PFC - Keenan - Winter JSOM PDF

An Ongoing Series
Prolonged Field Care for the Winter 2016 Edition

Sean Keenan, MD
with an introduction to the Virtual Critical Care Consultation (VC3) service. This educational case series
highlights actual cases managed in the field and the
benefit of clinical consultation from SOF Operators to
the expert consultation staff at military medical centers.
By informing the community of the practical application of teleconsultation, we hope to not only advertise
the service but also highlight the utility of this powerful
capability.
s the winter months approach, the community has

expanded the offerings in regard to Prolonged Field
Care (PFC) submissions. This issue marks a landmark
for the PFC Working Group (WG), with submissions
from multiple unique efforts that sprung from the original PFC WG analysis of PFC capabilities and knowledge
gaps in the force. By communicating the needs of Special
Operations Forces (SOF) to the greater Department of
Defense medical infrastructure, USSOCOM was able to
harness the talents of medical subspecialists to directly
support and, ultimately, enhance the resources for SOF
Medics in the field.
We also have a case report from the field of a presentation of combat trauma that morphed from a typical
TCCC scenario into a complex case involving PFC. This
case adroitly illustrates the operational constraints and
challenges of direct combat on patient management and
serves as a reminder of the realities of combat.
Included in this edition is a second Clinical Practice

Guideline (CPG), authored by the Joint Trauma System
medical experts, in conjunction with operational SOF
authors, for the practical management of burn casualties in austere environments. Based on the expertise
and framework of the original surgical CPG for burn
management, this CPG blends best practices from the
Institute of Surgical Research Burn Unit, with other PFC
CPGs and guideline papers, to provide practical, realistic tools to SOF medics. We hope it will inform current
protocols and teaching in the community.
We hope that you find these articles informative and

useful, as both teaching tools and reference documents.
If you have clinical cases that demonstrate the complexities of a PFC environment or highlight the advanced application of SOF medicine, please submit them to the
Editor to include in future editions of the Journal.
Thank you for your continued interest, and joining us in
this exciting effort to advance SOF medicine!
Additionally, we have the beginning of a relevant series

from our first Sub-Working Group in telemedicine,
86
Management of Burn Wounds Under Prolonged Field Care

Leopoldo C. Cancio, MD; Doug Powell, MD; Britton Adams, NREMT-P, ATP;
Kenneth Bull, MD; Alexander Keller, MD; Jennifer Gurney, MD; Jeremy Pamplin, MD;
Stacy Shackelford, MD; Sean Keenan, MD
his Role 1, prolonged field care (PFC) guideline is intended to be used after Tactical Combat Casualty Care
(TCCC) Guidelines, when evacuation to higher level of
care is not immediately possible. A provider of PFC must
first and foremost be an expert in TCCC. This Clinical
Practice Guideline (CPG) is meant to provide medical professionals who encounter burns in austere environments
with evidence-based guidance. Recommendations follow
a best, better, minimum format that provides alternate or improvised methods when optimal hospital options are unavailable. A more comprehensive guideline for
burn care is available in the Joint Theater Trauma System
Clinical Practice Guideline (JTS CPG) for Burn Care at
http://www.usaisr.amedd.army.mil/cpgs.html.
Patients with smoke inhalation injury may

present with a range of symptoms in terms of
severity.
Patients with severely symptomatic smoke inhalation injury (e.g., respiratory distress, stridor)
require immediate definitive airway (cuffed tube
in trachea) because they are at risk of immediate
airway loss. Oxygenate and ventilate.
All patients with burns covering >40% TBSA
should be intubated because total-body swelling
will tend to obstruct the airway. Patients with
facial burns around the mouth may require intubation (Figure 1).
Figure 1 Severe facial burns with airway secured.
Burns covering >20% of the total body surface

area (TBSA), or those with smoke inhalation injury (and airway or breathing problems), are life
threatening. Burns that affect vision, decrease
hand function, or cause severe pain can take the
warfighter out of action.
Hypothermia risk is high in burn patients. Anticipate that all burn casualties will become hypothermic and take immediate measures to prevent it by
covering patient. Aggressively rewarm if temperature falls below 36C (96.8F).
Best: Rapid-sequence intubation by skilled
provider, followed by continuous sedation
and airway maintenance, supplemental oxygen, portable ventilator.
Better: Cricothyroidotomy followed by continuous sedation and airway maintenance,
supplemental oxygen via an oxygen concentrator, portable ventilator.
Minimum: Cricothyroidotomy, ketamine,
ambu bag with positive end-expiratory pressure (PEEP) valve.
Notes:
Patients with mild symptoms of smoke inhalation injury (e.g., some cough, no respiratory distress) can be observed.
Telemedicine: Management of burns is complex. Also, burns are highly visual and a lot can
be communicated via pictures or video. Establish
telemedicine consult as soon as possible.
US Army Institute of Surgical Research
(USAISR) Burn Center
DSN 312-429-2876 (429-BURN)
Commercial (210) 916-2876 or (210) 222-2876
E-mail to burntrauma.consult.army@mail.mil
Airway management:
Goal: Avoid airway obstruction due to inhalation
injury or burn-induced swelling.
87
Burns or explosions in a closed space are associated with higher risk of inhalation injury
than burns occurring in open areas.
Supraglottic airway (e.g., laryngeal mask
airway [LMA], King LT [Ambu, http://www
.ambuusa.com/], or Combitube [Medtronic
Minimally Invasive Therapies, http://www
.medtronic.com/covidien]) is not appropriate because edema will continue to increase
over 48 hours and these tubes do not overcome vocal-cord edema.
Endotracheal tube must be secured circumferentially around the neck using cotton ties
or similar. Tape does not stick to the face
well enough in burn patients.
Place nasogastric (or orogastric) tube to decompress stomach in intubated patients.
Perform frequent endotracheal suction of intubated patients to ensure tube patency and
remove mucus/debris (approximately once
an hour or more frequently if oxygen saturation [SpO2] drops).
If there is evidence of inhalation injury, use
35mL of endotracheal saline to facilitate
suctioning and prevent tube insipation and
obstruction.
Monitoring end-tidal CO2 is an important
capability for all intubated patients. A rising end-tidal CO2 could indicate clogging of
endotracheal tube or poor ventilation from
another cause (e.g., bronchospasm, tight eschar across chest).
Use PEEP on all intubated patients.
Perform a surgical escharotomy of the chest
for tight, circumferential, full-thickness
burns that impair breathing. Incision goes
through the full thickness of the burn and
into the fat (Appendix A). Expect some pain
and bleeding.
Use bronchodilators (e.g., albuterol inhaler)
for intubated patients with inhalation injury,
if available.
Ventilator management of burn patients can be
complicated and evolve as pulmonary conditions change
due to volume overload/edema and acute respiratory
distress syndrome (ARDS). Telemedicine consultation
with skilled providers is recommended.
Assess Burn Size:
Goal: Accurately identify burn wound size to
identify appropriate fluid resuscitation needs.
Estimating burn wound size may be difficult. Engage remote specialty consultants early. If possible, send
pictures of wounds that have been cleaned and debrided.
88
Note: Significant over- or underestimation of

burn wound size (by more than 10%) may lead to
significant morbidity. Underestimation may lead to
under-resuscitation and organ failure (i.e., renal
failure, shock); overestimation may lead to resuscitation morbidity (i.e., respiratory failure, compartment syndromes).
1st degree (superficial) burns look like a
mild-moderate sunburn. They appear red,
blanch readily, do not blister, and hurt when
touched. Do NOT include these wounds in the
estimation of TBSA used for fluid resuscitation
(Figure 2).
2nd degree (partial thickness) burns are
moist, blister, blanch, and hurt. Include these
wounds in the TBSA estimation (Figure 3).
3rd degree (full thickness) burns appear
leathery, dry, nonblanching, do not hurt, and
often contain thrombosed vessels that are visible. Include these wounds in the TBSA estimation (Figure 4).
Best: When wounds are cleaned/debrided, recalculate TBSA using the Lund-Browder chart
(Appendix B).
Better: Same as minimum.
Minimum: For small wounds, calculate the size
of the wound by using the patients hand size
(including fingers) to represent a 1% TBSA.
For larger wounds, calculate the patients initial burn size using the Rule of Nines (Appendix C).
Fluid Resuscitation:
Goal: Over the first 2448 hours postburn,
plasma is lost into the burned and unburned tissues, causing hypovolemic shock (when burn size
is >20%). The goal of burn-shock resuscitation
is to replace these ongoing losses while avoiding
over-resuscitation.
Best: Isotonic crystalloids (e.g., lactated Ringers, Plasma-Lyte IV [Baxter, http://www.baxter

.com/]);
Start intravenous (IV) or intraosseous (IO)
administration IMMEDIATELY
IV/IO can be placed through burned skin if
necessary.
NO bolus (unless hypotensive, in which case,
bolus only until palpable pulses are restored)
Initial IV rate 500mL/h; start while completing initial assessment
Adults: measure burn size (TBSA) and multiply by 10. This is now your IV fluid rate. For
Journal of Special Operations Medicine Volume 16, Edition 4/Winter 2016
Figure 2 First-degree burns. (Do not include these wounds in
the TBSA estimate!)
(A) Sunburn.
example, if the burn size is 30%: 30 10 =

