plan Development

**PRC Plan Development**

**Notes:**
Example of a vented patient on a C-17 Globemaster enroute to Landstuhl, Germany.
Photo courtesy of the United States Air Force.

## PRC Plan Development

***Aviation Environment - Considerations Prior to Transport***
***  ******Decreased Barometric Pressure***
***  ******Consider a Cabin Altitude Restriction (CAR) for ******	******the following:***
***Penetrating eye injuries with intraocular air***
***Free air in any body cavity***
***Severe pulmonary disease***

**PRC Plan Development**

**Medical Issues Related to AE**

**Notes:**
“What kind of patients should I expect and from what source?”
These next few slides are included to help you understand the potential severity of injuries or illnesses that you should plan for among your patients.

Implications of Aviation Environment
Decreased Barometric Pressure.
- The diameter of a gas bubble in liquid doubles at 5,000 ft above sea level, doubles again at 8,000 ft, and doubles again at 18,000 ft. Cabin pressures in most military aircraft are maintained at altitudes between 8,000 and 10,000 feet. If an aircraft has the capability, the cabin altitude can be maintained at lower levels, with increased flight time and fuel.
- Consider a Cabin Altitude Restriction (CAR) for the following:
- Penetrating eye injuries with intraocular air.
- Free air in any body cavity.
- Severe pulmonary disease.

Reference:
Emergency War Surgery - Chapter 4 - Aeromedical Evacuation - 2004

## PRC Plan Development

**PRC Plan Development**

**Notes:**
Aeromedical evacuation of wounded service members from Iraq aboard a C-17 Globemaster enroute to Landstuhl, Germany.
Photo courtesy of the United States Air Force.

## PRC Plan Development

***Aviation Environment - Considerations Prior to Transport***
***  ******Decreased Partial Pressure of Oxygen***
***  ******Neurosurgical Patients***
***Hypoxia may worsen neurological injury***
***Ventilator meets oxygen demand at altitude***
***  ******Gravitational Stress***
***Traumatic brain injury patients***
***Increase intracranial pressure - takeoff or landing***
***Head forward on takeoff, head rearward on landing***

**PRC Plan Development**

**Medical Issues Related to AE**

**Notes:**
“What kind of patients should I expect and from what source?”
These next few slides are included to help you understand the potential severity of injuries or illnesses that you should plan for among your patients.

Implications of Aviation Environment
- Neurosurgical Patients: Hypoxia may worsen neurological injury. Adjust ventilator settings to meet increased oxygen demands at altitude.
- Gravitational Stress: Traumatic brain injury patients can experience transient marked increases in intracranial pressure during takeoff or landing. Patient positioning onboard the aircraft helps minimize this risk (head forward on takeoff, head rearward on landing).

Reference:
Emergency War Surgery - Chapter 4 - Aeromedical Evacuation - 2004

## PRC Plan Development

**PRC Plan Development**

**Notes:**
Medical care at 15,000 feet
SOUTHWEST ASIA -- Capt. (Dr.) Erik von Rosenvinge conducts an initial assessment of his patient before a C-130 Hercules cargo aircraft leaves for Baghdad on Jan. 28. The doctor is a 379th Aeromedical Squadron critical care air transport physician.
(U.S. Air Force photo by Tech. Sgt. Bob Oldham) 
Photo courtesy of the United States Air Force.

## PRC Plan Development

***Aviation Environment - Considerations Prior to Transport***
*** ******Thermal Stress***
*** ******Noise***
***Problems with communication***
***Provide hearing protection***
***Audible medical equipment alarms are useless***
*** ******Decreased Humidity***
***Low cabin humidity at altitude***
***Evaporative losses will increase***
***Patients will require additional fluids***

**PRC Plan Development**

**Medical Issues Related to AE**

**Notes:**
“What kind of patients should I expect and from what source?”
These next few slides are included to help you understand the potential severity of injuries or illnesses that you should plan for among your patients.

