Page 63 - Journal of Special Operations Medicine - Spring 2014

Study Limitations trigger tumultuous change. For example, CTS might
Despite using HFPS and a facility with realistic sensory change the training focus for out-of-hospital personnel,
overload and task saturation, this study remains based and even rural hospital staffs, from emergency proce-
on simulation. Thus, definitive validation of our find- dural competence and focused medical knowledge, to
ings requires demonstration in actual trauma patients procedural mastery (“do it right and fast”) and reliance
and ultimately in combat casualties. Despite that pos- on a telemedical consultant for clinical expertise (“when,
sible limitation, studies of simulation models in prehos- why, and to whom”). Interactions between practitioners
pital emergency care and existing anecdotal reports of at outlying facilities and specialty consultants at tertiary
successful telemedical support of rural emergency pro- care centers, already considered strained by some, might
viders demonstrate improvement in performance and, in become more contentious unless optimal clinical prac-
some cases, clinical correlation. 26-29 tices are implemented in advance. Regional telecom-
munications infrastructure and emergency power grids
An additional limitation of our design was the employ- would have to undergo significant transformation to
ment of a single casualty care case. While our intent was ensure reliable connectivity under all circumstances. Le-
to minimize confounding experimental factors and to gal and ethical policy for telemedical consultation will
make the best use of limited resources, this model came require further development and a nationwide scope.
at the cost of potential observer, selection, and interven- These and numerous other details will populate the
tion bias. We attempted to mitigate these by using an future landscape of telemedicine in regionalized care,
explicit non–cross-over model, rotating CTS medical whether in austere environments or at home.
consultants, and using two timers/graders for each ex-
perimental or control team. Reliability would have been Despite these potential challenges, perhaps it is most im-
further improved if multiple cases and multiple CTS portant to remember that, essentially, telemedicine rep-
consultants were used; however, such a design would resents improved interpersonal communication between
have exceeded available resources to conduct this study. emergency caregivers, and its greatest promise is in the
potential to do so in real-time, while projecting and re-
It is plausible that our observations may have arisen in ceiving not only thoughts but also the images we see
part simply as the result of the Hawthorne effect. While with our own eyes, despite monumental physical barri-
30
mentoring in itself constitutes a form of attention, we ers imposed by distance, obstacles, and time itself.
sought to mitigate the differential effect of observation
and attention between experimental and control teams Our next objective within the out-of-hospital battle-
by placement of their respective HFPS mannequins and field care domain is to investigate the utility of CTS as a
stretchers at opposite ends of the open laboratory, with means for projecting decision support, clinical expertise,
several HFPS/resuscitation team ensembles interspersed and regulatory oversight to paramedical personnel who
between them (see Figure 3). Also, we used proctors for might employ advanced pharmaceuticals and possibly
observation and time/data collection among both exper- blood product transfusions as they attempt to temporize
imental and control teams. casualties experiencing ongoing hemorrhage, as they
navigate the tactical evacuation system while en route to
CTS consultants were required to mentor experimental hemostatic surgical intervention. While this next fron-
teams repetitively through only one scenario, introducing tier in out-of-hospital care has been performed success-
additional risk for interventional bias. CTS consultants fully by physicians and nurses under medical direction,
were briefed and underwent a non-graded “washout” we propose that effective and reliable CTS could enable
encounter in which they were coached on telementoring a far broader use of a strategy for remote damage con-
approach and style. Although care was taken to avoid trol resuscitation, initiated by paramedical personnel,
“leading” experimental teams versus mentoring them as prior to arrival at the surgical facility. While fraught
needed, we cannot reject the possibility that our results with many challenges, such a strategy would broaden
would not translate in different cases or multiple patient the “resuscitation footprint” substantially.
encounters. Although we studied a broad range of cre-
dentialed practitioners, we believe it would be premature
to extrapolate our findings to other populations of com- Conclusion
bat medical personnel, such as mid-level providers, para- Within the constraints of an HFPS model, we have dem-
medics, combat medics/corpsmen, or first responders. onstrated that real-time telementoring of trauma resus-
citation is feasible and may improve the accuracy and
Conceptually, our enthusiasm for CTS is tempered by speed in completing critical actions by primary care re-
the observation that its integration into either military suscitators with limited trauma resuscitation expertise.
or civilian regionalized emergency care systems could As such, CTS holds the promise of improving battlefield

Contingency Telemedical Support to Improve Casualty Care: EM-ANGEL Study 55