300. Starting rate is 300mL/h.
For patients with weight >80kg, add an extra
100mL/h for each 10kg. For example, for a
100kg patient with 30% burns, the starting
rate is 300mL/h + 200mL/h = 500mL/h.
If resuscitation is delayed, DO NOT try
to catch up by giving extra fluids.
For children, 3 TBSA body weight in
kg gives the volume for the first 24 hours.
One half is given during the first 8 hours.
Better: enteral (oral or gastric) intake of electrolyte solution
Sufficient volume replacement will require
coached drinking on a schedule using approximately the same amount of fluids that
would be given IV/IO (see above).
Oral resuscitation of patients with burns up
to about 30% TBSA is possible (see Hydration box below).
If a nasogastric tube (NGT) is available,
it is preferable to resuscitate with infusion
of electrolyte solution via NGT (e.g., 300
500mL/h. But watch for nausea/vomiting.
Minimum: rectal infusion of electrolyte solution
Rectal infusion of up to 500mL/h can be
supplemented with oral hydration (see Hydration box below)
Monitoring:
Goal: maintain adequate oxygenation and ventilation, avoid hypotension, trend response to resuscitation. Document blood pressure (BP), heart
rate (HR), urine output (UO), mental status, pain,
pulse oximetry, and temperature, and record data
on a flowsheet (Appendix D).
(B) Mostly first-degree burns with small area of superficial second degree.
The principles of hypotensive resuscitation

according to TCCC DO NOT apply in the setting
of burns (without severe bleeding).
HOWEVER
In the unusual setting of burns associated with
noncompressible (e.g., thoracic, abdominal, pelvic)
hemorrhage, aggressive fluid resuscitation may result in increased hemorrhage. Balancing the risk of
uncontrolled hemorrhage against the risk of worsening burn shock from under-resuscitation should
be guided by expert medical advice (in-person or
telemedicine). Be prepared for blood transfusion.
PFC Guideline: Burn Management
Hydration
Plain water is ineffective for shock resuscitation
and can cause hyponatremia. If using oral or rectal
fluids, they must be in the form of a premixed or
improvised electrolyte solution to reduce this risk.
Examples:
World Health Organization (WHO) Oral Rehydration Solution (per package instructions or 1L
of potable water with 6 level teaspoons sugar,
0.5 level teaspoon salt)
Mix 1L of D5W solution with 2L of Plasma-Lyte
Per 1L water: add 8tsp sugar, 0.5tsp salt, 0.5tsp
baking soda
Per quart of Gatorade (Stokely-Van Camp Inc.,
http://www.gatorade.com/): add 0.25tsp salt,
0.25tsp baking soda (If no baking soda, double
the amount of salt in the recipe.)
89
Figure 3 Second-degree burns.
Figure 4 Third-degree burns.
(A) Second-degree burn with intact blisters.
(A) Third-degree burn with eschar.
(B) Third-degree burn before cleaning and debridement of loose, dead

skin.
(B) Deep (D), intermediate (I), and superficial (S) second-degree burns.
Vital signs
Best: Portable monitor providing continuous vital-signs display; capnography if intubated; document vital-signs trends frequently
(every 15 minutes initially, then every 30
60 minutes once stable for more than 2
hours).
Better: Capnometry in addition to minimum
requirements (if intubated).
Minimum: blood-pressure cuff, stethoscope,
pulse oximetry, document vital-signs trends
frequently.
Urine output
Urine output is the main indicator of resuscitation adequacy in burn shock.
Goal: adjust IV (or oral/rectal intake) rate to UO
goal of 3050mL/h. For children, titrate infusion
rate for a goal UO 0.51 mL/kg/hr.
Best: place Foley catheter
If UO too low, increase IV rate by 25% every
12 hours (e.g., if UO = 20mL/h and IV rate =
90
(C) Third-degree burn after cleaning and debridement and escharotomy.
(D) Extensive third-degree burns with eschar formation.
300mL/h, increase IV rate by 0.25 300 =

75mL/h. New rate is 375mL/h.)
If UO too high, decrease IV rate by 25%.
Better: Capture urine in premade or improvised
graduated cylinder
Collect all spontaneously voided urine
hourly and carefully measure; >180mL every
6 hours is adequate for adults.
A Nalgene (Thermo Fisher Scientific Inc.,
http://www.nalgene.com/) water bottle is an
example of an improvised graduated cylinder.
Minimum: use other measures
If unable to measure UO, adjust IV rate to
maintain HR less than 140, palpable peripheral pulses, good capillary refill, intact mental status.
Measure the BP and consider treating hypotension, but remember: BP does not decrease
until relatively late in burn shock, because
of catecholamine release. On the other hand,
BP may be inaccurate (artificially low) in
burned extremities.
Note: Electric injury
Patients with high-voltage electric injury
causing muscle damage and gross pigment in
the urine (and similar patients, such as rhabdomyolysis or crush injury) have a higher
target UO of 70100mL/h in adults. See PFC
Crush CPG.
If this does not cause gradual clearing of the
pigment (urine turns lighter on three or four
hourly checks), the patient likely needs urgent
surgery for decompression/debridement.
Extremity Burns:
Burned extremities are vulnerable to injury from
postburn swelling.
Goal: Prevent and manage swelling (edema) of
burned extremities to prevent long-term damage.
Best: Elevate burned extremities above heart
level. Encourage patient to exercise burned extremities to decrease edema. Monitor peripheral
pulses on all burned extremities hourly, using
a Doppler flowmeter if available. Perform escharotomies of circumferential burns to restore
blood flow (Appendix A). Anticipate blood loss
and prepare for blood transfusion.
Obtain teleconsultation.
Better: Consider doing escharotomies for circumferential full thickness (3rd degree) burns of
an extremity if extremity is edematous, you are
unable to palpate distal pulses, and evacuation
will be delayed. Anticipate blood loss and prepare for blood transfusion.
Obtain teleconsultation.
Minimum: Triage patient to more rapid evacuation if extremity is edematous and you are
unable to palpate distal pulses. Elevate burned
extremities above heart level and have patient
exercise or provide passive range of motion
(PROM) to burned extremities to mobilize
edema. Provide pain control to enable PROM.
Pain Management:
Refer to Analgesia and Sedation CPG.
Burns can be painful and can cause hypovolemia.
Thus, frequent, smaller doses of an IV opioid or
ketamine are preferred.
In hypovolemic burn patients, ketamine can be
used for severe pain or for painful procedures,
but less than the full anesthetic dose is safer
(e.g., 0.10.2mg/kg IV push, assess response
and redose ketamine as needed every 510
minutes).
For prolonged care of burn patients, a ketamine infusion may provide more consistent
analgesia and help conserve supplies of analgesic medications.
Burn wound care is extremely painful. Ensure
an adequate supply of analgesic agents is available before starting wound cleaning, debridement, escharotomy, or dressing change. Refer
to Analgesia and Sedation CPG or obtain telemedicine advice for adequate dosing of procedural analgesia for burn care.
Consider administering an oral or IV benzodiazepine for anxiety (common with repeated
painful wound care).
Infection:
Burn wounds are easily infected.
Goal: Prevent burn wound infection through
wound care. If evacuation to higher level of care
is anticipated within 24 hours, simply cover burns
with clean, dry gauze and leave intact blisters in
place. Always avoid wet dressings, because of the
risk of hypothermia. If evacuation is not anticipated for more than 24 hours, and time, medication, and human resources permit, provide wound
care as soon as possible after the injury (within
the first 24 hours). If resources are not available
initially, provide wound care as soon as possible.
Best: Clean wounds and debride loose dead
skin by scrubbing gently with gauze and
chlorhexidine gluconate solution (e.g., Hibiclens, Mlnylcke Health Care, http://www.
hibiclens.com/) in clean water; apply topical
antimicrobial cream (silver sulfadiazine [Silvadene, Pfizer Inc., http://www.pfizer.com/] or
mafenide acetate [Sulfamylon, Mylan, http://
www.mylan.com/]), followed by gauze dressing. Repeat daily.
91
Alternative: instead of cream, use silver nylon dressing (Silverlon, Argentum Medical,
http://www.silverlon.com/), covered by gauze
dressing.
Silverlon can be left in place for 35 days as
long as the wound is clean when the Silverlon is applied.
The outer gauze dressings (e.g., Kerlix [Covidien]) should be moistened (not soaked) at
least daily. Use sterile (or at least clean, uncontaminated) water or normal saline.
The outer gauze dressings should be changed,
leaving the Silverlon in place, sooner than 3
days if they become saturated with exudate
or otherwise dirty.
If the patient develops any evidence of infection, the Silverlon must be removed and the
wound inspected sooner than 35 days.
The Silverlon can be removed and cleaned
in sterile, or at least clean uncontaminated,
water and reused for up to 5 days.
Better: Clean wounds and debride loose dead
skin by washing with any antibacterial soap in
clean water, dress wounds with any available
dressings; optimize wound and patient hygiene
to the extent possible given environment.
Minimum: Cover with clean sheet or dry gauze.
Leave blisters intact. Avoid wet dressings.
Antibiotics
IV or oral antibiotics are not normally used
for prophylaxis in burn patients in the absence of other open wounds requiring them
(e.g., open fractures.)
After several days, if patient develops cellulitis (spreading erythema around edges of
burn), treat for gram-positive organisms,
(e.g., cefazolin or clindamycin).
If patient develops invasive burn wound infection (signs: sepsis/septic shock, changes
in color of wound, possible foul smell of
wound), treat with broad-spectrum antibiotics to include gram-positive and gram-negative coverage that ideally includes coverage
for Pseudomonas aeruginosa (e.g., ertapenem + ciprofloxacin).
Fluid and equipment planning considerations. See Appendix E.
Summary Table. See Appendix F.
MAJ Powell, MC, USA, is an intensive care physician cur-
rently serving as the 4th Battalion 3rd Special Forces Group