Implications of Aviation Environment
Thermal Stress: Plan for cabin temperature changes from 15°C (59°F) to 25°C (77°F) on winter missions, and from 20°C (68°F) to 35°C (95°F) on summer missions.
Noise: Exposure to noise can produce problems with communication and patient evaluation (auscultation is impossible — use noninvasive blood pressure [NIBP] and an arterial line). Provide hearing protection. Audible medical equipment alarms are useless.
Decreased Humidity: Airplanes have very low cabin humidity at altitude. Evaporative losses will increase; therefore, patients will require additional fluids, especially
those with large burns, and those at risk for mucous plugging.

Reference:
Emergency War Surgery - Chapter 4 - Aeromedical Evacuation - 2004

## PRC Plan Development

**PRC Plan Development**

**Notes:**
Medical team and C-17 Globemaster III aircrew carefully move the more than 800-pound mobile extracorporeal membrane oxygenation, or ECMO, machine and Meaghan Ababa down the aircraft ramp to a waiting ambulance.
Photo courtesy of the United States Air Force.

## PRC Plan Development

***CCATT - Critical Care Air Transport Teams***
***  ******A four-person burn transport team***
***    ******required inhalation injury and/or severe burns***
***  ******Determine patient movement items (PMI)***
***Ventilators***
***Pulse oximeters***
***All items cleared for in-flight use***

**PRC Plan Development**

**Medical Issues Related to AE**

**Notes:**
“What kind of patients should I expect and from what source?”
These next few slides are included to help you understand the potential severity of injuries or illnesses that you should plan for among your patients.

This slide is included to assist you in notifying your clinical staff as to what level of care this type of patient would require.

CCATT - Critical Care Air Transport Teams
- A four-person burn transport team can augment a CCATT team as required for inhalation injury and/or severe burns.
- Determine if special requirements exist for transport; eg, CAR, and splinting.
- Determine patient movement items (PMI) required (eg, ventilators, pulse oximeters, among others). Flight surgeon must verify that all items accompanying the patient are cleared for in-flight use.

Reference:
Emergency War Surgery - Chapter 4 - Aeromedical Evacuation - 2004

## PRC Plan Development

**PRC Plan Development**

**Notes:**
Critical Care Air Transport Team - CCATT team cares for patient during aeromedical evacuation mission aboard a C-17 Globemaster enroute to Landstuhl, Germany.
Photo courtesy of the United States Air Force.

## PRC Plan Development

***Department of Defense with VA backup - principal health care for the Armed Forces during an armed conflict***
***Commander of the United States (U.S.) Northern Command will coordinate military medical operations***
***Primary Receiving Centers throughout the United States***
***PRC develop plans to accomplish this mission***

**PRC Plan Development**

**Mission**

**Notes:**
Mission
Department of Defense with the VA as backup serves as the principal health care for the Armed Forces during and immediately following an armed conflict.  
During a period of war or national emergency that involves armed conflict, the Commander of the United States (U.S.) Northern Command will coordinate military medical operations.
Pursuant to this mission Primary Receiving Centers have been identified throughout the United States.  Your facility has been identified as a Primary Receiving Center.  This block of instruction is designed to assist you in developing a plan to accomplish this mission.

## PRC Plan Development

***Patients could arrive within 24 hours of activation***
***May be direct from wartime theater to PRC***
***May be from other CONUS medical facilities***
***Patients needs come first ***
***Keep in touch in case the 24 hour window collapses***

**PRC Plan Development**

**Mission**

**Notes:**
Your overall concept of how to accomplish your patient reception mission.

The program reads that patients could arrive within 24 hours of activation of your Primary Receiving Center.  Patients may be routed directly from a wartime theater to a civilian or military airport near the destination Primary Receiving Center, or may be transported from other CONUS medical facilities.  In any case the needs of the patients come first.  We need to keep in touch with the patient movement authorities, in case the 24 window collapses.

