Page 84 - Journal of Special Operations Medicine - Winter 2015

wound was created by an open surgical dissection to Figure 2 Screen shot of remote mentoring surgeon’s
the common femoral artery proximal to the bifurcation computer.
into the superficial and profunda branches and creation
of a near transsection with only the arterial back wall
left intact to prevent retraction of the ends. Thereafter, a
firefighter with paramedical training but no previous ul-
trasound experience was guided by a remote ultrasound
expert to image the groin and especially the arteriotomy
site before and after application of a single iTClamp.

The firefighter, located in the Memphis, Tennessee, lab-
oratory, was guided in real time by a trauma surgeon in Large arrow denotes the native common femoral artery with residual
Calgary, Alberta, Canada (2,600km away) using a low- flow. Hatched arrow denotes bleeding into a no- contained pseudoan-
cost, simple off-the-shelf tele-ultrasound system that eurysm (white bracket).
has been previously described. Briefly, the ultrasound the specific site of bleeding, which was effective in com-
19
images of a portable hand-carried ultrasound machine pletely controlling arterial bleeding into the pseudoan-
(NanoMaxx; FujiFilm SonoSite Corp.; http://www eurysm (Figure 3). Release of this mentored compression
.sonosite.com) were digitized (video codec; Monoprice allowed the bleeding to continue (Figure 4). Although
Inc.; http://www.monoprice.com) and imported along the magnitude of the compressive force exerted was not
with the display of a head-mounted video camera (1.3 formally measured, the firefighter commented on how
megapixels; Microsoft Corp., http://www.microsoft. little force was required to control the bleeding once it
com) onto the screen of a commercial software (XSplit was accurately localized.
Broadcaster; SplitMediaLabs Ltd., http://www.split-
medialabs.com), which was then securely shared via a The bleeding was allowed to continue into the pseudoa-
password-protected Skype application (Skype; http:// neurysm, with remote monitoring via tele-ultrasound in
www.skype.com). In this way, the firefighter was di-
rected to identify the actual site of bleeding from the Figure 3 Remotely mentored tele-ultrasound–guided manual
common femoral artery, with egress of blood into the compression over the traumatic pseudoaneurysm is effective
wound pocket as well as externally (Figure 1). The color in completely controlling the bleeding from the native artery
power Doppler function on the ultrasound was used, as (large white arrow).
this mode has superior ability to recognize flow at the
expense of direction and speed information, compared
with the more typical color Doppler mode. 20,21
Figure 1 Localization of bleeding with remote telementored
ultrasound.

Figure 4 With release of the remotely mentored tele-
ultrasound–guided manual compression over the traumatic
Large arrow denotes the common femoral artery. Stippled arrow de- pseudoaneurysm, bleeding is into a now-contained
notes perceived site of bleeding into the wound pocket and externally. pseudoaneurysm (white bracket).
Double smaller arrows illustrate blood forming a hematoma in the
wound pocket (external hemorrhage visualized clinically but not on
ultrasound).
After 3 minutes of established free bleeding, an iTClamp
was applied to the external wound such that the external
hemorrhage was controlled. The firefighter was thereaf-
ter mentored to sonographically visualize the arteriot-
omy and, thus, to demonstrate a pseudoaneurysm with
active bleeding within (Figure 2). After identification of
the actual site of bleeding, the firefighter was remotely
mentored to exert manual ultrasound compression on

72 Journal of Special Operations Medicine Volume 15, Edition 4/Winter 2015