(Airborne) Surgeon and a staff intensivist at Womack Army
Medical Center.
MSgt Adams, USAF, is an IDMT-P, FP-C, ATP, and Combat Aviation Advisor with the Air Force Special Operations
Air Warfare Center (AFSOAWC)/Irregular Warfare Directorate, where he directs/coordinates Aviation Foreign Internal
Defense/Global Health Engagement missions in Special Operations Command Africa (SOCAF). He has served multiple
deployments to Iraq/Afghanistan and Africa supporting Base
Support Operations, casualty evacuations (CASEVAC) and
the CAA TCCC/CASEVAC missions. He also works part-time
as a civilian critical care flight paramedic.
LT Bull, MC, USN, formerly the Battalion Surgeon for 3d
Marine Raider Battalion, Marine Special Operations Command, is a family medicine resident at Naval Hospital Camp
Lejeune. He is also a Navy Undersea Medical Officer.
Maj Keller, MC, USAF, is an emergency medicine physi-
cian serving as the group surgeon for the 720th Special Tactics Group (AFSOC). He previously served as a CSAR flight
surgeon with multiple deployments to Iraq and Afghanistan
supporting rescue forces. Maj Keller is also an experienced
tactical EMS provider having provided support to multiple
law enforcement agencies to include the Dayton Police Department SWAT and Vice Squad, as well as the FBI.
LTC Gurney, MC USA, is a general, trauma, and burn surgeon and currently works as the Chief of Trauma Systems Development, Joint Trauma System, and the Deputy Director of
the Burn Center in San Antonio, Texas. She has multiple deployments to Iraq and Afghanistan as part of Combat Support
Hospitals and Forward Surgical Teams.
LTC Pamplin, MC, USA, is a board-certified intensivist and
is currently the Director of Virtual Critical Care at Madigan
Army Medical Center, Joint Base Lewis-McChord, Washington. Previously, he was the Director of the US Army Burn Intensive Care Unit and Chief of Clinical Trials in Burns and Trauma
at the US Army Institute of Surgical Research, San Antonio,
Texas, and has served as the Simulation and Training Director
for the Extracorporeal Membrane Oxygenation Program, San
Antonio Military Medical Center, and the Director of the Surgical Intensive Care Unit, Brooke Army Medical Center.
Col Shackelford, MC, USAF, is a trauma surgeon, currently serving as the Chief of Performance Improvement, Joint
Trauma System, San Antonio, Texas. She is a member of the
Committee on TCCC and has previously deployed as the director of the Joint Theater Trauma System.
COL Keenan, MC, USA, is a board-certified emergency
COL (Ret) Cancio, MC, USA, is the senior burn surgeon at
the US Army Burn Center. He directs the Multi-Organ Support

Task area. He deployed as 504 Parachute Infantry Regiment
92
Surgeon, 82d Airborne Division, Operation Just Cause and

Desert Storm; with SOCCENT and 86th Combat Support
Hospital during Operation Iraqi Freedom; and with a Forward Surgical Team during Operation Enduring Freedom.
medicine physician, and is currently serving as Command Surgeon, Special Operations Command, Europe. He has previously served as Battalion Surgeon in both 1st and 3rd SFG(A),
and as Group Surgeon, 10th SFG(A). He is the coordinator
for the SOMA Prolonged Field Care Working Group. E-mail:
sean.keenan1.mil@mail.mil.
Appendix A Escharotomy incisions
The incisions on the extremities are placed along the mid-medial and/
or mid-lateral joint lines. The bold lines indicate the importance of
always carrying the incisions across any involved joints. The incisions
on the chest are intended to free up a mobile plate of tissue to restore adequate chest movement with breathing. Source: Figure 26.1,
p. 379, Chapter 26 (Burns). In: Anonymous, Emergency War Surgery,
4th United States Revision. Fort Sam Houston, TX: Office of the Surgeon General, Borden Institute, 2013.
Figure A1 Photograph of a patient undergoing escharotomy
Figure A2 Photograph of a patient undergoing escharotomy
of the leg, using electrocautery. The goal is to go through the

burned skin into viable tissue (i.e., subcutaneous fat).
of the leg and foot, using a scalpel. When using a

scalpel, there may be increased blood loss compared to
electrocautery, as shown here.
93
Appendix B Lund and Browder Burn Wound Calculation Worksheet
Burn Estimate and Diagram (Age vs. Area)
Appendix C Rule of Nines Burn Wound Calculation

Use this image to calculate the percent of total body surface area (%TBSA)
involved by second and third degree burn wounds (do NOT include first
degree wounds in this assessment). Example: Second and third degree
wounds involving the entire anterior torso and right upper extremity,
front and back, would be cover 27% TBSA. If this wound had scattered
areas of unburned skin and/or first degree burns, adjust the %TBSA
downward. %TBSA is an estimate. Both over- and underestimates have
potential negative impacts on a patients resuscitation.
94
95
24th
23rd
22nd
21st
20th
19th
18th
17th
16th
15th
14th
13th
12th
11th
10th
9th
8th
7th
6th
5th
4th
3rd
2nd
1st
HR from burn
Local Time
Date and Time of Injury
Name
Crystalloid*
(LR) /
Colloid
SSN
Total
Base Deficit /
Lactate
Calculate Rule of Tens

(if >40<80kg, %TBSA
10 = starting rate for LR
Calculate max 24hr

volume (250mL kg)
Avoid overresuscitation,
use adjuncts if necessary
Heart Rate
MAP
(>55) / CVP
(68mmHg)
Pressors
(Vasopressin 0.04 U/min)
Bladder Pressure (Q4)
BAMC/ISR Burn Team DSN 312-429-2876: Yes No
%TBSA
(Do not include superficial
1st degree burn)
*Titrate LR hourly to maintain adequate UOP (30-50mL/hr) and tissue perfusion
UOP
(Target
30-50mL/hr)
Preburn
est. wt (kg)
Initial Treatment Facility
BAMC/ISR, Brooke Army Medical Center/Institute of Surgical Research; CVP, central venous pressure; est wt, estimated weight; HR, heart rate; LR, lactated Ringers solution; MAP, mean arterial
pressure; max, maximum; Tx, therapy; UOP, urine output.
Total Fluids: (Use adjuncts if >24hr max)
Tx Site/
Team
Date
Appendix D Joint Trauma System (JTS) Burn Resuscitation Flow Sheet
Appendix E Fluid and equipment planning considerations
Assumptions: one patient with a 50% total body surface area (TBSA) burn, weighing 80kg, and requiring 4mL/kg/%TBSA for resuscitation the first day
(16L), half that the second day (8L), and half that
the third day (4L). Note: For planning purposes only,
the Parlkand formula of 4mL/kg/%TBSA provides
an estimate for the first 24-hour fluid requirements;
however, hourly fluid resuscitation should start with
the rule of 10s.
Best:
Fluids: IV fluid (lactated Ringers solution or

Plasma-Lyte) to provide resuscitation for 72
hours (28L)
Equipment: Portable monitor with capnography; lab capability for serum electrolytes, arterial blood gases, and lactate; Foley catheter with
graduated collection system; portable ventilator; portable suction; electrocautery or scapel;
oxygen or oxygen concentrator; airway management kit to include endotracheal suction
catheter
Medications: pain medications (refer to Analgesia, Sedation CPG)
Burn-specific dressings: Hibiclens to clean
wounds, Silvadene and/or Sulfamylon cream
(two 400g jars per patient per day), or silver nylon (Silverlon) dressings
Nonspecific dressings: roller gauze, torso dressings, tape or stapler
Hypothermia prevention: sleeping bag or Hypothermia Prevention & Management Kit (HPMK)
Monitoring: Portable monitor providing continuous vital-signs display; capnography, if intubated; document vital-signs trends, intake and
output, GCS, and pain level on a regular basis;
burn-resuscitation flow sheet
Communications: real-time video telemedicine
consultation
Push-pack capability: prepackaged additional
24-hour supplies of fluids, dressings for scenarios >24 hours or >1 patient
96
Better:
Fluids: IV fluid (lactated Ringers solution or

Plasma-Lyte) to provide resuscitation for 24
hours (16L); oral electrolyte replacement
Equipment: Blood pressure cuff, stethoscope,
pulse oximeter, capnometer, portable ventilator,
oxygen or oxygen concentrator, airway management kit to include endotracheal suction
catheter
Graduated container to monitor urine output
Pain medications
Nonspecific dressings: roller gauze, torso dressings, tape or stapler
Hypothermia prevention: sleeping bag/HPMK/
Blizzard Blanket (Blizzard Protection Systems
Ltd., http://www.blizzardsurvival.com/)
Monitoring: Frequent vital signs, examination,
fluid input, urine output, flowsheet to document
Communications: telephone; e-mail digital
photos
Minimum:
Fluids: Resuscitation with commercial or improvised electrolyte solution (oral, enteral, rectal)
Equipment: Blood pressure cuff, stethoscope,
pulse oximeter, bag-valve mask with positive
end-expiratory pressure (PEEP) valve, airway
management kit
Graduated or improvised graduated container
to monitor urine output
Pain medications
Clean sheet, any available trauma dressings
Hypothermia prevention: sleeping bag/emergency blanket/blankets
Monitoring: Frequent vital signs, examination,
fluid input, urine output documented on preprinted or improvised flowsheet
Communications: telephone
Appendix F Summary Table
Airway
Best
Rapid-sequence intubation
Continuous sedation + airway maintenance and suctioning
O2 and portable ventilator
Better
Cricothyroidotomy
Continuous sedation + airway suctioning
O2 concentrator and portable ventilator
Minimum
Cricothyroidotomy
Ketamine
Bag-valve mask with PEEP valve
Assess Burn Size

Best
For initial estimate: Rule of 9s

After wounds are cleaned/debrided: recalculate burn size using Lund-Browder chart
Better
Same as minimum
Minimum
For large burns: Rule of 9s

For small burns: Patients hand = 1% TBSA
Fluid Resuscitation
Best
Use isotonic crystalloid (lactated Ringers or Plasma-Lyte)

