Page 125 - JSOM Summer 2019

Fever of Unknown Origin in US Soldier

Telemedical Consultation Limitations in a Deployment to West Africa

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Paul J. Auchincloss, APA-C ; Jason J. Nam, MD *; Dana Blyth, MD ;
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Gabrielle Childs, RN ; Kyle Kraft, EMT-B ; Paul M. Robben, MD, PhD ;
Jeremy Pamplin, MD, FCCM, FACP 7

Objective: Review the application of telemedicine support for rotation, one of the medics presented with left lower extremity
managing a patient with possible sepsis, suspected malaria, pain and low-grade fever. Forty-eight hours later, the patient
and unusual musculoskeletal symptoms. returned with a temperature of 39.8°C. No evacuation plat-
forms existed locally.
Clinical Context: Regionally Aligned Forces (RAF) support-
ing US Army Africa/Southern European Task Force (USARAF/
SETAF) in the Africa Command area of responsibility. Care Case Presentation
provided by a small Role I facility on the compound.
A 21-year-old male US Army medic presented to fellow med-
Organic Medical Expertise: Five 68W combat medics (one is ics with a 48-hour history of polyarthralgias of the left ankle,
the patient); one SOCM trained 68W combat medic. No US knee, and hip without preceding trauma. Before seeking help,
provider present in country. the patient attempted self-care with ice, compression, and el-
evation of the limb, and oral nonsteroidal anti-inflammatory
Closest Medical Support: Organic battalion physician assis- drugs. He had no other medical problems and had started
tant (PA) located in the USA; USARAF PA located in Italy; malarial prophylaxis (atovaquone/proguanil) on the day be-
French Role II located in bordering West African country; fore entering Africa. Initial vital signs demonstrated tachycar-
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medical consultation sought via telephone, WhatsApp (com- dia (111 bpm) and 96/48mmHg blood pressure. The patient
munication with French physician) or over unclassified, en- was febrile to 103.7°F. Left lower extremity pain was 5/10
crypted e-mail.
without provocation but became unbearable when the patient
Earliest Evacuation: Estimated at 12 to 24 hours with appro- attempted to move or bear weight. Additional complaints in-
priate country clearances and approval to fly from three coun- cluded an insidious headache localized to the bilateral perior-
tries including French forces support approval. bital/retro-orbital region, nausea, chills, and general malaise.

Keywords: critical care; telemedicine; military medicine; Physical examination revealed the following abnormal find-
emer gency treatment; prolonged field care; combat casu- ings: peritonsillar edema and erythema; left lower limb was
alty care; patient transfer exquisitely painful with active range of motion of the hip,
knee, and ankle; and weight-bearing was intolerable. The
skin was hot and dry. A rapid malaria test performed using a
BinaxNow malaria test kit was negative. A second rapid ma-
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Introduction
laria test conducted approximately 8 hours later also returned
Limited medical capabilities supported a small contingent of a negative result.
US forces forward deployed in West Africa. Planning con-
straints meant that the unit was without a medical provider The medics initiated an asynchronous telemedicine consul-
for the beginning of the rotation. The leadership assumed risk tation through email. The response from the specialist came
knowing five combat medics (68W) supported the organiza- approximately 4 hours later and asked for additional infor-
tion along with an additional medic (attached) with Special mation. The consultant asked for multiple laboratory studies
Operations Combat Medic (SOCM) training. This medical to include a complete blood count, a chemistry panel, blood
team provided medical coverage for approximately 200 mil- smears, and blood cultures and recommended that a US physi-
itary and civilian personnel from a Role I medical tent with a cian see the patient as soon as possible.
standard medical trauma and sick call set. Communications
were limited to a DSN telephone and NIPR email with in- Blood was drawn and tested in a host nation facility. Initial
termittent connectivity. On approximately day 10 of their labs revealed leukocytosis and an elevated C-reactive protein.
*Correspondence to jason.nam04@gmail.com
1 MAJ Auchincloss was formerly the US Army Africa PA and is now serving as the command PA and deputy surgeon for Clinical Services for
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Special Operations Command Africa. MAJ Nam is a Special Operations Resuscitation Team (SORT) physician, 528th Sustainment Brigade (SO)
(A) in Fort Bragg, NC. Maj Blyth is key clinical faculty for the San Antonio Uniformed Services Health Education Consortium Infectious Disease
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Fellowship Program and serves as an ADVISOR consultant. Ms Childs works as a medical plans and operations specialist with US Army Africa
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and is a PhD candidate, International Relations and Diplomacy, at the American Graduate School in Paris. SSG Kraft is a US Army combat
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medic with 10th Mountain Division (LI). LTC Robben previously served as the battalion surgeon for the 96th Civil Affairs Battalion (Airborne)
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and is currently a fellow in infectious diseases. LTC(P) Pamplin is the deputy director for the Telemedicine and Advanced Technology Research
Center and a critical care medicine physician.
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