Page 95 - JSOM Fall 2021

Telementorship in Underway Naval Operations

Leveraging Operational Virtual Health for Tactical Combat Casualty Care

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Lyndsey E. Wessels, MC, USN ; Michelle T. Roper, MC, USN ;
Romeo C. Ignacio, MC, USN ; Konrad L. Davis, MC, USN ; Art A. Ambrosio, MC, USN *
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ABSTRACT
Background: Virtual health (VH) may enhance mentorship to Field care encompasses all medical care occurring outside the
remote first responders. We evaluated the feasibility of syn- forward-operating hospital level, which may or may not si-
chronous bidirectional VH to mentor life-saving procedures multaneously be in a hostile environment. These first respond-
performed by deployed novice providers. Methods: Video tele- ers must be familiar with life-saving stabilization procedures,
conferencing (VTC) was established between the USNS Mercy such as competencies gained through TCCC or Advanced
(T-AH 19) underway in the Pacific Ocean to Naval Medical Trauma Life Support (ATLS), to optimize medical care. Risk
Center San Diego using surgeon teleconsultation. The adult and Hetzler define the care required during these phases as
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simulated clinical vignette included injuries following a ship- “damage control resuscitation,” and the skills required at that
board explosion with subsequent fire. The pediatric simulated vital phase of care must be “trainable, sustainable, and retain-
vignette included injuries that resulted from an improvised ex- able.” To enhance potential success rates, the performance of
plosive device (IED) blast. Using VTC, augmented reality (AR) prolonged field care must include surgical and procedural sup-
goggles, and airway simulation equipment, corpsmen (HMs) port by relatively novice healthcare providers.
received visual cues to perform advanced life-saving proce-
dures. Results: In adult scenarios, 100% of novice hospital VH, also referred to as telemedicine, is a mode of medical care
HMs performed tasks on first attempt (n = 12). Mean time delivery that can link expertise in medical and surgical trauma
for tourniquet placement was 46 seconds (standard deviation care to patients in remote or austere locations using various
[SD], 19 seconds); needle thoracostomy, 70 seconds (SD, 67 methods of communication, including asynchronous text or
seconds); tube thoracostomy, 313 seconds (SD, 152 seconds); email, as well as synchronous audiovisual transmission.
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and cricothyroidotomy, 274 seconds (SD, 82 seconds). In pe- Our goal was to perform a pilot study to examine the feasi-
diatric scenarios, 100% of novice HMs performed tasks on bility of synchronous bidirectional VH to facilitate life-saving
first attempt (n = 5). Mean time for tube thoracostomy com- procedures on simulated adult and pediatric trauma patients
pletion was 532 seconds (SD, 109 seconds). Conclusion: VH performed by novice operators aboard a United States Naval
can enhance the training and delivery of trauma care during Ship while deployed in the Pacific Ocean in order to enhance
prolonged field care in resource-limited settings. training in first-responder resuscitative techniques.

Keywords: Tactical Combat Casualty Care; thoracostomy tube;
cricothyroidotomy; augmented reality; tourniquet Methods
This pilot study was approved as an exempt quality-improve-
ment protocol by the Institutional Review Board at Naval
Medical Center San Diego (2018.0007 and 2018.0012), in
Introduction
compliance with all applicable federal regulations governing
Since 1996, the Department of Defense (DoD) Tactical Combat the protection of human subjects. Clinical vignettes simulating
Casualty Care (TCCC) Committee has created a set of guide- adult or pediatric trauma patients were used to remotely men-
lines that covers the three phases of care in the combat setting. tor hospital HMs in first-responder techniques in emergency
These include (1) Care Under Fire, (2) Tactical Field Care, and scenarios requiring advanced resuscitative maneuvers. The
(3) Tactical Evacuation (TACEVAC) Care. Forward-deployed outcome of interest was to determine the feasibility of using
medical providers may be in the position of providing pro- VH in this setting. The VH communications used for these
longed field care, which may include resuscitation prior to scenarios consisted of Microsoft HoloLens augmented reality
evacuation of the patient for definitive treatment. 1-4 goggles and VTC using a Cisco platform.
*Correspondence to the Department of Otolaryngology–Head and Neck Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive,
San Diego, CA 92101; or art.a.ambrosio.mil@mail.mil
1 LCDR Lyndsey E. Wessels is affiliated with the Department of General Surgery, Naval Medical Center San Diego, CA. LCDR Michelle T. Roper
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is affiliated with the Department of General Surgery, Naval Medical Center Camp Lejeune, Jacksonville, NC. CAPT (Ret) Romeo C. Ignacio
is affiliated with the Department of General Surgery, Naval Medical Center San Diego, and the Department of Trauma, Surgical Critical Care,
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Burns and Acute Care Surgery, University of California, San Diego (UCSD) School of Medicine, San Diego. CAPT Konrad L. Davis is affiliated
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with the Department of Tele-Critical Care, Virtual Medical Center Indo-Pacific, San Diego. CDR(s) Art A. Ambrosio is affiliated with the De-
partment of Tele-Critical Care, Virtual Medical Center Indo-Pacific, San Diego, and the Department of Otolaryngology–Head and Neck Surgery,
Naval Medical Center San Diego, San Diego.
Invited podium presentation at the 2019 American College of Surgeons (ACS) Clinical Congress held October 27–31, 2019, San Francisco, CA.
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