Page 95 - JSOM Winter 2022

The Challenges of Treating Complex Medical Patients

in the Role 2 Environment

A Case Series

Howard Ward, MD *; Nichole Downing, MD, MPH ;
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Shane Goller, MD ; Justine Stremick, MD, MPH 4

ABSTRACT
The Role 2 environment presents several challenges in diagnos- predicted in the civilian environment, however in an austere
ing and treating complex medical and life-threatening condi- military environment they are invariably changing due to tac-
tions. They are primarily designed to perform damage control tical considerations.
resuscitation and surgery in the setting of trauma with less
emphasis on complex medical care and limited ability to hold First, human factors compounding the difficulties already
patients for more than 72 hours. Providing care to Soldiers experienced in theater include limited personnel, exhaustion
and civilians in the deployed setting is made more difficult by hindering their decision-making capacities, and inadequate
the limited number of personnel, lack of advanced diagnostic training. Lack of appropriate personnel could mean the lack
equipment such as CT scanners, harsh working conditions, of anesthesiologists, postoperative nurses, radiologists, and
and austere resources. Despite these challenges, deployed phy- lab technicians. This creates additional stressors in an already
sicians have continued to provide high levels of care to injured stressful environment and may place personnel in roles that
Soldiers and civilians by using clinical judgment, validated they are not fully trained for.
clinical decision-making tools, and adjunct diagnostic tools,
such as ultrasound. In this case series we will present three The second factor is equipment. Most Role 2s do not have ac-
complex medical cases involving pulmonary embolism (PE), cess to cutting-edge technology, such as CT scanners, because
ventricular tachycardia (VT), and aortic dissection that were this requires stable electricity, the ability to transport and de-
seen in a deployed Role 2 setting. This article will highlight liver such equipment, personnel trained to operate the equip-
and discuss the challenges faced by deployed providers and ment and the cost of operation, amongst other limitations.
ways to mitigate these challenges.
The final considerations are the environment itself along with
Keywords: Role 2; damage control resuscitation; surgery; pul- local socioeconomic considerations. Military operations en-
monary embolism; ventricular tachycardia; aortic dissection counter different threats than civilian practice environments,
including hostile fire, darkness, necessary evacuations, and the
absence of clean water. The latter considerations can lead to an
environment that favors outbreaks of various diseases preva-
Introduction
lent in the area, leading to public health crises. In addition,
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Role 2 facilities are designed to provide a limited number roads may be dangerous to travel on or conditions may make
of medical services to include forward resuscitative care and flight unsafe, further limiting evacuation opportunities. 6
damage control surgery in a combat environment, namely for
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the goal of stabilizing patients for transfer to Role 3. Role 2 Despite these obstacles, deployed physicians have continued to
facilities come with their own challenges with limited ability to provide high level care to injured Soldiers and civilians. With
hold patients for more than 72 hours and an emphasis on in- the lack of diagnostic equipment comes a reliance on the phys-
jury over illness. The Role 2 medical treatment facility (MTF) ical exam and use of adjuncts like ultrasound to assist in their
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typically has the capability to provide limited blood products, diagnosis and disposition. In a system designed to care for
plain films, laboratory, operational dental support, combat trauma patients, complex medical patients bring unique chal-
and operational stress control, operational public health, and lenges. Here, we would like to present three separate cases seen
when augmented, physical therapy and optometry services. at a deployed combat Role 2 facility and discuss some of the
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Not only is the environment primarily designed for surgical challenges encountered in their diagnosis and treatment. The
interventions, but the efficiency of healthcare provided is Role 2 facility in which the cases took place does not fit neatly
dependent on a variety of factors. These factors can be bro- into the Forward Resuscitative Surgical Detachment (FRSD)
ken down into four separate categories: human, equipment, model since it was a North Atlantic Treaty Organization
environmental, and socioeconomic. These factors are easily (NATO) facility essentially set up as a Role 2. The facility had
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*Correspondence to hwj00117@gmail.com
1 CPT Howard Ward, CPT Nichole Downing, CPT Shane Goller, and MAJ Justine Stremik are emergency medicine physicians affiliated with
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Madigan Army Medical Center, Joint Base Lewis-McCord, WA.
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