Starting fluid rate calculated by Rule of 10s (TBSA 10; +100mL/h for each 10kg over 80kg)
Better
Oral resuscitation with electrolyte solution (avoid plain water)

Possible for up to 30% TBSA burns
Coached drinking on a schedule to meet target fluid rate
Minimum
Rectal infusion of electrolyte solution

Can infuse up to 500mL/h
May use to supplement oral hydration
Teleconsultation
Establish contact early

Ventilator management
Measuring burn size
Hemorrhagic shock + burns
Burn >20% TBSA

Electrical burn
Escharotomy needed
Infection
Monitoring
Vital Signs
Best
Portable monitor
Capnography
Document vital signs (VS) and intake/output (I/O) on flow sheet
Better
Blood pressure (BP) cuff, stethoscope

Pulse oximetry, capnometry
Document VS and I/O on flow sheet
Minimum
BP cuff, stethoscope
Pulse oximetry
Document VS on flow sheet
Urine Output
Best
Foley catheter, titrate fluids to keep urine output (UO) 3050mL/h

Increase or decrease fluid rate by 25% each hour if UO not at goal
Better
Collect urine in graduated container

>180mL every 6 hours is adequate
Minimum
If unable to measure UO, adjust fluids to maintain HR <140, good capillary refill, intact
mental status
Treat hypotension if needed, but this is a late sign of hypovolemia
(continues)
97
Appendix F Summary Table (cont.)
Extremity Burns
Best
Elevate, exercise
Monitor pulses hourly, Doppler flowmeter
Escharotomy if circumferential third degree burn
Better
Elevate, exercise
Monitor pulses hourly
Escharotomy only if unable to palpate distal pulses and evacuation delayed
Minimum
Elevate, exercise
Monitor pulses hourly
Pain Management
Best
Ketamine infusion
Supplement with IV opioids and midazolam (e.g., Versed), frequent small doses
Better
Ketamine IV
Supplement with IV opioids and midazolam, frequent small doses
Minimum
Fentanyl lozenge
Oral acetaminophen/oxycodone (e.g., Percocet, Endo Pharmaceuticals, http://www.endo.com/)
Infection
Prevent Infection
Best
Clean wound and debride loose dead skin using gauze and Hibiclens in clean water
Apply antimicrobial cream (Silvadene or Sulfamylon, cover with gauze)
Alternative: Apply Silverlon dressings to clean wounds, cover with gauze
Better
Clean wound and debride loose dead skin using any antibacterial soap in clean water
Apply any available dressing
Optimize wound care and hygiene to extent possible
Minimum
Cover with clean sheet or dry gauze

Leave blisters intact
Treat Infection
Best
If cellulitis (spreading erythema around edge of burn), treat with IV antibiotics (e.g., cefazolin or
clindamycin)
If invasive infection with sepsis, foul smell, or burn wound color change, cover gram-positive, gramnegative, and Pseudomonas bacteria (e.g., ertapenem + ciprofloxacin)
Better
Same as minimum
Minimum
If cellulitis (spreading erythema around edge of burn) or invasive infection, treat with any available
antibiotic
98
Prolonged Field Care of a Casualty

With Penetrating Chest Trauma
Case Report
Graham Barnhart, 18D; William Cullinan, 18D; Jason Pickett, MD
ABSTRACT
a medical treatment facility.3 Implications of prolonged
evacuation times are profound in todays conflicts, because TCCC does not address prolonged prehospital
care of the trauma casualty. As part of an analysis of
current and future SOF missions, the Special Operations
Medical Association (SOMA), in conjunction with US
Special Operations Command (SOCOM), initiated the
Prolonged Field Care Working Group in December of
2013, with the intent of creating guidelines and position
papers to support training and education for medics to
conduct extended casualty care in the field.
As Special Operations mission sets shift to regions with

less coalition medical infrastructure, the need for quality long-term field care has increased. More and more,
Special Operations Medics will be expected to maintain
casualties in the field well past the golden hour with
limited resources and other tactical limitations. This
case report describes an extended-care scenario (>12
hours) of a casualty with a chest wound, from point of
injury to eventual casualty evacuation and hand off at
a Role II facility. This case demonstrates the importance
of long-term tactical medical considerations and the
effectiveness of minimal fluid resuscitation in treating
penetrating thoracic trauma.
Case Presentation
A partner-enabled helicopter assault operation was
planned and conducted by a US Army Special Forces
(SF) Operational Detachment Alpha (ODA) and the
Afghan counter narcotics interdiction unit (NIU) targeting a series of narcotics manufacturing facilities.
The target objective was well within the golden hour
of medical evacuation (MEDEVAC) flight, so prolonged
field care was not expected to be a necessity during mission planning. Additionally, because the mission called
for a helicopter assault, supplies were limited to what
could be easily carried and dispersed among the partner
force. Threat assessment led the 18Ds to bring a North
American Rescue WALK Kit Bag (http://www.narescue.
com) stocked with additional supplies in anticipation
of prolonged field care. This included North American
Rescue hypothermia kits, Chinook chest-tube kits, and
field blood-transfusion kits (Tactical Medical Module
FBTK). However, it was assumed that use of the field
blood-transfusion kits would be reserved for American casualties (US to US) as the blood types of the Afghan NIU members were unknowndried plasma was
unavailable. Each 18D carried an identical supply of
tranexamic acid (TXA), narcotics, and antibiotics sufficient to provide prolonged care to several casualties.
KEYWORDS: prolonged field care; chest trauma, penetrating;

resuscitation, fluid
Introduction
With the drawdown of combat troops and medical assets in Afghanistan, smaller deployed forces operate in
areas of low-intensity conflict globally, with minimally
developed US medical facilities. The Special Operations
Forces (SOF) Medic must be prepared to care for surgical casualties for an extended time until arrival at a
facility with definitive surgical care, and may need to
rely on host-nation medical capabilities within many
theaters of operation. Terrain, weather, and operational
considerations also may impact evacuation times in areas where prolonged field care would not otherwise be
expected. Movement of casualties may cross national
borders, using multiple evacuation platforms, many of
which may not be outfitted for casualty care.
Application of Tactical Combat Casualty Care (TCCC)
principles at the point of injury has helped reduce
the number of troops dying of potentially survivable
wounds among US casualtiesfrom 24% to 3% in
Operation Iraqi Freedom and Operation Enduring
Freedom, respectively.1,2 Nevertheless, the majority of
combat deaths occur before the casualty ever reaches
During the assault, a male Afghan officer, approximately

32 years old, was injured when the enemy initiated a coordinated small arms attack at around 1300. An 18D
99
collocated with the casualty conducted an initial assessment under fire, identifying what appeared to be a
gunshot wound to the left upper chest approximately
3 inches below the clavicle and 1 inch medial to the
midclavicular line. Further assessment also revealed a
4-inch contusion with significant ecchymosis along the
casualtys left lower posterior rib cage. The casualty was
conscious, ambulatory, and able to move under his own
power with direction from the 18D to a covered position south of the main element, which remained engaged
from the north.
After placing a nonvented occlusive chest seal (HALO
Chest Seal; Curaplex, http://www.curaplex.com/), the
18D conducted a thorough secondary assessment, noting crepitus and a significant pain response across the
entire left torso with no apparent exit wound. The
casualty was warm and diaphoretic with a weak carotid pulse of 120 bpm, absent radial pulses, and 32
shallow respirations per minute with bilateral chest
expansion. He complained of extreme pain on his left
side and difficulty breathing. These findings suggested
that the round, having struck the upper chest, was redirected down through the torso, fracturing ribs and
lodging somewhere in the vicinity of the identified contusion. The casualty was diagnosed with uncontrolled
internal hemorrhage along with likely traumatic hemo-/
pneumothorax. Air MEDEVAC was requested. The
casualty then received 800g of oral transmucosal fentanyl citrate and a needle thoracentesis on the left side,
which provided minimal relief. Intravenous (IV) access
was acquired in the right antecubital fossa.
The casualty was transferred to a litter and covered
with a hypothermia-prevention management kit (outer
shell; HPMK, North American Rescue Products), but
further treatments were deferred in order to move the
casualty to an emergency helicopter landing zone (HLZ)
approximately 400m away. On reaching the proposed
HLZ, heavy enemy fire coming from the south and
west on the exposed position resulted in the Afghan litter team abandoning the casualty and 18Ds for distant
cover. MEDEVAC was denied because of heavy enemy
machine gun and rocket-propelled grenade fire, forcing
the 18Ds to drag the casualty into a nearby sewer for
defilade. The casualtys level of conscious gradually decreased, shifting between verbal and pain responses as
his carotid pulse increased to 136 bpm. The 18Ds continued to monitor the casualty and return effective fire,
but were unable to provide further treatment until the
main element breached and occupied a nearby walled
compound approximately 45 minutes later, providing a
safe working area with cover from direct fire.
Inside the compound, the casualty was given 500mL Hextend (BioTime, http://www.biotimeinc.com/), 1g TXA,
100
and 1g ertapenem IV through the previously established

