Page 148 - JSOM Spring 2018

Patella Fracture in US Servicemember
in an Austere Location

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Sophia Schermerhorn, BS ; Paul J. Auchincloss, APA-C, MPAS ; Kyle Kraft, EMT-B; LTC(P) ;
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Kenneth J. Nelson, MD ; Jeremy Pamplin, MD, FCCM, FACP *
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ABSTRACT
Objective: Review the management of a patient with acute FIGURE 1 (A) Posteroanterior radiograph of right knee. (B) Lateral
patella fracture supported by telemedical consultation. Clini- radiograph of the right knee demonstrates a transverse patella fracture.
cal Context: Regionally Aligned Forces (RAF) supporting
US Army Africa/Southern European Task Force (USARAF/
SETAF) in Africa Command area of responsibility. Care was
provided by a Role I facility on the compound. Organic Ex-
pertise: Three 68W combat medics; one Special Operations
Combat Medic (SOCM). Closest Medical Support: Organic
battalion physician assistant (PA) located in the United States;
USARAF PA located in a European country; French Role II
located in nearby West African country; telemedical consults
via e-mail, phone, or videoteleconsultation. Earliest Evacua-
tion: Estimated at 12 to 24 hours with appropriate clearances.

Keywords: critical care; telemedicine; military personnel; Following this discussion, the PA sought additional expert con-
emergency treatment; patient transfer; prolonged field care sultation with an orthopedic surgeon by using the Advanced
Virtual Support for Special Operations (ADVISSOR) system.
This system allows caregivers to call a published phone num-
ber, select a specialty care service from a menu of options, and
Introduction
be connected directly to the specialty consultant, a physician,
A small contingent of US forces recently deployed to a location within minutes. The system has “back-up” capability in the
in the AFRICOM AOR (West Africa). Due to planning and event the specialty physician is unavailable (i.e., poor cell-
operational constraints, they were supported by three combat phone service, engaged in other direct patient care/operation/
medics (68W), approximately eight Combat Life Saver–trained procedure at the time of the call). If the primary call provider
personnel, and one attached SOCM. Medical personnel func- is unavailable, the automatic call distribution system auto-
tioned from a tent stocked with a basic Role I medical equip- matically calls a second on-call specialist. If this specialist is
ment set. Telephone and NIPR e-mail communications were also unavailable, the call is routed to an on-call emergency de-
available, although with intermittent reliability. partment that can facilitate a solution (i.e., answer the caller’s
question or call the hospital’s on-call specialist). Army, Navy,
On approximately day 14 of the rotation, a US Servicemember and Air Force physicians who are on-call for the ADVISSOR
presented after a trip and fall from a standing height. Radio- system are located throughout the military health system.
graphs were obtained at a host nation medical clinic, and a
displaced transverse fracture of the right patella was identified Case Presentation
(Figure 1). A synchronous telemedicine consult using a phone A 20-year-old US Servicemember presented to his medic with
was conducted with the USARAF PA to seek guidance about exquisite pain and inability to extend his right knee after a fall
injury management. The PA and local medic then conferred from standing height. The patient reported a fall directly on
using synchronous videoteleconsultation technology (i.e., the the anterior aspect of his knee. On presentation, the patient
military’s “Telehealth in a Bag” [THIAB], a set of off-the-shelf was hemodynamically stable and unable to bear weight on the
universal serial bus [USB] devices that attach to a computer affected extremity. Examination of the knee revealed intact
including a stethoscope and a high-definition camera with skin, tenderness to palpation over the patella, a large effusion
attachments for otoscopic, funduscopic, and nasal/oropha- and inability to perform a straight leg raise. The remainder of
ryngeal examinations). The system connects to remote consul- his exam was normal with no tenderness of his femur or tibia,
tants using “Web RTC” (Web real-time communication) no obvious deformity, and a normal neurovascular examina-
tion. The patient was transported to a host nation medical
*Address correspondence to jeremy.c.pamplin.mil@mail.mil
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1 ENS Schermerhorn is a third-year medical student at the Uniform Services University of the Health Sciences. MAJ Auchincloss is a flight medi-
cine–trained physician assistant (PA) and is currently serving as the US Army Africa PA. SGT Kraft is a US Army combat medic serving as the
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medical platoon sergeant in West Africa, assigned to HHC 1-87IN 10MTN DIV. LTC Pamplin is the director of Virtual Critical Care and Virtual
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Health at Madigan Army Medical Center and is the medical director of the ADvanced VIrtual Support for Special OpeRations (ADVISSOR)
System. COL Nelson is the Orthopedic Surgery Program director at Womack Army Medical Center.
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