Page 131 - Journal of Special Operations Medicine - Winter 2016

• Followed up by telephone within 10 minutes to VC3 • Aggressive surgical wound care will facilitate faster heal-
intensivist on call. ing of contaminated wounds only. Most contaminated
• Three attempts to contact VC3 on call provider were wounds will, nevertheless, still heal, albeit more slowly, if
unsuccessful; thus, 18D contacted the Institute for they are kept clean with dressing changes and irrigation.
Surgical Research Burn Unit at San Antonio Military • Partially closing a wound (i.e., turning a mostly cir-
Medical Center (SAMMC) and was immediately an- cular/elliptical wound into a more linear wound) will
swered. Case information was then relayed to the on- facilitate a more cosmetic and rapid closure. A pitfall
call VC3 provider who then contacted 18D to provide of this approach, however, is that by creating poten-
guidance. tial space under the partial closure, it becomes more
• Due to technical surgical aspects of the teleconsul- difficult to effectively pack the wound. This may lead
tation, an on-call trauma surgeon at SAMMC was to infection. It is better not to close or partially close
brought into the teleconsultation loop to provide di- a wound if it will impede proper wound care; instead,
rect guidance to and answer questions from the 18D. pack with wet-to-dry dressing changes.
• Not all fragments should be retrieved. Large frag-
Consultation Recommendations ments that impede function, particularly joint range
Partial closure of ends of exit wound to facilitate linear of motion, can be cautiously retrieved. Any frag-
and rapid healing of wound while allowing the over- ments that affect vascular flow or neurologic function
all wound to heal by secondary intention Aggressive should be evaluated at a level of care, if possible, that
wound care: cleaning the wound daily, dressing changes can perform vascular repairs and/or further vascular
two or three times daily to encourage microdebridement imaging. We recommend a surgical consultation prior
and lowering the bacterial burden of the wound. to retrieving most fragments.

Follow-up Lessons Learned
After following the recommendations provided by the • Teleconsultation with experienced critical care phy-
VC3 staff, the 18D continued to debride and irrigate the sicians and surgeons can improve the care provided
wounds and dress them with wet-to-dry dressings; how- to and outcomes of medical and surgical casualties
ever, three-times-daily wound irrigation and dressing in austere environments with limited to no access to
changes were not possible because of logistical constraints, definitive care.
so a second debridement was performed on postinjury day • Key elements needed for teleconsultation are reliable
4 (Figure 2). By postinjury day 5, the patient felt better voice link and the ability of the provider downrange
and was beginning to use his right upper extremity for to send an e-mail with images. Image transmission
daily activities. He was then counseled to continue to keep proved beneficial because the VC3 staff could provide
the wound clean and dressed while at the COP. recommendations and plan of care based on a more
comprehensive picture of the patient and wound char-
Figure 2 (A) Wounds postinjury day 5 after partial closure acteristics, available supplies, and operational environ-
of lateral edges. (B) Image of anterior (entry) and posterior ment than that provided by voice description alone.
(surgical) wounds. • More reliable access to secret communication may be
A B beneficial because secure communication allows de-
ployed providers more liberty to elaborate about the
clinical scenario, especially with respect to the context
of logistical constraints they may have that could im-
pact treatment plans; however, lack of secure commu-
nications should not be a barrier to teleconsultation.
• A redundant call system, including a central call center
with 24/7 staffing, would be beneficial; the provider
Teaching Points in this case was unable to reach on-call VC3 physician
because of cell-phone dead zones. The alternate VC3
Wound Management 1-4 contact plan, contacting the SAMMC Burn Center,
• Basic wound care: frequent irrigation (with showers if was used in this case and succeeded in connecting the
possible), dressing changes with wet-to-dry dressings remote provider with the on-call intensivist.
(microdebridement); removal of any gross contamina-
tion or devitalized tissue from the wound (sharp de- Disclaimer
bridement with a scalpel or substitute), and repeated
wound examination will result in healing of most soft The views expressed are those of the author(s) and do
tissue wounds. not reflect the official policy or position of the US Army

Case Report: Telemedicine Support for Wound Care 115