Page 25 - JSOM Spring 2018

Discussion form of evidence-based protocols, quality assurance reviews,
and online support should help guide care. Preidentified pa-
This case demonstrates the importance of critical care skills tient-receiving centers like trauma centers and emergency de-
and the ability to perform advanced life-saving interventions in partments ready and able to receive critical patients should
the prehospital setting. According to the director of the receiv- also be considered. In our case, a quality assurance review
ing trauma center and on-call surgeon (E. M. Bulger, written might lead to a discussion of the increased risk of aspiration
communication, January 2017), the prehospital, Paramedic- with bag-valve-mask–assisted respirations in a patient with
level, critical care interventions saved the lives of these two altered mental status and confirm the decision to intubate. A
aviators. Specifically, rapid sequence induction, endotracheal discussion of the clinical value of hyperventilation as a strat-
intubation, needle decompression thoracostomy, and admin- egy to temporize traumatic brain injury without evidence of
istration of medications via IV infusion are defined as Para- herniation might increase the knowledge of the providers and
3
medic skills by the National EMS Scope of Practice Model benefit future patients. Reviewing the initial examination find-
and likely improved the outcome for both of these patients. ings of absent breath sounds on the left and decreased breath
While this concept is not novel, especially for prehospital pro- sounds on the right could lead to encouraging the SMT to
viders who support military operations, the US Navy has yet perform bilateral needle decompression thoracostomy for
to adopt a formal policy requiring SMTs to earn and maintain blast-injured patients in the future, especially in the setting of
Paramedic certification.
declining respiratory status after multiple decompressions on
the same side.
In 2012, the US Congress
mandated that the US Army We could use this case as an
train their DUSTOFF Med- excellent example of the need
ics to the Critical Care Flight for frequent reassessments,
Paramedic standard. The US as the providers did, and re-
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Air Force has been training inforce the potential need to
and certifying their PJs to the repeat an intervention (ie,
National Registry of EMT needle decompression tho-
Paramedic standard since racostomy). The impact of
1995. As in this case report, positive pressure ventilation
Sailors and Marines who are on a patient with a suspected
cared for by Navy medicine pneumothorax would also
providers can benefit from a be a valuable learning point
similar standard of care. Both from this case. These items
SMTs involved in this case are mentioned to acknowl-
report are National Registry edge that the care presented
Paramedic and Critical Care in this case report was not
Flight Paramedic certified. perfect and, more impor-
They are also the only two tantly, to emphasize the value
SMTs in the current inven- of a systematic approach to
tory of 71 qualified SMTs to support improvements in
hold both certifications. Navy prehospital care.
Hoist training. (Photo courtesy of NASWI SAR.)
Several authors have discussed disparities in en route care ca- This case presentation highlights a single encounter where the
pabilities for military air evacuation and the need for contin- critical care skills of SMTs contributed to saving the lives of
ued innovation. While it is still not clear what level of care is two aviators. A review of 428 Navy en route care transports
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ideal for all situations, there is evidence of improved outcomes during a 3-year interval identified that more than 50% of
with higher-level–trained providers onboard MEDEVAC plat- transports required advanced life support skills. We encour-
9
forms. Mabry et al. showed a 66% lower risk of mortality age Navy medicine leadership to take the necessary steps to
with care provided by Critical Care Flight Paramedics ver- make Navy en route care an Advanced Life Support–certified
sus the standard Army EMT Flight Medics in Afghanistan. platform, starting with supporting National Registry EMT
6
These findings were further supported by the analysis of Apo- Paramedic and Critical Care Flight Paramedic certifications
daca and colleagues in a comparison between DUSTOFF (US for SMTs.
Army), PEDRO (US Air Force) and MERT (UK) platforms
with improved outcomes with higher level care (MERT). Ad- Funding
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ditionally, concern has been raised about secondary transport, There was no funding associated with the development of this
particularly in the military setting when a patient needs to be manuscript.
moved from one level facility to a higher level facility but the
transport team is not certified to provide a commensurate level Disclaimer
of en route care. 8 The views expressed are those of the authors and do not reflect
the official policy of the US Navy Bureau of Medicine and
Simply increasing the training and certification of prehospital Surgery, Department of the Navy, Department of Defense, or
providers, as in this case, will likely improve patient outcomes, the US Government.
but prehospital medicine is not just about the provider. Other
factors are also essential. Equipment and supplies are needed Disclosures
to facilitate advanced interventions. Medical direction in the The authors have nothing to disclose.

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