Page 126 - Journal of Special Operations Medicine - Winter 2016

Case of a 5-Year-Old Foreign National
Who Sustained Penetrating Abdominal Trauma

Robert D. McLeroy, MD; Jabon L. Ellis, DO; Jason M. Karnopp, NREMT-P, ATP;
Jeffrey Dellavolpe, MD; Jennifer Gurney, MD; Sean Keenan, MD; Doug Powell, MD;
Jamie Riesberg, MD; Mary Edwards, MD; Renee Matos, MD, MPH; Jeremy Pamplin, MD

Objective: Review application of telemedicine support bringing the boy to a local military hospital. There was
for penetrating trauma. minimal bleeding reported at the wound site.
Clinical context: Special Operations Resuscitation Team On presentation to the healthcare facility (which consisted
(SORT) deployed in Africa Area of Responsibility (AOR)
of several tents with no running water, limited power sup-
Organic expertise: Internal Medicine physician, two ply, and limited pharmacy), the patient’s vital signs were
Special Operations Combat medics (SOCMs), and one notable for a heart rate of 120 bpm and respiratory rate
radiology technician of 30/min. The patient was afebrile and normotensive,
with oxygen saturation of 100% on room air. Physical
Closest surgical support: Non-US surgical support 20km examination revealed a slightly distended abdomen with
away; a nonsurgeon who will perform surgeries; neigh- pain around the wound site and absent bowel sounds.
boring country partner-force surgeon 2 hours by fixed- Pulmonary examination was unremarkable. A focused as-
wing flight.
sessment with sonography in trauma (FAST) examination
Earliest evacuation: Evacuated 4 days after presentation (Figure 2), performed by one of the SOCMs, revealed a
to a neighboring country with surgical capability. pericardial effusion and chest radiography (Figure 3) was
concerning for pneumopericardium as well as pneumo-
Keywords: critical care; telemedicine; military personnel; peritoneum versus left diaphragmatic rupture with bowel
emergency treatment; patient transfer; combat casualty in the left thoracic cavity. The initial request for evacua-
care tion for definitive surgical intervention was denied.
Medical management over the next several days included
antibiotic therapy with metronidazole, ampicillin, and cip-
Introduction
rofloxacin, as well as intravenous (IV) fluids; however, the
An internal medicine physician, two Special Operations
Combat Medics (SOCMs), and one radiology technician Figure 1 A 5-year-old local national on initial presentation
requested telemedicine guidance about a pediatric pa- to local military hospital with occlusive dressing in place.
tient with delayed presentation of penetrating trauma.
This Special Operations Resuscitation Team (SORT)
was deployed in Africa Area of Responsibility (AOR).
The closest non-US surgical support was a nonsurgeon
willing to perform operations who was 20km away or a
partner-force surgeon in neighboring country who was
2 hours by fixed-wing flight. At the time of presenta-
tion, evacuation was not considered an available option
despite multiple attempts.

Case Report

A male, 5-year-old foreign national was brought to the
Special Operations Resuscitation Team (SORT) team by
a partner force 1 day after falling on a small 5cm knife.
The knife penetrated the ninth intercostal space on the
left (Figure 1). His mother had removed the knife before

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