## PRC Plan Development

***Nothing is specified regarding a Primary Receiving Center Plan format***
***If a local policy applies, follow the local guidance***
***If no local guidance pertains, here is a suggested outline following the sequence of development, activation, and mission conduct***

**PRC Plan Development**

**Plan Format**

**Notes:**
Plan Format – Nothing is specified regarding a Primary Receiving Center Plan format.  If a local policy applies, follow the local guidance.  If no local guidance pertains, here is a suggested outline following the sequence of development, activation, and mission conduct.

For military:
Five paragraph format for military plans.

1. ( ) Situation
2. ( ) Mission
3. ( ) Execution
4. ( ) Administration and Logistics
5. ( ) Command and Control

## PRC Plan Development

***Active duty patients will be placed into medical facilities that can best meet the following criteria:***
***	******Deliver the most appropriate medical care***
***	******Nearest to home or unit of record***
***	******Seamless transition - military to veteran***

**PRC Plan Development**

**Mission**

**Notes:**
Your overall concept of how to accomplish your patient reception mission.

Active duty patients will be placed into medical facilities that can best meet the following criteria:
	(1)  Capability to deliver the most appropriate medical care,
	(2)  Nearest to home or unit of record, and
	(3)  Capability to provide seamless transition from military to veteran status.

## PRC Plan Development

***During a time of military conflict or national emergency, Primary Receiving Centers will provide the maximum number of staffed beds possible to active duty military patients***
***Beds in Primary Receiving Center facilities reported as available to the DOD GPMRC may be fully utilized by DOD patients***

**PRC Plan Development**

**Mission**

**Notes:**
Your overall concept of how to accomplish your patient reception mission.

During a time of military conflict or national emergency, Primary Receiving Centers will provide the maximum number of staffed beds possible to active duty military patients.  
Beds in Primary Receiving Center facilities reported as available to the DOD GPMRC may be fully utilized by DOD patients.

## PRC Plan Development

***Determine Medical Capacity and Capability***
***Primary Receiving Centers measure medical capacity and capability in terms of available beds***
***Each Primary Receiving Center will conduct an initial bed estimation assessment to determine how many beds can be made available to DoD in an emergency***

**PRC Plan Development**

**Mission**

**Notes:**
Your overall concept of how to accomplish your patient reception mission.

Determine Medical Capacity and Capability
Primary Receiving Centers measure medical capacity and capability in terms of available beds.  Each Primary Receiving Center will conduct an initial bed estimation assessment to determine how many beds can be made available to DoD in an emergency.

## PRC Plan Development

***Primary Receiving Centers use the following categories of medical care to identify the nature of a patient’s illness or injury when determining the capability and capacity of their medical facility.  ***
***The five contingency categories (as well as their TRAC2ES codes in parentheses) are:***
***  ******Critical Care (CC)***
***  ******Medical and Surgery (MM-SS)***
***(3)  Psychiatry (MP)***
***  ******Burns (SBN)***
***(5)  Pediatrics (MC)***

**PRC Plan Development**

**Mission**

**Notes:**
Your overall concept of how to accomplish your patient reception mission.

Primary Receiving Centers use the following categories of medical care to identify the nature of a patient’s illness or injury when determining the capability and capacity of their medical facility.  The five contingency categories (as well as their TRAC2ES codes in parentheses) are:
	(1)  Critical Care (CC),
	(2)  Medical and Surgery (MM-SS),
	(3)  Psychiatry (MP),
	(4)  Burns (SBN), and
	(5)  Pediatrics (MC). 

