Page 58 - Journal of Special Operations Medicine - Spring 2014

Evaluation of Contingency Telemedical Support
to Improve Casualty Care at a Simulated Military

Intermediate Resuscitation Facility:
The EM-ANGEL Study

Robert Gerhardt, MD, MPH, FACEP; Johnathon Berry, DO; Robert L. Mabry, MD, FACEP;
Lawrence Flournoy, BSPE; Robert G. Arnold, PhD; Christopher Hults, MD, FACS;
John B. Robinson, PA-C; Robert A. Thaxton, MD, FACEP; Ramon Cestero, MD, FACS;
Jason D. Heiner, MD; Alexandra R. Koller, BS; Kevin M. Cox, RN, MSN; Jay N. Patterson;
Warren R. Dalton, MD, FACEP; Anne L. McKeague, PhD; Gary Gilbert, PhD;
Carl Manemeit, MA; Bruce D. Adams, MD, FACEP

ABSTRACT
Objective: We sought to determine whether Contingency 95) was 12 minutes (10–14) for CTS versus 18 (16–20)
Telemedical Support (CTS) improves the success rate and for controls, with 75% of control teams not complet-
efficiency of primary care providers performing critical ing all critical actions. Conclusion: In this model, real-
actions during simulated combat trauma resuscitation. time telementoring of simulated trauma resuscitation
Critical actions included advanced airway, chest decom- was feasible and improved accuracy and efficiency of
pression, extremity hemorrhage control, hypothermia non–emergency-trained resuscitators. Clinical validation
pre vention, antibiotics and analgesics, and hypotensive and replicated study of these findings for guiding remote
resuscitation, among others. Background: Recent studies damage control resuscitation are warranted.
report improved survival associated with skilled triage
and treatment in the out-of-hospital/preoperative phase Keywords: military medicine, war, emergency medical ser-
of combat casualty care. Historically, ground combat vices, resuscitation, telemedicine, wounds and injuries
units are assigned primary care physicians and physician
assistants as medical staff, due to resource limitations.
Although they are recognized as optimal resuscitators,
demand for military trauma surgeons and emergency Introduction
physicians exceeds supply and is unlikely to improve in Victims of trauma who experience ongoing and uncon-
the near term. Methods: A prospective trial of telemedical trolled major hemorrhage (UMH), coupled with pro-
mentoring during a casualty resuscitation encounter was longed evacuation periods prior to surgical intervention,
studied using a high-fidelity patient simulator (HFPS). are more likely to die. Both the contemporary battle-
1
Subjects were randomized and formed into experimental field and the emerging domestic phenomenon of region-
(CTS) or control teams. CTS team leaders were equipped alized emergency care networks reflect this scenario.
with a headset/microphone interface and telementored
by a combat-experienced emergency physician or trauma The use of telemedicine in trauma is not a new con-
surgeon. A standardized, scripted clinical scenario and cept. Several prior studies have investigated the effects
HFPS were used with 14 critical actions. At completion, of care in rural intermediate resuscitation facilities, us-
subjects were surveyed. Statistical approach included ing telementoring between their emergency departments
contingency table analysis, two-tailed t-test, and correla- and receiving trauma centers within their network of
tion coefficient. This study was reviewed and approved care. Prior studies comparing rural and urban-based
2,3
by our institutional review board (IRB). Results: Eigh- emergency medical services (EMS) organizations identi-
teen CTS teams and 16 control teams were studied. By fied associations between distance from a metropolitan
4,5
intention-to-treat ITT analysis, 89% of CTS teams versus hub and a decrement in scope-of-practice rendered.
56% of controls completed all life-threatening inventions If clinical demonstrations validate our hypothesis, CTS
(LSIs) (p < .01); 78% versus 19% completed all critical adapted for domestic use may provide a bridge across
6,7
actions (p < .01); and 89% versus 56% established ad- this geospatial “quality chasm.” It is likely that telep-
vanced airways within 8 minutes (p < .06). Average time resence in multiple forms will become a critical under-
to completion in minutes (95% confidence interval [CI] pinning of emerging regionalized healthcare networks. 8

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