access. Within 20 minutes, the casualtys level of consciousness improved enough to maintain conversation.
Over the next hour, radial pulses returned, decreasing
to 120 bpm. Blood pressure averaged 90mmHg. Respirations remained approximately 30/min. The casualty
complained of pain on his left side and upon deep inhalations but otherwise no difficulty breathing. Breath
sounds were diminished but present on the affected
side, and strong and regular on the unaffected side. The
compound was under direct enemy fire from the north,
west, and south for the remaining daylight hours. During this time the 18Ds rotated between casualty care,
sniper overwatch/breach security, and assessing minor
fragmentation wounds among partner force and inhalation injuries of fellow teammates from a drug laboratory destroyed several hours earlier.
Based on the casualtys apparent stability, a chest-tube
kit was prepped, but administration was delayed barring
any worsening of the casualtys condition and security
priorities of work. The 18Ds considered a course of IV
ketamine but opted for a second dose of 800g fentanyl
to maintain the casualtys responsiveness and preserve
the limited supply of medical resources in anticipation
of an increasingly prolonged time on target. The casualty was positioned on an incline with feet slightly elevated, and allowed to sleep. Water intake was reduced
to a minimum because it was expected he would enter
surgery immediately following exfiltration. The 18Ds
continued to closely monitor the casualtys vital signs
(initially recorded on a casualty evacuation card and
later on their smartphones) and twice performed finger
thoracostomy for decompression relief. Hours of darkness allowed the main element to transport the casualty
1600m across two ridgelines to an HLZ for exfiltration.
Despite extremely inhospitable terrain navigated by
litter teams without night-vision goggles, the casualty
remained stable and arrived at the HLZ alert and conscious with a heart rate of 110 bpm, respirations of 24/
min, and systolic blood pressure averaging 110mmHg.
On arrival at the final exfiltration point, an approaching
storm deterred the teams departure indefinitely. Tentative plans were made to find defensible real estate for
the next 24 hours. Effort was necessary to keep the casualty warm and dry during a brief rain shower and to
monitor him over the next several hours while awaiting
a delayed departure time. No further treatments were
administered until the casualty was delivered to a Role
II emergency department around 0200, 13 hours after
injury.
Upon arrival at the American Role II surgical facility, a
focused assessment by sonogram for trauma (FAST examination) revealed fluid in the pelvis. A chest tube was
placed that drained 600mL of blood. Four fractured ribs

and subcutaneous emphysema were identified in initial
radiographs, but no bullet was located. The casualty was
then taken to the operating room for a laparotomy. No
injuries to the abdomen were identified. After surgery,
the casualty remained intubated and stable for 2 days,
during which further imaging revealed the bullet lodged
in soft tissue in the vicinity of the L3 vertebral body. The
casualty remained in hospital care for the next 2 weeks
with few complications. He developed a climbing white
blood cell count, fever, and worsening pleural effusion
adjacent to the left lower lobe. A broad spectrum of antibiotic treatment with meropenem, vancomycin, and
levofloxacin was initiated and his symptoms resolved.
A number of pulmonary embolisms were also identified. Three weeks after injury, he was discharged with
a prescription for rivaroxaban for his pulmonary embolisms and continued his recovery at home. Checkups
at 1 and 3 weeks after discharge revealed an unremarkable postoperative course. The casualty complained of
mild discomfort on the affected side and some difficulty
breathing when lying prone, but both of these symptoms diminished over time.
Discussion
Supportive care in casualty transport and management
for prevention of hypothermia proved crucial during
this scenario of limited advanced treatment options. The
ability of the partner force to provide these supportive
measures in addition to standard TCCC care allowed
the 18Ds to effect , safe casualty transport and increase
the overall capabilities of the ODA by freeing up manpower. Prolonged field care situations many times tax
the sole medical provider(s), and cross-training team
members allows the medic to view the overall casualty
assessment and develop and modify treatment plans
rather than participating in work that can be delegated
to people with less medical training.
A tube thoracostomy was indicated by mechanism of
injury and physical findings, the casualtys difficulty
breathing, and evidence of uncontrolled, internal hemorrhage. However, the application of less invasive treatments first and close monitoring eventually suggested
a field tube thoracostomy was unnecessary. Although a
chest tube would have enabled the 18Ds to reclaim lost
blood and transfuse it to the casualty, using the field
blood-transfusion kit, the casualtys stable presentation
led the medics to suspend further treatments pending
continued assessment and vital signs trending.
Despite the casualtys initial presentation as urgent surgical, a MEDEVAC request could have been delayed.
This decision may have prevented developments in the
tactical situation that led to the casualty and caregivers
Extended Care of Casualty With Chest Trauma
being isolated from the main element and to delayed application of treatments, specifically Hextend and TXA,
which subsequently stabilized the casualty. Our recommendation is that while engaged in a developing and unstable tactical situation in which the HLZ is not secured,
consider delaying MEDEVAC requests and develop a
casualty collection point pending all other attempts to
stabilize the casualty or significant change in the tactical
environment.
Prolonged field care should be central to a medics provision considerations, and mission parameters will dictate
the load out between team members and speed-ball
air resupply feasibility in the field. The 18Ds possessed
the supplies and ability to perform higher interventions
on this casualty prior to exfiltration. However, it is important to weigh improving an individual casualtys vital signs against the prospect of uncertain extraction or
air resupply, further casualties in the immediate future,
and tapping into finite supplies. When exfiltration was
accomplished 4 hours later, the casualtys vital signs
were stable. The 18Ds did not transfuse (US) blood to
the casualty, but having identified universal or type-specific donors among the partner force prior to the mission would have been an effective method for prolonged
casualty hemostasis in lieu of MEDEVAC or air resupply of blood products. There is a need in this setting to
identify indicators for further resuscitation, such as serum lactate, pulse oximetry, end tidal carbon dioxide, or
physiologic parameters to help medics preserve limited
resources such as blood products.
References
1. Kelly JF, Ritenour AE, McLaughlin DF, et al. Injury severity
and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 20032004 vs 2006. J Trauma. 2008;
64(suppl):S21S27.
2. Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating
preventable death on the battlefield. Arch Surg. 2011;146:
13501358.
3. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield
(20012011): implications for the future of combat casualty
care. J Trauma Acute Care Surg. 2012;73(suppl 5):S431S437.
SSG Barnhart is an 18D with B/2/19 Special Forces Group

(Airborne).
SSG Cullinan is an 18D with A/1/20 Special Forces Group

(Airborne).
MAJ Pickett is a practicing emergency physician and Battalion Surgeon for 2/19 Special Forces Group (Airborne). He
is the director of the Center for Prehospital and Operational
Medicine at Wright State University Boonshoft School of
Medicine, Dayton, Ohio. E-mail: jrpickett@mac.com.
101
Telemedicine to Reduce Medical Risk

in Austere Medical Environments
The Virtual Critical Care Consultation (VC3) Service
Doug Powell, MD; Robert D. McLeroy, MD; Jamie Riesberg, MD; William Vasios, MPAS;
Ethan Miles, MD; Jeffrey Dellavolpe, MD; Sean Keenan, MD; Jeremy Pamplin, MD
ABSTRACT
One of the core capabilities of prolonged field care is telemedicine. We developed the Virtual Critical Care Consult
(VC3) Service to provide Special Operations Forces (SOF)
medics with on-demand, virtual consultation with experienced critical care physicians to optimize management
and improve outcomes of complicated, critically injured
or ill patients. Intensive-care doctors staff VC3 continuously. SOF medics access this service via phone or e-mail.
A single phone call reaches an intensivist immediately.
An e-mail distribution list is used to share information
such as casualty images, vital signs flowsheet data, and
short video clips, and helps maintain situational awareness among the VC3 critical care providers and other
key SOF medical leaders. This real-time support enables
direct communication between the remote provider and
the clinical subject matter expert, thus facilitating expert
management from near the point of injury until definitive care can be administered. The VC3 pilot program has
been extensively tested in field training exercises and validated in several real-world encounters. It is an immediately available capability that can reduce medical risk and
is scalable to all Special Operations Command forces.
KEYWORDS: critical care; telemedicine; military personnel;
surgery, hemostatic (whole-blood or matched-component

therapy) blood-product resuscitation, Joint Trauma System management guidelines, and critical care casualty
transportation, all require advanced medical capabilities
and significant logistical support. Constrained geography
and recognition that outcomes improved when casualties
received rapid, definitive, surgical resuscitative care led
to the development of increasingly more robust medical
evacuation capabilities in OIF and OEF.8 As the military
transitions from operating environments with mature
medical and evacuation resources to more resource-limited operations, a shift in medical capabilities is necessary because advanced trauma care from combat support
hospitals (CSHs) and forward surgical teams (FSTs) is
unlikely to be available within the golden hour, if at
all (Figure 1). The concept of prolonged field care (PFC),
currently being trained and iteratively refined, addresses
this operational constraint.911
Figure 1 Comparison of time to critical care trained clinical
providers from OIF/OEF 20092014 to current operations in the
AFRICOM area of responsibility. Time in red represents field care
without critical care trained providers. Maps with relative country
sizes are shown to to illustrate the scale of evacuation distances in
different operational theaters.
emergency treatment; patient transfer; combat casualty care
Introduction
SOF Medicine in the Gray Zone Environment
Throughout history, armed conflict has led to substantial
medical innovation that improves outcomes for Combat casualties and civilians when innovations translate to civilian
healthcare. The case-fatality rates during Operation Iraqi
Freedom (OIF) and Operation Enduring Freedom (OEF)
are the lowest in recorded conflict.1 Multiple medical advances have contributed to this success,14 but only Tactical
Combat Casualty Care (TCCC)5,6 and, in many cases, prehospital damage control resuscitation (DCR),7 can be reliably implemented before casualties reach a surgical facility.
Other important interventions, including damage control
CASEVAC, casualty evacuation; CONUS, contiguous United

States; FWD, forward; LRMC, Landstuhl Regional Medical Center;
MEDCOM, Medical Command; MERT, medical emergency response
team; POI, point of injury; STRATEVAC, strategic evacuation.
102
PFC: Tactical Solutions for Austere,

