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# Medical professionals from BAMC, Argentine Army discuss COVID best practices

By  Robert A. Whetstone

                JOINT BASE SAN ANTONIO-FORT SAM HOUSTON, Texas  –              
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.

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 was 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 best practices focused not only on readiness, but how to treat both COVID and non-COVID patients, staff protection, research and development, and testing protocols. A total of 17 medical practitioners (6 from BAMC; 11 from CMMH) participated in the virtual SMEE.

**Staff Protection**

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 local 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,” said U.S. Army Col. Michael Wirt, BAMC deputy commanding officer. “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 COVID crisis.”

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 and non-COVID patients are treated in separate areas. The CMMH team stated that COVID areas follow strict protocols, requiring personal protective equipment in all entrance points. COVID wards are routinely disinfected and CMMH employs a security committee that ensures the non-COVID area stays COVID free.

Supply and demand, particularly with PPE and COVID 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 their hospital staff of over 2,400 every 15 days. They test about 5,000 for COVID on a daily basis.

**Readiness and Protocols**

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.

“Certainly in San Antonio and the local area coordinating with the non-military healthcare systems, the trauma and emergency management platform was utilized for the pandemic,” said U.S. Air Force Col. Patrick Osborn, BAMC deputy commander for surgical services. “That allowed for discussions on resources, testing, and policies on managing the pandemic, from a regional standpoint.”

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 allowed. The ECMO program provided significant community support for the sickest COVID-19 patients while furthering the readiness of numerous critical care personnel. For more about BAMC go to: https://www.bamc.health.mil/

“Through the infectious disease and public health communities, we have been working with public health in the state,” said U.S. Air Force Col. Heather Yun, BAMC deputy commander for medical services. “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 guidelines).”

Because of the fluid nature of, and constant learning surrounding COVID, protocols have been continuously 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 (virtual), while protocols for critical patients are changing.

**Facing Challenges**

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 kinds of settings. Argentina is in the Southern Hemisphere, requiring CMMH to handle the COVID pandemic simultaneously with 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.

Practices and procedures that require high exposure is an obstacle medical treatment facilities have to negotiate in order to maintain a safe environment during the pandemic.

When community transmission has been high, many non-emergent 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,” said Yun. All patients are treated as a potential COVID patient, guarding against the risk of transmission, she stated.

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 would have otherwise been face-to-face.

**Research and Development**

BAMC is one of the participating sites of the clinical trials for Remdesivir as a treatment for COVID 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, to include BAMC, have been identified to participate in the Phase III trial evaluating the vaccine candidate AZD1222 under development by AstraZeneca.  For information, visit https://www.hhs.gov/coronavirus/explaining-operation-warp-speed/index.html

The COVID 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,” explained Wirt. “At the same time, we learn and share information that can lead to improving efficiencies as we deal with COVID, and that makes us better prepared for the next challenge.”

For more information about ARSOUTH, go to: https://www.arsouth.army.mil/

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ArgentinaCOVID-19U.S. Army SouthMedical