Page 98 - JSOM Winter 2022

patients. Equipment such as CT scanners, personnel, and re- Disclosures
source limitations are some of the major challenges to the Role There is no financial gain or conflict of interest for any of the
2 clinician in landing the correct diagnosis and providing the authors involved in the presentation of these cases.
correct treatment to patients. In these cases, it is important to
use clinical judgment and all available resources, such as basic Disclaimer
labs, plain films, ECG, and ultrasound to provide initial diag- The views expressed are those of the author(s) and do not re-
nosis and treatment prior to transfer. flect the official policy of the Department of the Army, the
Department of Defense, or the US Government.
The lack of access to equipment such as a CT scanner brought
additional challenges to this Role 2 facility and personnel in Author Contributions
the above cases. The diagnosis of pulmonary embolism re- JS was involved in all the above-mentioned cases. HW, ND,
quired reliance on other diagnostic tools and clinical gestalt. and SG researched and edited this case series.
Given that the patient had a (falsely) negative D-dimer and
DVT ultrasound, it would have been possible for this PE to References
have been missed. However clinical concern for a PE based on 1. Ministry of Defence. Allied Joint Doctrine for Medical Support.
patient presentation led to treatment with aspirin and heparin, https://assets.publishing.service.gov.uk/government/uploads/
as well as transfer to a higher level of care for further workup system/uploads/attachment_data/file/922182/doctrine_nato_med_
spt_ajp_4_10.pdf. Accessed 9 August 2022.
and evaluation. Lack of CT scanning capabilities also proved 2. NATO Logistics Handbook. Chapter 16: medical support. https://
to lead to a diagnostic challenge in the case of the aortic dissec- www.nato.int/docu/logi-en/1997/lo-1610.htm. Accessed 9 August
tion. Clinical tools such as ECG, troponin, chest radiograph, 2022.
and US were used to assist with the diagnosis. These tools ulti- 3. Army Health System. 17 November 2020. https://armypubs.army.
mately led to transfer of the patient to a facility with appropri- mil/epubs/DR_pubs/DR_a/ARN31133-FM_4-02-000-WEB-1.pdf.
ate surgical capabilities. These two cases illustrate that while Accessed 9 August 2022.
CT scans may be the gold standard for the diagnosis of PE 4. Anagnostou E, Michas A, Giannou C. Practicing military medicine
in truly austere environments: what to expect, how to prepare,
and aortic dissection, Role 2 facilities can use other resources when to improvise. Mil Med. 2020;185(5–6):e656–e661.
and knowledge to make the appropriate diagnosis and begin 5. Toole MJ, Galson S, Brady W. Are war and public health compati-
treatment. ble? Lancet. 1993;341(8854):1193–1196.
6. Mann-Salinas EA, Le TD, Shackelford SA, et al. Evaluation of role
These cases demonstrate the challenges that medical teams 2 (R2) medical resources in the Afghanistan combat theater: initial
face when medically complex patients present to Role 2 fa- review of the joint trauma system R2 registry. J Trauma Acute Care
Surg. 2016;81(5 Suppl 2 Proceedings of the 2015 Military Health
cilities primarily designed for trauma care. Although Role 2 System Research Symposium):S121–S127.
facilities are equipped with the resources to treat a wide range 7. Kagima J, Stolbrink M, Masheti S, et al. Diagnostic accuracy of
of medical and trauma-related presentations, these complex combined thoracic and cardiac sonography for the diagnosis of
medical cases can push the limits of the Role 2 capabilities. pulmonary embolism: a systematic review and meta-analysis. PLoS
These cases highlight the fact that any pathology can present One. 2020;15(9):e0235940.
to a Role 2 facility and often require mental keenness, agile
thinking, and cognitive flexibility to arrive at the correct di-
agnosis. These cases also highlight the importance of clinical
acumen and creativity in the austere environment to render the
best care possible to those that we treat.

96 | JSOM Volume 22, Edition 4 / Winter 2022