Page 150 - Journal of Special Operations Medicine - Spring 2017

operations, telemedicine, advanced wound care, and demonstrate that PFC constitutes a broad range of pa-
more training on monitors and ventilators. tient presentation and clinical care that is not easily
addressed with linear or algorithmic patient treatment
Successful efforts to sustain included buddy care and the protocols alone. Although mastery of PFC techniques
use of telemedicine, as noted in two cases each. Employ- for all contingencies may prove difficult, providers must
ment of a “walking blood bank” was found to be ef- at least be familiar or proficient with skills required for
fective for one case requiring multiple transfusions of common PFC scenarios, and train on such through a
whole blood. Utilization of a nurse-level provider for variety of different operational settings and evacuation
monitoring vital signs, Foley catheterization, and pain platforms. Prehospital patient care may span the spec-
and sedation management was effective and allowed the trum from initial patient stabilization, to ongoing assess-
physician to focus on MEDEVAC coordination. Limb ment, resuscitation, and interventions usually reserved
immobilization was noted to be useful in two cases, for facility-based patient management. This breadth of
one using a femoral traction device and the other an air care presents unique and obvious challenges to remote
splint. and austere medical providers, both in and outside of
the military.
The most prevalent opportunity to improve was con-
tingency planning for medic incapacitation, which Skillsets that bridge the gap include both simple and
occurred in four cases including one seasick rescuer. complex interventions. During the PFC phase of care,
Inadequate documentation was noted in three cases recording serial vital signs, measuring urine output and
including one case in which the tourniquet placement interpreting trends over time are invaluable, low cost,
time was not documented. Lack of tourniquet conver- and low tech means by which to continuously evalu-
sion training was identified as a shortfall in two cases. ate the patient and identify early decompensation. More
Medical evacuation planning and rehearsals, as well as complex skillsets may include subsequent treatment
identification and contingency planning for in-country through prolonged mechanical ventilation with com-
medical assets, would have been useful in three cases. mensurate requirements for sedation, balancing pressor
The need for PFC training, specifically for patient hy- and fluid management, and the ability to perform essen-
giene, was noted. Equipment shortfalls identified were tial acute surgical interventions. Procedures such as tube
need for oxygen concentrator, monitors, blood prod- thoracostomy, cricothyroidotomy, and, in some cases,
ucts, additional supply of IV crystalloid fluids, field fasciotomy and escharotomy have the potential to save
laboratory (e.g., iSTAT), capnography, and ultrasound. life and limb, but are not routinely trained and practiced
Teleconsultation would have been a benefit in two cases. by the prehospital provider.
Implementation of pain management protocols was rec-
ommended to decrease risk of over medicating patients, Particularly where there are knowledge and experience
and nerve block training was suggested as a means to gaps, as there will inevitably be with the various pre-
improve pain control during PFC scenarios. sentations and complex treatment plans sometimes en-
countered in PFC, telemedicine can be a force multiplier
when employed effectively. In 14.8% of the cases re-
Discussion
viewed in this study, telemedicine played an integral role
Prolonged field care in the military prehospital setting in the management of the patient by guiding judgement,
remains ill-defined. It is an extremely vital area of medi- differential diagnoses, interventions, or other advanced
cal care about which data are sparse. Repositories of efforts. When prehospital supplies and equipment are
PFC data are generally found in AARs at the unit level as available and robust, electronic monitoring devices (ie.
well as in the memory of those care providers who were Tempus Pro™, HeartStartMRx™) can allow for the
involved in PFC events. Historically, these data have not remote transmission of patient vital signs and diagnos-
been collected, consolidated, and analyzed, which adds tics to a distant advanced medical provider (e.g., physi-
to the challenges encountered when developing appro- cian, physician assistant, nurse) or group of such (e.g.,
priate training courses, guidelines, and mission prepara- joint trauma system, burn center, infectious disease ser-
tion tools. This review was an initial analysis of recent vice). In its most basic form, however, simple telephone
US military PFC experiences, with descriptive findings communication, augmented with low-bandwidth email
that should prove helpful for future efforts to include connections when available, is highly effective and ac-
defining unique skillsets and capabilities needed to effec- cepted by most to include those within the Special Op-
tively respond to a variety of PFC contingencies. erations community. This capability, combined with a
pool of consultants (trauma, critical care, neurosurgery,
Provider Training burns, pediatrics, cardiology, etc.) allows the PFC pro-
The capabilities of the individual provider can influence vider access to numerous advanced providers with an
patient outcomes during PFC scenarios. Our results abundance of expertise. Telemedicine can also support

126 Journal of Special Operations Medicine Volume 17, Edition 1/Spring 2017