Page 119 - Journal of Special Operations Medicine - Winter 2016

PFC: Tactical Solutions for Austere, Figure 2 Consultations placed to the Army Medical
Dispersed Operations Command Teleconsultation Program FY14 and FY15. Of
these, 14.6% were identified as possibly needing critical care
Of the medical advances most responsible for improv- consultation, which likely underrepresents the true volume of
ing outcomes in OIF and OEF, TCCC and, in many need, because urgent or emergent consultations traditionally
cases, DCR are currently the only reliably available in- occur via synchronous methods like phone calls and are not
tervention to SOF in the gray-zone operational environ- represented in these data or by this asynchronous capability.
ment. 12–14 During these missions, SOF medics are often Actual number of cases is given in parentheses.
the most advanced US or North Atlantic Treaty Orga-
nization medical provider, and mission constraints may
prevent evacuation of critically ill or injured patients to
definitive care for hours or days.

The PFC Working Group has identified 10 capabilities
to train and mature that will optimize SOF medics’ abil-
ity to care for critical casualties for extended periods
and enable successful evacuation to definitive care (Ta-
11
ble 1). The PFC Working Group also identified four
basic operational scenarios in which PFC is practiced:
ruck, truck, house, and plane. Care in these scenarios is
not sequential and not all casualties will receive care in
all scenarios. 10

The challenge PFC caregivers must address is how to
optimize medical outcomes and mitigate medical risk
in areas that lack traditional echelons of care or rapid 1. Availability of expert consultation should be real
evacuation. The solutions most readily available in the time (i.e., synchronous), simple to obtain, and rap-
1,9
short term are (1) training to increase austere critical idly accessible (within minutes). Critically ill patients
care and evacuation capabilities of SOF medics and (2) may decompensate rapidly and the need for decisive
providing medics with access to expert consultation in management is immediate.
real time to assist in the care of critically ill casualties. 2. Telephonic consultation is the primary mode of as-
Real-time consultation between the medic and a specialty sistance, not video or data transfer. The rationale for
consultant can be broken down into synchronous (tel- this criterion was twofold. First, telephonic commu-
ephonic or video telecommunication) and asynchronous nication is nearly universally available, is very low
(texts, data, images, video, and so forth, sent via short bandwidth, and does not require additional equip-
message service or e-mail) forms of communication.
ment that may cause operators to stand out in the
local operating environment. Second, telephonic
consultation has a long history of successful imple-
Development of a PFC Teleconsultation Solution: mentation and is practiced every day in academic and
The Virtual Critical Care Consult (VC3) Service
remote medical centers where consulting physicians
In August 2015, the PFC Working Group began col- work; thus, the skillset for this type of consultation
laborating with a team of critical care physicians at the requires minimal training. Generations of clinicians
US Army Institute of Surgical Research (USAISR) to have improved the care of patients by simply talking
create a solution for the ninth PFC capability: obtain with more experienced providers with no visual data
telemedicine consultation. A retrospective review of all guiding the reporting or recommendations.
consultations placed to the Army Medical Department’s 3. Telecommunications may be augmented by images
e-mail teleconsultation program from January 2014 to sent via e-mail or text, given the ubiquity of transmit-
December 2015 confirmed a need to continue with so- ting visual data by these means from even the most
lution development, because 15% of consultations had austere settings. Images can assist remote consultants
potential for clinical deterioration or death (Figure 2). with providing consultation in context, and these
can convey significant amounts of information more
Crucial to the development of a solution was the involve- rapidly than voice alone. Data sent in this manner
ment of SOF medics at every stage of conceptualization, also require significantly less continuous bandwidth.
testing, and refinement. The following initial criteria for If bandwidth is not available, they are not required.
an on-demand telemedicine service were identified by 4. Teleconsultation should be obtained via devices cur-
focus group consensus: rently carried by SOF medics and include commercial

Virtual Critical Care Consultation Service 103