## PRC Plan Development

***Available Beds***
***Those beds to which patients can immediately be transported***
***They must be set up and ready for all aspects for the care of a patient***
***Include space, equipment, material, support services and staff***

**PRC Plan Development**

**Mission**

**Notes:**
Your overall concept of how to accomplish your patient reception mission.

Available beds are those beds to which patients can immediately be transported.  They must be set up and ready for all aspects for the care of a patient.  Available beds must include supporting space, equipment, medical material, ancillary and support services and staff to operate under normal circumstances.
Primary Receiving Centers will determine how many beds can be made available to DoD patients in an emergency.  However when reporting beds, Primary Receiving Centers will report only those beds that are immediately available as of the bed report date and time.  This means empty, fully staffed beds- not beds that we hope can be made available by sending patients home or that we think can be set up in the near future. 

## PRC Plan Development

***Primary Receiving Centers***
***Determine how many beds can be made available to DoD patients***
***Report beds that are immediately available***
***Empty, fully staffed beds***
***Not beds that can be made available by sending patients***

**PRC Plan Development**

**Mission**

**Notes:**
Your overall concept of how to accomplish your patient reception mission.

Available beds are those beds to which patients can immediately be transported.  They must be set up and ready for all aspects for the care of a patient.  Available beds must include supporting space, equipment, medical material, ancillary and support services and staff to operate under normal circumstances.
Primary Receiving Centers will determine how many beds can be made available to DoD patients in an emergency.  However when reporting beds, Primary Receiving Centers will report only those beds that are immediately available as of the bed report date and time.  This means empty, fully staffed beds- not beds that we hope can be made available by sending patients home or that we think can be set up in the near future. 

## PRC Plan Development

***Primary Receiving Centers Plans ***
***Receive patients and transport to definitive medical care***
***Focus on aero-medical evacuation in DoD aircraft***
***Primary airfield located within the Patient Reception Area***
***Airfield assigned by DoD - listed in TRAC2ES***
***Alternate means of patient transport - alternate plans developed***
***Establish and exercise primary airfield oriented mission***

**PRC Plan Development**

**Develop Course of Action**

**Notes:**
Your overall concept of how to accomplish your patient reception mission.

PRC Plan Development
Primary Receiving Centers must develop a plan to receive patients and transport them to definitive medical care.  The typical mission is focused on aero-medical evacuation in DoD aircraft.  Hence, the Primary Receiving Center plan must start with a primary airfield located within the Patient Reception Area.  The primary airfield is assigned by the DoD and information about your primary airfield can be located in TRAC2ES.

While, alternate means of patient transport must be considered and eventually alternate plans should be developed, Primary Receiving Centers should focus initially on establishing and exercising their primary airfield oriented mission.

## PRC Plan Development

***Primary Receiving Center Mission Elements***
***Conditions - existing programs - procedures vary by location***
***Primary Receiving Centers makes best use of local resources***
***Local working group personnel who understand care within the area***

**PRC Plan Development**

**Develop Course of Action**

**Notes:**
Your overall concept of how to accomplish your patient reception mission.

PRC Mission Elements
Conditions, existing programs, and procedures will vary within different locations.  Primary Receiving Centers need to conduct research into available existing systems to ensure that the PRC Operations Plan makes best use of local resources.
One way to accomplish this is for Primary Receiving Centers to establish a local working group, of some type, made up of local personnel that understand how medical care is managed within the Patient Reception Area.

## PRC Plan Development

***Primary Receiving Center Mission Elements***
***Plans - substantially different across country***
***Some common mission elements***
***Should be addressed in most PRC plans***
***Management of each mission element ***

**PRC Plan Development**

**Develop Course of Action**

**Notes:**
Your overall concept of how to accomplish your patient reception mission.

Primary Receiving Center plans, for this reason, may be substantially different from area to area across the country.  Nonetheless, there are some common PRC mission elements, which should be addressed in most PRC plans.  What follows is a discussion about how to approach management of each of these mission elements. 