Dispersed Operations
Of the medical advances most responsible for improving outcomes in OIF and OEF, TCCC and, in many
cases, DCR are currently the only reliably available intervention to SOF in the gray-zone operational environment.1214 During these missions, SOF medics are often
the most advanced US or North Atlantic Treaty Organization medical provider, and mission constraints may
prevent evacuation of critically ill or injured patients to
definitive care for hours or days.
Figure 2 Consultations placed to the Army Medical
Command Teleconsultation Program FY14 and FY15. Of

these, 14.6% were identified as possibly needing critical care
consultation, which likely underrepresents the true volume of
need, because urgent or emergent consultations traditionally
occur via synchronous methods like phone calls and are not
represented in these data or by this asynchronous capability.
Actual number of cases is given in parentheses.
The PFC Working Group has identified 10 capabilities

to train and mature that will optimize SOF medics ability to care for critical casualties for extended periods
and enable successful evacuation to definitive care (Table 1).11 The PFC Working Group also identified four
basic operational scenarios in which PFC is practiced:
ruck, truck, house, and plane. Care in these scenarios is
not sequential and not all casualties will receive care in
all scenarios.10
The challenge PFC caregivers must address is how to
optimize medical outcomes and mitigate medical risk
in areas that lack traditional echelons of care or rapid
evacuation.1,9 The solutions most readily available in the
short term are (1) training to increase austere critical
care and evacuation capabilities of SOF medics and (2)
providing medics with access to expert consultation in
real time to assist in the care of critically ill casualties.
Real-time consultation between the medic and a specialty
consultant can be broken down into synchronous (telephonic or video telecommunication) and asynchronous
(texts, data, images, video, and so forth, sent via short
message service or e-mail) forms of communication.
Development of a PFC Teleconsultation Solution:

The Virtual Critical Care Consult (VC3) Service
In August 2015, the PFC Working Group began collaborating with a team of critical care physicians at the
US Army Institute of Surgical Research (USAISR) to
create a solution for the ninth PFC capability: obtain
telemedicine consultation. A retrospective review of all
consultations placed to the Army Medical Departments
e-mail teleconsultation program from January 2014 to
December 2015 confirmed a need to continue with solution development, because 15% of consultations had
potential for clinical deterioration or death (Figure 2).
Crucial to the development of a solution was the involvement of SOF medics at every stage of conceptualization,
testing, and refinement. The following initial criteria for
an on-demand telemedicine service were identified by
focus group consensus:
Virtual Critical Care Consultation Service
1. Availability of expert consultation should be real

time (i.e., synchronous), simple to obtain, and rapidly accessible (within minutes). Critically ill patients
may decompensate rapidly and the need for decisive
management is immediate.
2. Telephonic consultation is the primary mode of assistance, not video or data transfer. The rationale for
this criterion was twofold. First, telephonic communication is nearly universally available, is very low
bandwidth, and does not require additional equipment that may cause operators to stand out in the
local operating environment. Second, telephonic
consultation has a long history of successful implementation and is practiced every day in academic and
remote medical centers where consulting physicians
work; thus, the skillset for this type of consultation
requires minimal training. Generations of clinicians
have improved the care of patients by simply talking
with more experienced providers with no visual data
guiding the reporting or recommendations.
3. Telecommunications may be augmented by images
sent via e-mail or text, given the ubiquity of transmitting visual data by these means from even the most
austere settings. Images can assist remote consultants
with providing consultation in context, and these
can convey significant amounts of information more
rapidly than voice alone. Data sent in this manner
also require significantly less continuous bandwidth.
If bandwidth is not available, they are not required.
4. Teleconsultation should be obtained via devices currently carried by SOF medics and include commercial
103
104
Blood pressure cuff, stethoscope,

pulse oximetry, Foley catheter
(measure urine output), mental status,
and understanding of vital signs
interpretation
Field fresh whole-blood (FWB)
transfusion kits
Provide positive end-expiratory pressure

(PEEP) via bag-valve mask (you cannot
ventilate a patient in the PFC setting
[prolonged ventilation] without PEEP or
they will be at risk of developing acute
respiratory distress syndrome)
Medic is prepared for a ketamine
cricothyrotomy
Provide opiate analgesics titrated

intravenously
Uses physical examination without

advanced diagnostics, maintain
awareness of potential unseen injuries
(e.g., abdominal bleed, head injury)
Ensure the patient is clean, warm, dry,
padded, catheterized, and provides basic
wound care
Chest tube, cricothyrotomy
Make reliable communications, present
patient, pass trends of key vital signs
Be familiar with physiologic stressors
of flight
2. Resuscitate the patient beyond

crystalloid or colloid infusion
3. Ventilate/oxygenate the patient
4. Gain definitive control of the

patients airway with an inflated
cuff in the trachea (and can keep
the patient comfortable)
5. Use sedation/pain control to

accomplish the above tasks
6. Use physical examination/

diagnostic measures to gain
awareness of potential problems
7. Provide nursing, hygiene,

and comfort measures
8. Perform advanced surgical

interventions
9. Perform telemedicine consult
10. Prepare the patient for flight
Minimum
1. Monitor the patient to create a

useful vital sign trend
PFC Tasks
levels may reflect medical training or experience or available resources.11
Trained in critical care transport
Add laboratory findings and ultrasound

images
Fasciotomy, wound debridement,

amputation, and so forth
Elevate head of bed, debride wounds,

perform washouts, wet-to-dry dressings,
decompress stomach
Trained to use advanced diagnostics such as

ultrasound, point-of-care laboratory testing,
and so forth
Trained to sedate with ketamine (and

adjunctive midazolam as needed)
Experienced in critical care transport
Video teleconference
Experienced in both
Experienced in both
Experienced in both
Experienced with and maintains

currency in long-term sedation
practice using IV morphine, ketamine,
midazolam, fentanyl, and so forth
Add a responsible rapid-sequence

intubation capability with subsequent
airway maintenance skills, in addition
to providing long-term sedation (to
include suction and paralysis with
adequate sedation)
Portable ventilator (e.g., Eagle Impact

ventilator, Zoll Medical Corp., http://
www.impact instrumentation.com; or
similar) with supplemental O2
Provide supplemental oxygen (O2) via an

oxygen concentrator
Add ability to provide long-duration

sedation
Maintain a stock of packed red blood

cells, fresh frozen plasma, and have
type-specific donors identified for
immediate FWB draw
Vital signs monitor to provide

hands-free vital signs data at regular
intervals
Best
Maintenance crystalloids also prepared

for a major burn and/or closed-head
injury resuscitation (two to three cases of
lactated Ringers solution or PlasmaLyte
A; hypertonic saline); consider adding
lyophilized plasma as available; fluid warmer
Add capnometry
Better
Table 1 PFC Core Capabilities as Identified by the Special Operations Medical Association PFC Workgroup. Minimum-better-best is a planning tool. Differences between
cellular and satellite devices. Obtaining teleconsultation should not place a burden for acquiring, learning, carrying, and powering additional devices by
medics already facing significant time, space, and
weight constraints.
5. The initial consultants should be a critical care physician with experience in medical, trauma, surgical,
and burn critical care. These physicians are specialty
trained experts in the nonoperative management of
critically ill patients who may clinically decompensate in the time beyond the golden houra significant risk for casualties who cannot receive timely,
definitive surgical or medical care.
6. PFC is defined as prehospital care. Prehospital care
does not require documentation in an electronic
medical record. This allows solutions to req uire
less technology. Documentation can be handwritten.
Because medics do not store personal health information and they do not need send personally identifiable information, transmission can be over media
and networks not certified for these purposes. This
enables more rapid development and use of a teleconsultation system.
The PFC Working Group began testing teleconsultation
in October 2015. Initially, two methods were evaluated: a current commercially available telemedicine
service for travelers and the USAISR burn phone line.
The commercial service routed calls through a nonphysician provider, usually a paramedic, during a triage
step. Callers were dissatisfied with the time it took to
get past triage to the expert consultant, with the delay
in call transfer to the consultant or waiting for consultant to call back, and with having to provide duplicate
information during the triage phase and subsequently to
the consultant. Calls to the burn hotline suffered from
inconsistent awareness from the large Burn ICU staff
about how to route calls for a new category of critical
care consultation.
These problems ultimately led to a third model: calls
direct to an on-call intensive care physician. A dedicated phone number was assigned to call forward to the
mobile phone of an on-call critical care physician. An
e-mail address was also created to send messages to a
distribution list of VC3 providers and PFC telemedicine
Working Group leaders as a mechanism for the team to
maintain situational awareness of VC3 activity and as
a potential back-up solution should the phone line fail.
Medics consistently preferred this method for both its
expediency and for the quality of advice obtained from
the military critical care physicians.
Equally important to the development of the VC3 Service was the development of a format by which callers
inexperienced in conveying information about complicated, critically ill patients could consistently communicate such information to a consultant in a compressed,
high-yield format.15,16 VC3 revised this format multiple
times based on feedback from testing until it reached the
current operational script (Figure 3). An important
element of the script is the capabilities section, which
addresses a concern of SOF medics: that the consultant
physician will not appreciate the austerity and limitations of the environment in which they are operating.
Finally, a process evolved to optimize the efficient exchange of information. In best case scenarios, medics
send images to the VC3 e-mail consisting of the capabilities section of the script, the clinical flowsheet (Figure
4), and any relevant images of wounds, care environment, equipment, and any other important information
shortly before calling the VC3 number (preferably 1015 minutes lead time). Images must not reveal patient
identity, location, or compromise operational security.
At the beginning of a call, medics and the consultant exchange call-back or text-back information to facilitate
follow-up and reconnection if the call is interrupted. Importantly, if images cannot be sent or there is no time to
delay calls, the service may still be engaged immediately
using the phone call, and information will be exchanged
as optimally as possible.
Results
Testing continued into the spring of 2016 and involved
numerous SOF units from Army, Marines, and Joint
Special Operations Command. Devices tested were
most commonly commercial cell phones but also included satellite phone and tactical communications
systems. No appreciable differences in call quality were
noted, provided a good signal was available. Satellite
phones were limited by the ability to perform voice-only
communication.
Operationally, VC3 has been used in support of the
Special Operations Command Africa and Special Operations Command Central since late 2015. Real-world
VC3 cases involving threatened airway compromise
secondary to cellulitis; threatened vision due to ophthalmitis; penetrating abdominal trauma; and fragment
injury requiring wound-tract debridement, foreign body
removal, complex wound closure, and wound care validate the need for this capability. The abdominal trauma
and wound management cases are detailed in this edition of Journal of Special Operations Medicine. In all
cases, real-time teleconsultation improved local provider confidence, patient outcome and, in at least one
case, increased partner force confidence and alliance
with the embedded SOF element.
105
Figure 3 The VC3 call script. Structured communication has been demonstrated to increase information transfer in both
volume and content.16 The script is broken into five sections: Introductions & Call-Back, Clinical History and Problem, Vital
Signs/Exam/Previous Interventions, Recommendations, Follow-up. At the end of each section, a pause point is designed to
give the consultant or medic an opportunity to review information presented, via a read back, and to ask clarifying questions.
The section on capabilities is intended to be sent ahead of the voice consultation as a form of background information;
however, medics often send images of the entire script, which allows consultants to review the case before receiving the phone
call and often reduces talk time and may facilitate more concise recommendations.
Discussion
Current Special Operations doctrine predicts prolonged
gray-zone operations.12,13 In this environment, smaller
elements will operate in more dispersed, austere environments with little health-service support, often in
failed states, with little to no organic medical infrastructure. The nature of risk in these environments is
shifting from penetrating and blast trauma, to include
significant rates of blunt trauma, burns, and infectious
disease. Low-frequency, higher-risk resuscitations are
predicted to become a normal experience in the next decades operational environment. Although operational
medical risk remains moderate to high, wide geographic
dispersion of small elements operating in areas with
limited country clearance who incur low casualty rates
make it difficult, if not impossible, to provide conventional medical support through conventional echelons
of care and military medical evacuation.
The use of critical care teleconsultation services and a
multidisciplinary team approach to the care of patients
106
in the intensive care unit (ICU) have been demonstrated

