Page 59 - Journal of Special Operations Medicine - Spring 2014

The primary contributors to mortality in such circum- supporting combatant units, such as battalion task
stances are progressive tissue hypoxia and the “lethal forces, brigade combat teams (BCTs), and special mis-
triad” of acute traumatic coagulopathy, hypothermia, sion units (SMUs). As such, DREAMS represents a po-
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and acidosis. 9-11 Recently, the term “exsanguination tential and promising approach to link remotely located
shock” was coined to further distinguish this premorbid tactical medical personnel with emergency physicians or
state. Patients experiencing this phenomenon may die trauma surgeons who could provide decision support
12
long before terminal exsanguination if one or more imme- and medical oversight of advanced interventions when
diate life-threatening conditions are present and remain required.
unchecked. These conditions include airway or ventila-
tory compromise, compressible major hemorrhage, in- Objectives
trathoracic tension physiology, or chemical/biological The primary objective of this study was to test the hy-
toxicity associated with their injury. 13-17 Thus, proficient pothesis that real-time telemedical decision support and
emergency care, an effective therapeutic package focused clinical mentoring of primary care resuscitation teams by
on delaying progression of coagulopathy, and expeditious a combat-experienced emergency physician or trauma
transport to definitive surgical intervention must be inte- surgeon, hereafter referred to as contingency telemedi-
grated into any potential strategy for improving patient cal support (CTS), would improve the success rate and
outcomes and ultimate survival in these settings. time-to-completion for critical actions performed in a
simulated NATO Role I combat casualty resuscitation
Throughout the modern era, conventional ground com- setting. Implicitly, we also sought to establish proof-
24
bat units in the U.S. Army and Marine Corps are assigned of-concept of the DREAMS telemedical suite.
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primary care physicians (PCPs) and physician assistants
(Pas) as medical staff and are augmented by combat
medics (Army) or fleet marine force hospital corpsmen Methods
(Marines). These medics’ scope-of-practice is consistent This was a prospective, randomized, controlled, high-
with emergency medical technicians-basic (EMT-Bs). fidelity patient simulator (HFPS)–based trial of telemed-
18
Presumably, these clinical personnel practices arise from ical intervention during simulated advanced life support
several contributors, notably historical precedent and combat casualty resuscitation encounters. Subjects were
human resources constraints. While available evidence licensed and credentialed military medical personnel
from the contemporary battlefield supports the associa- (predominantly physicians in postgraduate training,
tion between skilled battlefield emergency care and im- registered nurses [RNs], and dentists) participating in
proved casualty survival rates, the majority of tactical the tactical medical exercise conducted as part of the
medical personnel deployed in the out-of-hospital and Combat Casualty Care Course (C4). 25
preoperative phase of care (defined as NATO Role I
health service support) possess limited clinical experi- Sampling and Environment
ence in trauma resuscitation. 18-21 As a result, the military
research and development community is actively seeking C4 is a basic 8-day tri-service continuing medical educa-
alternative methods of projecting the clinical and pro- tion program designed to enhance the operational medical
cedural expertise normally associated with emergency readiness skills of physicians, RNs and nurse practitio-
medicine practitioners and EMT-paramedics. ners, PAs, dentists, and other specialty healthcare provid-
ers intended for initial entry medical professionals with
DREAMS (Disaster Relief and Emergency Medical Ser- minimal field exposure. C4 provides junior tri-service
™
vices) was a U.S. Army–sponsored program led by The medical officers and clinicians with the knowledge criti-
University of Texas Health Science Center at Houston, cal to conducting battalion- and brigade-level healthcare
Texas A&M University, and Memorial Hermann Hospi- operations in austere combat environments. C4 trains
tal. 22,23 One of the program’s objectives was to improve participants in leadership skills, field medical knowledge,
emergency care through development of a digital EMS and the practical information needed for direct medical
telemedicine suite possessing components permitting support of tactical units under combat conditions. The
real-time, on-demand, and clinically transparent voice, course includes 3 days of professional programs at the
image, and signal data transmission between a remote Defense Medical Readiness Training Institute (DMRTI),
location and a base station, using satellite or wireless Fort Sam Houston, Texas, and 5 days of intensive field
technology. The system was portable, self-contained (ex- training at the Tactical Simulator for Military Medicine
cepting its power source) and sufficiently rugged to per- (TacSiMM) training facility, Camp Bullis, Texas.
mit its use in a deployment setting. Recently, DREAMS ™
was modified and packaged into a hardened, self- Students attending C4 have the opportunity to receive
contained unit that could be transported and rap- certification in Advanced Trauma Life Support (physi-
®
idly placed into operation by medical treatment teams cians and oral surgeons may be certified; dentists, PAs,

Contingency Telemedical Support to Improve Casualty Care: EM-ANGEL Study 51