Page 133 - JSOM Spring 2018

o o Note the time casualty is received and include time of o o The unclassified medical AAR should be accom-
injury (if known and different from when received) plished in addition to unit-required classified AARs.
and time of all key interventions (e.g., tourniquet,
blood transfusion, tranexamic acid [TXA] dosing). Telemedicine Guide
o o List injuries and annotate on the diagram. Tourni-
quets and tourniquet times are also annotated on the ➤ o Goal: Facilitate communication between prehospital pro-
diagram. vider and telemedicine consultant.
o o Vital signs, including mental status AVPU (alert or Rehearsal of telemedicine consultation between prehospital
responsive to voice, pain, or unresponsive) and pain providers and remote physician consultants has shown that
scale, should be recorded to the greatest extent pos- communication is optimized when the caller completes a
sible—up to four sets of vital signs can be recorded telemedicine guide or script before calling the consultant
on the TCCC card. and uses it during the consultation. In addition to transmit-
o o Document treatments to include external hemor- ting medical information to the consultant, it is important
rhage control, airway, breathing, fluids, medications, for the caller to provide information about the care context
and other interventions on the reverse side of the and a summary of capabilities currently available. An im-
TCCC card. age of the casualty and an image of the care environment
■ o Better: PFC Flowsheet are helpful for remote consultants to understand the opera-
As a follow-on to the TCCC card, the PFC flowsheet tional constraints faced by the local caregiver. Capabilities
is used to document trends over time and is the most that are important to convey to remote consultants may
useful tool to recognize important clinical changes in include the training level of the provider, available medica-
complex casualties such as decompensation, response to tions, medical supplies, monitoring, ultrasound, etc. Read-
resuscitation, development of complications, effective- ing or sending a photograph of a written capabilities list
ness of medications, etc. The PFC flowsheet is one of will more quickly orient the consultant to the operational
the most effective ways to improve the level of care pro- environment of the caller and reduce time spent asking the
vided in PFC situations. caller for items that are not available. If urgent teleconsul-
o o When prehospital care transitions to PFC, documen- tation is needed, do not delay calling to fill out a guide
tation should transition from the TCCC card to the sheet or send e-mails. For additional details, see Teleconsul-
PFC flowsheet. There is no exact time for this transi- tation in prolonged field care position paper. 1
tion to occur; however, once all of the available time ■ o Minimum: read from TCCC card.
blocks on the TCCC card are filled and evacuation to ■ o Better: use telemedicine report incorporated in the PFC
higher level of care is not imminent, then documenta- flowsheet.
tion can transition to the PFC flowsheet (Appendix B). ■ o Best: use the Virtual Critical Care Consultation guide
o o The PFC flowsheet not only serves to document care (Appendix C) and send a picture of casualty, capabili-
and identify trends but also contains a checklist of in- ties, and vital sign trends to the consultant via email or
terventions that may be needed through the included text using appropriate operational security and protec-
patient care and nursing care checklists. Such checklists tions of patient privacy.
can greatly aid task-saturated, fatigued Medics by pro-
viding a quick point of reference for important tasks Handoff Report
that should be performed regularly to improve care
and reduce the risk of complications to their patients. ➤ o Goal: Ensure safe transition to the next level of care.
o o The PFC flowsheet also includes: Adverse events may occur due to poor handover of a pa-
• Vital signs tient from one level of care to another. The PFC provider’s
• Fluid input and output job is not done until the receiving team understands the
• Medication times, route, dose patient’s condition and can begin to manage the patient
• Physical exam findings appropriately.
• Problem list
• Treatment plan Summarize in organized format:
• Telemedicine call script – Overall condition of the patient: stable or unstable; better,
■ o Best: AAR same, or worse.
o o An AAR should be completed after patient handoff. – Mechanism of injury or illness
o o In addition to the TCCC card and PFC flowsheet, – Injury(ies), current physical exam
a structured AAR is used to collect lessons learned – Vital signs to include trends and urine output
and improve care. In cases where documentation is – Treatments (procedures, dressings, airway management, flu-
not able to be completed before patient handoff or ids, blood products, medications)
was lost after handoff, the AAR can also serve as a ■ o Minimum: written handoff report that follows the MIST
supplement to the medical record. format (e.g., TCCC Card).
o o TCCC and PFC AARs are available online (Appen- ■ o Better: add the PFC flowsheet.
dix D). ■ o Best: add a dedicated handoff sheet (e.g., SBAR handoff
o o TCCC or PFC AARs, along with any medical docu- report, PFC handoff report ).
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mentation not completed before patient handoff,
should be completed within 24 hours of patient Electronic Documentation
handoff and summited to the Joint Trauma System
(JTS) prehospital organizational email box: usarmy. Electronic documentation is the standard in hospitals and
jbsa.medcom-aisr.list.jts-prehospital@mail.mil. advanced field medical facilities. Devices such as the Tempus

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