to improve mortality in civilian and military ICUs.1721
Real-time teleconsultation can bring the expert to the
patient in austere settings where the patient cannot be
transported to the ICU for definitive care in a timely
manner.19 It is expected that the widespread availability
and use of critical care teleconsultation by SOF elements
conducting gray-zone operations will result in a reduction of medical risk and an improvement in outcomes
for critically injured and sick casualties. Ongoing research efforts are targeted to demonstrate this benefit.
VC3 is a solution that provides synchronous teleconsultation to deployed SOF. It has been developed with the
close collaboration of SOF medics, SOF providers, and
expert clinicians in the only military level 1 trauma and
burn center. VC3 has been tested and refined in dozens of
training exercises and validated in real-world scenarios.
The most important near-term challenges to SOF teleconsultation and VC3 are scalability, sustainability, and
physician participation. Scaling VC3 to be available to
Figure 4 The PFC flow sheet. This document is intended to help medics (or other PFC providers) not only document care
but identify important trends in data (e.g., declining urine output with steadily increasing heart rate and respiratory rate may
suggest volume depletion), and not miss routine care that is vital during prolonged evacuation (e.g., repositioning casualties
so they do not develop pressure ulcers, scheduled pulse checks, routine medication administration like acetaminophen
every 46 hours). Images of this information sent ahead of consultation helps consultants make more informed and concise
recommendations.
107
all SOCOM forces operating in austere environments is

one of the most high-yield, immediately available methods to reduce medical risk. The investment needed to
achieve such scaling is small: call-forwarding software
to ensure that a medics call will be answered if the primary on-call provider is occupied or out of coverage
range, a coordinator to manage a roster of critical care
physicians who volunteer to take VC3 calls, and a research coordinator to collect data from the calls, thus
helping to further refine the system and enable future
enhancements in operational telemedicine.4
All branches of the military employ physicians with the
required training and experience to be expert VC3 consultants. Establishing a cadre of VC3 providers requires
selection, vetting, and training, as well as recognition of
activities in support of operational teleconsultation by
parent medical directorates. Regarding the former, the
importance of a critical care provider (receiver) understanding the operational context of the SOF provider
(sender) cannot be overstated. Introducing providers to
VC3 via participation in training events ensures that physicians have a working knowledge of the equipment and
capabilities of the SOF medic and develop rapport, both
of which will optimize real-world interactions. VC3 providers should be afforded the opportunity to train in the
field with the medics they may be supporting, to stay current with training levels and equipment used. In this context, traditional metrics of physician performance such as
productivity or revenue generating units may be difficult
to extrapolate from VC3 encounters and training. Modification of the VC3 service to fit current productivity
and reimbursement standards would be detrimental, and
would likely discourage SOF medic use, and thus negatively impact patient outcomes. Because the primary role
of military medicine is the support of combat operations,
metrics that account for the value of physician participation in programs that support operations and reduce
operational risk, such as VC3, should be developed.
Future Directions
Current efforts are focused on expanding this pilot program to allow all deployed forces access to the consultation service. Additional effort is underway to create a
unified military program that includes immediate access
to multiple subspecialty services and guidelines regarding access to this system across the spectrum of illness
(i.e., routine, nonurgent consultation through immediate/emergency consultation). Pursuit of technology must
allow telemedicine services to remain flexible and scalable according to SOF mission needs and account for
wide variation in technological capability at the point of
need. Research efforts are ongoing to determine when
or if more advanced technologies can provide better
consultation and improve patient outcomes than the
voice and e-mail consultation solutions described here.
108
Conclusion
VC3 is an immediately available method to reduce medical risk in gray-zone operating environments. It meets
the SOCOM requirement for telemedicine support of
decentralized operations. With minimal investment,
VC3 can be sustained and scaled to all SOCOM forces.
This is an essential first step before exploring additional
capabilities or scaling to support conventional force
operations.
Key points
The VC3 service is a direct link between medics in
austere environments and critical care subject matter
experts that enables best possible care of critically injured and sick patients during PFC.
VC3 provides effective consultation by telephone;
meeting a core requirement voiced by SOF medics
that telemedicine be accessible in a wide variety of
environments without specialized communications
equipment. The addition of images transmitted by email can enhance communication but is not a requirement.
The VC3 service has demonstrated success in multiple
training and real-world scenarios.
Access to this service is expanding and is available to
US SOF units for training and operational use via unit
surgeon sections, Theater Special Operations Command Surgeon sections, and the Special Operations
Medical Association (SOMA) PFC Working Group.
Acknowledgments
We thank the following individuals for their efforts in
this project: the innumerable medics who offered advice
during the development and testing of this service. COL
Daniel Kral, Telemedicine and Advanced Technology
Center (TATRC), for his leadership and mentorship with
getting this program started, as well as Gary Gilbert and
James Beach, TATRC, for their continued support; Nicole Caldwell, US Army Institute of Surgical Research
(USAISR), for her support with maintaining research
and regulatory files; LTC(P) Kevin Chung, COL Michael Wirt, and LTC(P) Andre Cap, USAISR, for their
notable support of this effort; and LTC(P) Kevin Chung,
USAISR, and MAJ James Lantry and LTC Philip Mason, San Antonio Military Medical Center, for providing exceptional consultative advice during VC3 calls.
Funding
This effort was initiated in conjunction with funding by
an Army Medical Department Advance Medical Technology Initiative grant from the Telemedicine and Advance Technology Center.
Disclaimer
The views expressed are those of the author(s) and do
not reflect the official policy or position of the US Army
Medical Department, Department of the Army, Department of Defense, or the US Government.
Disclosures
The authors have nothing to disclose.
References
1. Rasmussen TE, Gross KR, Baer DG. Where do we go from
here? J Trauma Acute Care Surg. 2013;75:S105S106.
2. Blackbourne LH, Baer DG, Eastridge BJ, et al. Military medical
revolution. J Trauma Acute Care Surg. 2012;73:S378S387.
3. Butler FK, Smith DJ, Carmona RH. Implementing and preserving the advances in combat casualty care from Iraq and
Afghanistan throughout the US Military. J Trauma Acute
Care Surg. 2015;79:321326.
4. Palm K, Apodaca A, Spencer D, et al. Evaluation of military
trauma system practices related to complications after injury.
J Trauma Acute Care Surg. 2012;73(6 suppl 5):S465S471.
5. Butler FK, Hagmann J, Butler EG. Tactical combat casualty
care in special operations. Mil Med. 1996;161 Suppl:316.
6. Butler FK. Tactical Combat Casualty Care: update 2009.
J Trauma. 2010;69(suppl):S10S13.
7. Fisher AD, Miles EA, Cap AP, et al. Tactical damage control
resuscitation. Mil. Med. 2015;180:869875.
8. Kotwal RS, Howard JT, Orman JA, et al. The effect of a
golden hour policy on the morbidity and mortality of combat
casualties. JAMA Surg. 2015;151:110.
9. Rasmussen TE, Baer DG, Lein BC. Ahead of the curve: sustained innovation for future combat casualty care. J Trauma.
2015:112.
10. Mohr CJ, Keenan S. Prolonged Field Care Working Group
position paper: operational context for prolonged field care.
J Spec Oper Med. 2015;15:7880.
11. Ball JA, Keenan S. Prolonged Field Care Working Group position paper: prolonged field care capabilities. J Spec Oper
Med. 2015;15:7677.
12. Votel JL, Clevland CT, Connett CT, et al. Unconventional warfare in the gray zone. Joint Forces Quarterly. 2016:101109.
13. US Army Special Operations Command. ARSOF 2022. Special Warefare. 2013:132.
14. US Army Special Operations Command. ARSOC 2035.
15. Agarwal HS, Saville BR, Slayton JM, et al. Standardized
postoperative handover process improves outcomes in the
intensive care unit: a model for operational sustainability
and improved team performance. Crit Care Med. 2012;40:
21092115.
16. Catchpole KR, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop
and aviation models to improve safety and quality. Paediatr
Anaesth. 2007;17:470478.
17. Weled BJ, Adzhigirey LA, Hodgman TM, et al. Critical care
delivery. Crit Care Med. 2015;43:15201525.
18. Grathwohl KW, Venticinque SG. Organizational characteristics of the austere intensive care unit: the evolution of
military trauma and critical care medicine; applications for
civilian medical care systems. Crit Care Med. 2008;36(7
suppl):S275S283.
19. Lettieri CJ, Shah AA, Greenburg DL. An intensivist-directed
intensive care unit improves clinical outcomes in a combat
zone. Crit Care Med. 2009;37:12561260.
20. Lilly CM, Cody S, Zhao H, et al. Hospital mortality, length
of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care
processes. JAMA. 2011;305:21752183.
21. Lilly CM, McLaughlin JM, Zhao H, et al. A multicenter
study of ICU telemedicine reengineering of adult critical care.
Chest. 2014;145:500507.
MAJ Powell is at the Third Special Forces Group (Airborne)

and Womack Army Medical Center, Fort Bragg, North Carolina.
CPT McLeroy is at Madigan Army Medical Center, Joint