## PRC Plan Development

***Primary Receiving Centers - Common Mission Elements***
***1)  Notification, confirmation, and acknowledgement of mission orders***
***Alert, activation, or orders - via chain of command***
***Local confirmation and authentication policies***
***Specific conditions under which the order is issued***
***Acknowledgement confirms PRC ready and able to receive patients***
***In the numbers and categories reported on bed report***
***Consistent with the throughput***
***If the PRC cannot function at this level the throughput must be officially adjusted through GPMRC prior to the commencement of air operations***
***Contact any state, county, and city agencies - coordination ***

**PRC Plan Development**

**Plan in Detail**

**Notes:**
Establishing specific tasks or mission elements to accomplish your patient reception mission.

Primary Receiving Centers need to develop plans that address all of the following common mission elements:

1)  Notification, confirmation, and acknowledgement of mission orders.
Primary Receiving Centers would be alerted, activated, or otherwise directed to receive patients, via their chain of command.  It is essential to follow your local confirmation policies to ensure that the order is authentic and to understand the specific conditions under which the order is issued.  Acknowledgement of such orders serves to confirm that the PRC is ready and able to receive patients in the numbers and categories up to the total bed capacity reported on the most recent bed report, consistent with the throughput.  If the PRC cannot function at this level for any reason the throughput must be officially adjusted through GPMRC prior to the commencement of air operations.

During this phase of activity the PRC should contact any state, county, and city agencies to make coordination or notifications consist with local policies and agreements. 

## PRC Plan Development

***Primary Receiving Centers - Common Mission Elements***
*** ******Receipt of information about inbound patients***
***Specific information - each sortie regulated to PRA  ***
***Information should include at a minimum:***
***Number and category of each patient***
***Means of conveyance: air, ground, or rail***
***Airfield location, bus station address or rail station***
***Compare list of patients - available beds***
***Notify GPMRC of any contra-indications***

**PRC Plan Development**

**Plan in Detail**

**Notes:**
Establishing specific tasks or mission elements to accomplish your patient reception mission.

2)  Receipt of information about inbound patients.
Primary Receiving Centers should expect to be told specific information about each sortie regulated to their PRA.  Information should include at a minimum:
•	Number and category of each patient
•	Means of conveyance; air, ground, or rail, etc.
•	Point of embarkation; airfield location, bus station address; or rail station, etc.

At this point the Primary Receiving Centers should compare the list of patients against the available beds and notify GPMRC of any contra-indications.

## PRC Plan Development

***Primary Receiving Centers - Common Mission Elements***
***3)  Mobilize Patient Reception Team & Transportation Assets***
***Activate their task organized Patient Reception Teams***
***PRTs deployed with time phased assessments based on:***
***Expected time of arrival of the patients***
***Staging and setup time estimates***
***Other rate limiting processes***

**PRC Plan Development**

**Plan in Detail**

**Notes:**
Establishing specific tasks or mission elements to accomplish your patient reception mission.

3)  Mobilization of Patient Reception Team & Transportation Assets
Primary Receiving Centers, when in receipt of proper orders, will activate their task organized Patient Reception Teams (PRT).

PRTs should be deployed consistent with time phased assessments based on:
–	Expected time of arrival of the patients
–	Staging and setup time estimates
–	Other rate limiting processes 

## PRC Plan Development

***Primary Receiving Centers - Common Mission Elements***
***3)  Mobilization of Patient Reception Team and Transportation ******	******Assets***
***PRTs skill sets - quantities consistent with the scale of the mission:***
***Medical personnel - interface with flight crew and assess patients***
***Administrative - record pertinent information about each patient***
***Logistical support-anything the PRT needs ***
***Lifting teams-strong health personnel***
***Plan for 4 person lifts-some may require 6 or 8***
***Factor fatigue based on prevailing conditions***

**PRC Plan Development**

**Plan in Detail**

**Notes:**
Establishing specific tasks or mission elements to accomplish your patient reception mission.

3)  Mobilization of Patient Reception Team & Transportation Assets
PRTs would normally contain personnel the following skill sets in quantities consistent with the scale of the mission:
–	Medical personnel - to interface with flight crew and to assess patients
–	Administrative - to record pertinent information about each patient
–	Logistical support – anything the PRT needs 
–	Lifting teams – strong health personnel
o	plan for four person lifts
o	factor fatigue based on prevailing conditions

