Page 94 - 2020 JSOM Winter

Isolating Populations to Control Pandemic Spread
in an Austere Military Environment

2
1
Andrew B. Hall, MD *; Michael D. Dixon, BSN, CRNA, MSN ;
3
Andrew J. Dennis, BSN ; Ramey L. Wilson, MD, MPH 4

ABSTRACT
Background: The COVID-19 pandemic has been a struggle for patients move through the different “Roles” of care. At the
medical systems throughout the world. In austere locations in lowest level is a Role 1, consisting of outpatient medical care
which testing, resupply, and evacuation have been limited or and emergency resuscitation, and transitioning up to a Role
impossible, unique challenges exist. This case series demon- 4, which is a large inpatient medical center level of care. In
2
strates the importance of population isolation in preventing theory, patients are initially seen at the lowest level of care
disease from overwhelming medical assets. Methods: This is and transitioned through the evacuation chain to higher levels
a case series describing the outbreak of COVID-19 in an iso- of care, eventually arriving at the Role 4 facilities located in
lated population in Africa. The population consists of a main the United States. By doctrine, this construct, when applied to
population with a Role 2 capability, with several supported US Forces serving in remote locations in Africa, would have
satellite populations with a Role 1 capability. Outbreaks in ill patients transferred through bases with large populations
five satellite population centers occurred over the course of and medical assets en route to the highest levels of care in
the COVID-19 pandemic from its start on approximately Europe. When dealing with infectious disease, unlike trauma,
1 March 2020 until 28 April 2020, when a more robust medi- there are risks of contaminating crew, local populations, and
cal asset became available at the central evacuation hub within resources. Specific infectious disease transport exists, but this
the main population. Results: Population movement controls capability is limited; therefore, during a large pandemic, the
and the use of telehealth prevented the spread within the main question becomes whether patients should be transported or
3
population at risk and enabled the setup of medical assets to left in place if clinically stable. If the patient is brought to an
prepare for anticipated widespread disease. Conclusion: Isola- unexposed population and the disease spreads, there is risk of
tion of disease in the satellite populations and treating in place, overwhelming the medical assets available for the larger pop-
rather than immediately moving to the larger population cen- ulation and infecting evacuation assets. If left in place, there
ter’s medical facilities, prevented widespread exposure. Isola- is a risk of the patient decompensating at a location with-
tion also protected critical patient transport capabilities for out the needed medical capabilities. This paper discusses the
use for high-risk patients. In addition, this strategy provided solutions found to mitigate this risk in isolated and austere
time and resources to develop infrastructure to handle antici- populations for managing COVID-19 infections early in the
pated larger outbreaks. pandemic.

Keywords: COVID-19; coronavirus; austere; military
Methods
Clinically diagnosed outbreaks of COVID-19 within the iso-
Introduction lated American military population were reviewed between
1 March 2020 and 28 April 2020. March 1 corresponds to the
The COVID-19 outbreak began in the United States on ap- rough start of the global pandemic involving the United States
proximately 1 March 2020. Special Operations Command and ends with the arrival of a more robust medical asset in the
1
Africa (SOCAF) and its austere locations began to prepare isolated population, specifically sent to augment medical care
and plan for a medical response. Initial guidance was for an for COVID-19 patients. An outbreak was defined as the first
approximate 50% infection rate without guarantees of medi- clinically diagnosed case (in accordance with the current Cen-
cal evacuation and difficulty with resupply. American medical ters for Disease Control and Prevention [CDC] case definition)
assets on the continent were distributed at multiple sites in the at any location. COVID-19 testing was not available during
operational region. this period, and all cases were clinically diagnosed. The to-
tal population in this study consisted of a “main population,”
After many years of being in sustained combat operations including the main medical and surgical treatment team, and
around the world, the US military has developed an echeloned the majority of the military population and “satellite popu-
expeditionary system for delivering medical and trauma sup- lations.” The latter consisted of small groups of people who
port to patients. It provides increasing medical capabilities as used resources from the main population.
*Correspondence to Eglin Air Force Base Hospital, 307 Boatner Rd., Eglin AFB, FL 32542; or andrew.b.hall14.mil@mail.mil
2
1 Maj Hall is a general surgeon at Eglin Air Force Base, Eglin AFB, FL; and part of Special Operations Command Africa. LtCol Dixon is a cer-
4
3
tified registered nurse anesthetist and Capt Dennis is a nurse, both of the Special Operations Command Africa. COL Wilson is the Command
Surgeon for Special Operations Command Africa and is the deputy director for Military Internal Medicine at the Uniformed Services University,
Bethesda, MD.
92