Page 127 - JSOM Fall 2020

Discussion conditions by SAR entities and concluded that telemedicine
has not yet been fully exploited largely because of structural,
This case series adds to the evolving literature of PFC and fo- practical, and policy issues inherent to the maritime environ-
cuses on a unique aspect: aerial insertion to remote ocean loca- ment. Teleconsultation can be a force-multiplier when used
8,9
tions. This analysis expands on previous work by providing effectively ; however, it requires some level of familiarization
9
greater detail on mission execution and patient care to help and technical rehearsal to be done well.
guide training and preparation for these long-range maritime
search-and-rescue missions.
Teleconsultation Training
In our data set, there were instances when the teleconsulting
Maritime rescue operations have been described in four sepa- physician asked the PJ to prepare a script and practice before
rate international case series. Of these, three were military SAR calling back, because the initial call was too disjointed to un-
entities from Norway, the United Kingdom, and France, and derstand. Our recommendation is to practice teleconsultation
4–7
one was a nonprofit organization in South Africa. Of these with a physician (preferably your medical director) during
few reports, none discussed long-range ocean rescues >300 NM PFC and full mission profile training. Perform each telecon-
from land. Aerial medical rescues beyond this distance require sultation using the AT MIST format: age, time, mechanism
the use of air-to-air refueling or medical providers capable of of injury or illness, injuries or illnesses, last set of vital signs,
parachuting from a fixed-wing aircraft to reach the patient.
treatments. The treatments should be discussed in MARCH
PAWS (massive bleeding, airway, respiration, circulation, head
In 2014, the PFC working group from the Special Operations and hypothermia, pain, antibiotics, wounds, and splinting)
Medical Association published 10 core competencies for ef- format. The PFC teleconsultation script is another useful for-
14
fective PFC. The lessons learned from these missions can be mat. An abbreviated version is available for download on the
10
broadly categorized into the core competencies of nursing care PFC website. 11
and teleconsultation and the noncore measures of medical
training and crew resource management. These lessons learned Teleconsulting Provider
should help inform ocean-rescue tactics, techniques, and pro- Through practice with familiar medical oversight, we have
cedures performed by USAF and other assets in both military seen improvement in communication during training and re-
and civil SAR settings.
al-world scenarios. The FS, as the local PJ medical director,
knows the capabilities and limitations of PJs on the objective.
Nursing Care and Hygiene When possible, specialist care recommendations should be
The core measure of nursing care and hygiene strives to ensure crosschecked or made in concert with the FS to ensure they are
the patient is clean, warm, dry, and receives basic wound care. compatible with the PJs’ capabilities, equipment, and mission.
Much of providing good patient hygiene revolves around mis-
sion planning, including adequate PPE and patient-care sup- Even if the patient care seems straightforward, it helps reas-
plies during initial pack out.
sure the PJ when teleconsultation is performed early and often.
• Hygiene: Prepare for patient hygiene issues by loading This is particularly true for medical illnesses, because these
baby wipes or washcloths, adult diapers, contractor bags scenarios are not practiced as regularly compared with trau-
for biowaste, extra boxes of gloves, or bring reusable matic injuries. Teleconsultation is crucial in cases that result
dishwashing gloves. in death or severe patient morbidity, because the PJ benefits
• Hydration: Oral rehydration can also help preserve sup- from the confirmation that he has done all that he can with
plies and limit pack-out needs. The judicious use of sips the resources available.
of water with medications for patients with acute abdo-
men who can swallow is acceptable if intravenous fluids Medical Training and Readiness
are in short supply.
• Vital signs monitoring: Being able to regularly and con- Resuscitation
cisely obtain, record, and interpret the trend of vital signs Although most combat medics know the indications and
is a skill that requires practice and repetition. Anecdot- techniques for blood transfusion in patients with traumatic
ally, some care providers prefer trending vital signs with hemorrhagic shock, most never train for the realities of admin-
a simple table format to a more complex nursing flow istering blood products over prolonged periods or for medical
sheet, such as those provided for download on the PFC patients, such as the patients with GI bleeding in this series.
website. 11 Ideally, such experience would come from clinical rotations
• Hypothermia prevention: Given this report’s prevalence in medical and surgical intensive care units where trainees
of burn patients, keeping the patient warm is of great participate in the planning and execution of the resuscitation
importance. Nakajima et al. studied the effect of long and monitor the response to treatment. Additionally, the use
12
transit times in a helicopter on patient body tempera- of a Foley catheter to monitor hourly urine output and the use
ture and the effect on patient outcome compared with of protocolized burn resuscitation algorithms are ways to im-
initial temperature. They found that, on average, body prove training and competence for maritime missions.
temperature dropped 0.36°C with any duration of air
transport. Additionally, in-hospital death was associ- Maintaining Airway Skills
ated with larger decreases in body temperature and hy- Establishing and maintaining an advanced airway, providing
pothermia during air transport. mechanical ventilation, administering continuous sedation for
hours to days, and troubleshooting each of these steps are core
Teleconsultation PFC skills in the management of a critical patient. These skills
Woldaregay et al. performed a literature review of telemed- can be augmented through time in the emergency department
13
icine services used in maritime, Arctic, and extreme weather and operating room, observing and performing rapid sequence
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