## PRC Plan Development

***Receiving Centers - Common Mission Elements***
***3)  Mobilization of Patient Reception Team & Transportation ******	******Assets***
***Primary Receiving Centers ***
***Arrange transportation to medical center  ******	***
***Based on available assets***
***Including the following depending on your locality:***
***County EMS Ambulances***
***Contract Ambulances***
***Organic vehicles from within your organization***
***Ambuses***
***DVA vans***
***Other Local support such as Transportation Authority Buses***

**PRC Plan Development**

**Plan in Detail**

**Notes:**
Establishing specific tasks or mission elements to accomplish your patient reception mission.

3)  Mobilization of Patient Reception Team & Transportation Assets
Primary Receiving Centers should simultaneously arrange for transportation of the patients to the PRC medical center.  The transportation planned should be based on available assets.

Which could include any or all of the following depending on your locality:
-	County EMS Ambulances
-	Contract Ambulances
-	Organic vehicles from within your organization
o	Ambuses
o	DVA vans
-	Other Local support such as Transportation Authority Buses

## PRC Plan Development

**PRC Plan Development**

**Notes:**
Ambulance support at the Long Beach Patient Reception Exercise.
June 2006 – Photo courtesy of Jenny Gonzalez, AEM, Network 22.

## PRC Plan Development

***Primary Receiving Centers - Common Mission Elements***
***4)  Receive Patients at Point of Embarkation***
***Aircraft or other means of conveyance ***
***PRT Medical personnel meet Medical Crew Director ***
***Medical briefing - Updates PRC medical personnel***
***Current condition of the patients***
***Exigent circumstances that developed in transport***
***Patients prioritized for movement based on medical necessity***

**PRC Plan Development**

**Plan in Detail**

**Notes:**
Establishing specific tasks or mission elements to accomplish your patient reception mission.

4)  Receive Patients at Point of Embarkation
Once the aircraft lands, or other means of conveyance arrives, the PRT Medical personnel should plan to move foreword and meet the Medical Crew Director or other person in charge of the patients while in transport.  A medical briefing should occur to update the PRC medical personnel as to the current condition of the patients and any exigent circumstances that my have developed in transport.  Patients will be prioritized for movement to the PRC medical center based on medical necessity.

## PRC Plan Development

***Primary Receiving Centers - Common Mission Elements***
***5)  Assess Patient Condition***
***PRC medical personnel assess the patients***
***Contra-indications for further transport must be addressed***
***6)  Transport Patients to PRC Medical Center***
***Stabilization or other treatments are undertaken***
***Suitable transportation means employed ******	******for each patient***

**PRC Plan Development**

**Plan in Detail**

**Notes:**
Establishing specific tasks or mission elements to accomplish your patient reception mission.

5)  Assess Patient Condition
PRC medical personnel should be prepared to assess the patients to determine if further transportation to the PRC medical center is advisable.  Contra-indications for further transport should be addressed by the PRC medical personnel.

6)  Transport Patients to PRC Medical Center
Such medical preparations as stabilization or other treatments should be undertaken and an appropriate and suitable means of transportation should be employed for each patient. 

## PRC Plan Development

***Primary Receiving Centers - Common Mission Elements***
***7)  Receive Patients at PRC Medical Center***
***Existing hospital plans for an influx of patients***
***Implement influx of patients plans***
***Commence admission of patients at specific estimated time***
***8)  Admit Patients***
***Any necessary elements beyond hospital admission plans***

**PRC Plan Development**

**Plan in Detail**

**Notes:**
Establishing specific tasks or mission elements to accomplish your patient reception mission.

7)  Receive Patients at PRC Medical Center
The PRC plan should contain any necessary elements beyond the existing hospital plans for an influx of patients.  The PRC medical center should be advised to implement any such plan dealing with an influx of patients plans, and to be ready to commence admission of patients at a specific estimated time.

