Page 121 - Journal of Special Operations Medicine - Winter 2016

cellular and satellite devices. Obtaining teleconsulta- inexperienced in conveying information about compli-
tion should not place a burden for acquiring, learn- cated, critically ill patients could consistently communi-
ing, carrying, and powering additional devices by cate such information to a consultant in a compressed,
medics already facing significant time, space, and high-yield format. 15,16 VC3 revised this format multiple
weight constraints. times based on feedback from testing until it reached the
5. The initial consultants should be a critical care phy- current operational “script” (Figure 3). An important
sician with experience in medical, trauma, surgical, element of the script is the “capabilities” section, which
and burn critical care. These physicians are specialty addresses a concern of SOF medics: that the consultant
trained experts in the nonoperative management of physician will not appreciate the austerity and limita-
critically ill patients who may clinically decompen- tions of the environment in which they are operating.
sate in the time beyond the golden hour—a signifi-
cant risk for casualties who cannot receive timely, Finally, a process evolved to optimize the efficient ex-
definitive surgical or medical care. change of information. In best case scenarios, medics
6. PFC is defined as prehospital care. Prehospital care send images to the VC3 e-mail consisting of the capabil-
does not require documentation in an electronic ities section of the script, the clinical flowsheet (Figure
medical record. This allows solutions to req uire 4), and any relevant images of wounds, care environ-
less technology. Documentation can be handwritten. ment, equipment, and any other important information
Because medics do not store personal health infor- shortly before calling the VC3 number (preferably 10-
mation and they do not need send personally iden- 15 minutes lead time). Images must not reveal patient
tifiable information, transmission can be over media identity, location, or compromise operational security.
and networks not certified for these purposes. This At the beginning of a call, medics and the consultant ex-
enables more rapid development and use of a tele- change call-back or text-back information to facilitate
consultation system. follow-up and reconnection if the call is interrupted. Im-
portantly, if images cannot be sent or there is no time to
The PFC Working Group began testing teleconsultation delay calls, the service may still be engaged immediately
in October 2015. Initially, two methods were evalu- using the phone call, and information will be exchanged
ated: a current commercially available telemedicine as optimally as possible.
service for travelers and the USAISR burn phone line.
The commercial service routed calls through a nonphy- Results
sician provider, usually a paramedic, during a “triage
step.” Callers were dissatisfied with the time it took to Testing continued into the spring of 2016 and involved
get past triage to the expert consultant, with the delay numerous SOF units from Army, Marines, and Joint
in call transfer to the consultant or waiting for consul- Special Operations Command. Devices tested were
tant to call back, and with having to provide duplicate most commonly commercial cell phones but also in-
information during the triage phase and subsequently to cluded satellite phone and tactical communications
the consultant. Calls to the burn hotline suffered from systems. No appreciable differences in call quality were
inconsistent awareness from the large Burn ICU staff noted, provided a good signal was available. Satellite
about how to route calls for a new category of critical phones were limited by the ability to perform voice-only
care consultation. communication.

These problems ultimately led to a third model: calls Operationally, VC3 has been used in support of the
direct to an on-call intensive care physician. A dedi- Special Operations Command Africa and Special Op-
cated phone number was assigned to call forward to the erations Command Central since late 2015. Real-world
mobile phone of an on-call critical care physician. An VC3 cases involving threatened airway compromise
e-mail address was also created to send messages to a secondary to cellulitis; threatened vision due to oph-
distribution list of VC3 providers and PFC telemedicine thalmitis; penetrating abdominal trauma; and fragment
Working Group leaders as a mechanism for the team to injury requiring wound-tract debridement, foreign body
maintain situational awareness of VC3 activity and as removal, complex wound closure, and wound care vali-
a potential back-up solution should the phone line fail. date the need for this capability. The abdominal trauma
Medics consistently preferred this method for both its and wound management cases are detailed in this edi-
expediency and for the quality of advice obtained from tion of Journal of Special Operations Medicine. In all
the military critical care physicians. cases, real-time teleconsultation improved local pro-
vider confidence, patient outcome and, in at least one
Equally important to the development of the VC3 Ser- case, increased partner force confidence and alliance
vice was the development of a format by which callers with the embedded SOF element.

Virtual Critical Care Consultation Service 105