8)  Admit Patients
The PRC plan should contain any necessary elements beyond the existing hospital plans for admission of patients.

## PRC Plan Development

***Primary Receiving Centers - Common Mission Elements***
***9)  Treat Patients***
***Same high standard for all patients***
***Altered standards of care - decision made by the senior clinician***
***Communicated to the chief of staff at the receiving hospital***

**PRC Plan Development**

**Plan in Detail**

**Notes:**
Establishing specific tasks or mission elements to accomplish your patient reception mission.

9)  Treat Patients
Patient treatment should occur at the same high standard for all patients. In the highly unlikely circumstance when altered standards of care are invoked such decision is made by the senior clinician on site and the PRA and communicated to the chief of staff at the receiving hospital. 

10)  Information Management and Record Keeping
The PRC plan should call for management of information to external authorities by a designated Public Information Officer (PIO).  Additionally the PRC plan should include any record keeping procedures beyond the PRC medical center’s normal record keeping.

## PRC Plan Development

***Primary Receiving Centers - Common Mission Elements***
***10)  Information Management and Record Keeping***
***Management of information to external authorities***
***Designated Public Information Officer (PIO)***
***Record keeping procedures - Beyond normal record keeping***

**PRC Plan Development**

**Plan in Detail**

**Notes:**
Establishing specific tasks or mission elements to accomplish your patient reception mission.

9)  Treat Patients
Patient treatment should occur at the same high standard for all patients. In the highly unlikely circumstance when altered standards of care are invoked such decision is made by the senior clinician on site and the PRA and communicated to the chief of staff at the receiving hospital. 

10)  Information Management and Record Keeping
The PRC plan should call for management of information to external authorities by a designated Public Information Officer (PIO).  Additionally the PRC plan should include any record keeping procedures beyond the PRC medical center’s normal record keeping.

## PRC Plan Development

***Primary Receiving Centers - Common Mission Elements***
***11)  Release of Patient to Next Phase***
***Eventual discharge and release of the patients***
***Outcomes that may need to be considered:***
***Back to unit***
***Transport to home***
***Discharge to civilian sector***
***Possible death of patient***

**PRC Plan Development**

**Plan in Detail**

**Notes:**
Establishing specific tasks or mission elements to accomplish your patient reception mission.

11)  Release of Patient to Next Phase
The PRC Plan should address eventual discharge and release of the patients.  Below are several possible outcomes that may need to be considered:
	- Back to unit
	- Transport to home
	- Discharge to civilian sector
	- Possible death of patient

## PRC Plan Development

***Primary Receiving Centers - Common Mission Elements***
***   ******Special Considerations***
***Night Operation***
***Inclement weather***
***Communications***
***Reach back to PRC hospital***
***Communications with GPMRC***
***Communications with local EMS***

**PRC Plan Development**

**Plan in Detail**

**Notes:**
Establishing specific tasks or mission elements to accomplish your patient reception mission.

11)  Release of Patient to Next Phase
The PRC Plan should address eventual discharge and release of the patients.  Below are several possible outcomes that may need to be considered:
	- Back to unit
	- Transport to home
	- Discharge to civilian sector
	- Possible death of patient

## PRC Plan Development

*** ******Definition of a Memorandum of Agreement***
*** ******Legal review***
*** ******Location specific***

**PRC Plan Development**

**Notes:**
A Memorandum of Agreement is a document among two or more parties that lists, in general terms, what the parties are supposed to do during the period of the agreement. A generic MOA for an airport PRA is in your folder. 
An MOA needs to be looked at by legal authority and the director of the managing agency and the director  or manager of the receiving location.

Generally the MOA is in effect unless one of the signers backs out of the agreement. However, like any agreement it should be reviewed periodically. We suggest once every three years.  

An MOA is location specific.  You should get an MOA with every location that might serve as a Patient Reception Area.  This would include train stations, bus stations, and facilities with large parking lots which would be nearly empty during the anticipated time of use. 

This is a legal document and one might expect some hesitancy on the part of the manager’s of parking lots to sign something like this.  Getting the signatures on this document will require some salesmanship.  

## Definition of a contract
Who are the parties that want to make the contract? 
Managing Agency
Management of the Location 

***Who are the parties that want to make the contract? ***
***Managing Agency***
***Management of the Location***

**PRC Plan Development**

**Contractual Development**

**Notes:**
There are three elements to any legally binding contract. Mutual consent, Offer and Acceptance, and exchange of something of value or promise there of.  There are snags in any contract often the something of value might be a retainer fee.  Normally we will not pay a retainer fee for a contract relative to a PRA.  However it is not a bad idea to have contracts on stand by ready to signed at a moments notice.  

2.  Ultimately any contract is only as good as the parties that make it.  The janitor cannot sign the agreement for either the PRA facility or the managing agency.  You can expect to deal with staff level people but the final contract should be signed by the highest authority available in the company, within reason.  In general they will tell you who that is. 

## If you have a PRC committee
If you don’t have a PRC committee

***If you don’t have a PRC committee***

**PRC Plan Development**

**Contractual Agreement**

**Notes:**
If you have a PRC committee try to get the principal members of that committee to make a contract for delivering their services.  

If you do not have a committee you should try to get a contract with
-Elected Officials 
-Local Law enforcement 
-Local Fire Chief 
-Local Emergency Medical Services 
-Supplies of medical equipment 
-Suppliers of ready to eat food
-Cleaning Services
-Ambulance Companies
-Media

We already assume you have a Memorandum of Agreement with the location and you as the representative of the managing agency. 

## Salesmanship
Education
Finances 

***Education***
***Finances ***

**PRC Plan Development**

**Contractual Relationship**

**Notes:**
Salesmanship.  You have nothing to offer them but, as Winston Churchill said, 
“Blood, Sweat, and Tears”.  The elected officials are especially conscious of publicity and you should make every effort to present what you want them to do in a positive light.  You should never fail offer them your presence at what could be a media event such as a signing of an agreement.  You are asking them to help you do your job, it is not the other way around.  

Education:  You job is not only to educate yourself about what goes on in a Patient Reception Area but to educate the other parties that are involved or want to be involved your PRC.  Listing, exercising and drilling on their exact duties are part of your responsibilities.

Finances: At the back of everyone’s mind is who pays the bill.  Its not a topic that should be glossed over.  Have the answer clear in your own mind.  Where will expenses come from.  Even the most generous people will eventually say to themselves “I’m at my limit.  They want me to spend my money to solve their problems.  Show me the money.” 

## Know who they are 
Meet with them 
Maintain contact information 

***Meet with them ***
***Maintain contact information***

**PRC Plan Development**

**Coordination with Local Authorities**

**Notes:**
You should make an effort to network with the people in your community who would be involved in the operation of the PRA.  

First that means drafting a list of who they are.  Your list should have “24 hour contact information” which means you need only the phone numbers that would allow you to get in touch with him in 24 hours. Often that is his/her business line.  You don’t need to press them for home telephone lines and cell phones all though if they give you those numbers record them.  But you take on the burden of keeping the personal data secure.  They give you privileged information they expect you to keep it confidential.  
You should meet with them.  Face to face, preferably at a time and place convenient for them. That means almost everyone from the incident commander to the Red Cross people to the local authorities.  Of course your time is important too.  You be the judge of whom you want to meet and how much time you can dedicate to this collateral duty.  

You also have to maintain the contact data for all of these people.  It should be reviewed at least once a year and it can be don by a simple e-mail.