Base Lewis-McChord, Washington.
LTC Riesberg is with the Special Warfare Medical Group,

Fort Bragg, North Carolina.
MAJ Vasios is with Special Operations Command Africa,

Stuttgart, Germany.
LTC Miles is with the 75th Ranger Regiment, Fort Benning,

Georgia.
MAJ Dellavolpe is at San Antonio Military Medical Center,

San Antonio, Texas.
COL Keenan is with Special Operations Command Europe,
Stuttgart, Germany.
LTC Pamplin is at Madigan Army Medical Center, Joint Base
Lewis-McChord, Washington, and Uniformed Services University, Bethesda, Maryland. E-mail: jeremy.c.pamplin@gmail.com.
109
Case of a 5-Year-Old Foreign National

Who Sustained Penetrating Abdominal Trauma
Robert D. McLeroy, MD; Jabon L. Ellis, DO; Jason M. Karnopp, NREMT-P, ATP;
Jeffrey Dellavolpe, MD; Jennifer Gurney, MD; Sean Keenan, MD; Doug Powell, MD;
Jamie Riesberg, MD; Mary Edwards, MD; Renee Matos, MD, MPH; Jeremy Pamplin, MD
Objective: Review application of telemedicine support

for penetrating trauma.
Clinical context: Special Operations Resuscitation Team
(SORT) deployed in Africa Area of Responsibility (AOR)
Organic expertise: Internal Medicine physician, two
Special Operations Combat medics (SOCMs), and one
radiology technician
Closest surgical support: Non-US surgical support 20km
away; a nonsurgeon who will perform surgeries; neighboring country partner-force surgeon 2 hours by fixedwing flight.
Earliest evacuation: Evacuated 4 days after presentation
to a neighboring country with surgical capability.
emergency treatment; patient transfer; combat casualty
care
bringing the boy to a local military hospital. There was

minimal bleeding reported at the wound site.
On presentation to the healthcare facility (which consisted
of several tents with no running water, limited power supply, and limited pharmacy), the patients vital signs were
notable for a heart rate of 120 bpm and respiratory rate
of 30/min. The patient was afebrile and normotensive,
with oxygen saturation of 100% on room air. Physical
examination revealed a slightly distended abdomen with
pain around the wound site and absent bowel sounds.
Pulmonary examination was unremarkable. A focused assessment with sonography in trauma (FAST) examination
(Figure 2), performed by one of the SOCMs, revealed a
pericardial effusion and chest radiography (Figure 3) was
concerning for pneumopericardium as well as pneumoperitoneum versus left diaphragmatic rupture with bowel
in the left thoracic cavity. The initial request for evacuation for definitive surgical intervention was denied.
Medical management over the next several days included
antibiotic therapy with metronidazole, ampicillin, and ciprofloxacin, as well as intravenous (IV) fluids; however, the
Introduction
An internal medicine physician, two Special Operations
Combat Medics (SOCMs), and one radiology technician
requested telemedicine guidance about a pediatric patient with delayed presentation of penetrating trauma.
This Special Operations Resuscitation Team (SORT)
was deployed in Africa Area of Responsibility (AOR).
The closest non-US surgical support was a nonsurgeon
willing to perform operations who was 20km away or a
partner-force surgeon in neighboring country who was
2 hours by fixed-wing flight. At the time of presentation, evacuation was not considered an available option
despite multiple attempts.
Figure 1 A 5-year-old local national on initial presentation
to local military hospital with occlusive dressing in place.
Case Report
A male, 5-year-old foreign national was brought to the
Special Operations Resuscitation Team (SORT) team by
a partner force 1 day after falling on a small 5cm knife.
The knife penetrated the ninth intercostal space on the
left (Figure 1). His mother had removed the knife before
110
Figure 2 Evidence of pericardial effusion (thick arrow and

pen tip between pericardium (thin solid arrow) and the
myocardium (outline) on focused abdominal sonography in
trauma (FAST) examination.
Figure 3 Chest radiograph showing probable
pneumopericardium (thick arrow) and pneumoperitoneum

(thin arrow).
patients clinical status continued to deteriorate over the

next few days: he developed fever, tachypnea, and altered mental status. Abdominal examination continued
to be notable for absent bowel sounds and the abdomen
developed tenderness to palpation. Pain was controlled
with IV morphine. Efforts for medical evacuation to a
facility with surgical capabilities were denied until hospital day 3.
Clinical Questions
Are there addition recommendations for medical
management of penetrating trauma to the abdomen/
thoracic cavity in a pediatric patient?
In particular, the SORT team was considering improvised
drain placement. Request for information regarding
considerations guidance for placement and management
from surgical specialty or pediatric specialty.
Child With Penetrating Abdominal Trauma
Consultation(s)
Local: None; a pediatric surgeon was deployed to
the same AOR but was only accessible by military
evacuation.
Telemedical: to the Virtual Critical Care Consultation
(VC3) Service.
Initiated with e-mail to the VC3 Service e-mail, a
group distribution list.
Followed up by telephone within 10 minutes to oncall VC3 intensivist.
VC3 medical intensivist answered call on first contact. Within the next 30 minutes, contact was established with the San Antonio Military Medical Center
pediatric intensivist on call.
Case discussed with pediatric surgeon on call as well
as pediatric infectious disease consultant for further
expertise and recommendations.
Use of the VC3 e-mail for initial notification also allowed for contact with an additional consultant deployed to a facility in the same AOR who was able to
provide further expertise and recommendations in the
same time zone.
Consultation Recommendations
General guidelines regarding fluid resuscitation and
monitoring
Recommended against drain placement.
Agreed with antibiotic therapy, given limited options
in austere environment.
Pediatric intensivist gave advice regarding pediatricspecific resuscitation, including vasopressor selection;
tendency for children to develop cold shocka
state induced by limited cardiovascular and neurohumoral reserves that requires vasopressor therapy,1
usually epinephrine; and that the provider should feel
comfortable tolerating tachypnea without evidence of
accessory muscle use or retractions in the pediatric
population.
Case discussed with pediatric surgeon to develop surgical plan, and with specialist in pediatric infectious
disease for any further antibiotic recommendations.
Recommendation made against drain placement and
to prioritize evacuation to surgical capability. Current
antibiotic selection was appropriate as a temporizing
intervention.
A physician deployed in the same AOR attempted to
coordinate with US surgeon from his team; however,
coordination with a nongovernmental organization
(NGO) enabled transfer to a civilian hospital.
Follow-up
The patient was medically managed for 3 days at the
original location on the current antibiotic regimen with
the plan to broaden antibiotic coverage by replacing
111
ampicillin with ertapenem if the patient further decompensated. On hospital day 3, coordination with an
NGO facilitated patient transfer to a healthcare facility with surgical capability. Upon last report, the patient
was doing well after emergent thoracotomy for hemothorax and was later discharged home.
considered, and only with expert consultation from

a surgeon. Watchful waiting (i.e., patiently monitoring the patient without procedural intervention) is
an acceptable approach until or unless a patient develops signs of peritonitis on physical examination.
These include rigid abdomen with distention, severe
pain, fever, and progressive tachycardia. The primary
therapy for peritonitis is surgery.2
Teaching Points
Penetrating Abdominal Trauma
Management of penetrating injury to the abdomen
depends on if the wound has penetrated the fascia, the
wound projectile, the zone of the abdomen injured,
and the presence of any blast/cavitary effect. Wounds
that penetrate the fascia often require surgical management and should be treated with antibiotics until
surgical consultation has been obtained. In the setting of low-velocity projectiles or stab wounds, the
location of abdominal penetration may suggest injury
to underlying structures, whereas high-velocity projectiles (e.g., gunshot wound or fragmentation from
blasts) may travel great distances inside the body and
the location of penetration does not predict ultimate
injury pattern.
In a resource-limited environment, a plain radiograph
can provide , basic information (e.g., presence of free
air, diaphragmatic injury, pneumothorax, fragment
projectile). If these are found, surgery is most likely
necessary.
Ultrasound can also be very informative anatomically
and may help explain physiologic changes (as in this
patient). A positive FAST examination suggests the
need for emergent surgery if it is performed before resuscitation. Delayed FAST examinations, as in this patient, can be misleading because they may result from
inflammatory effects of the injury or from fluid resuscitation. Physical examination that demonstrates signs
of peritonitis (discussed below) indicates a probable
injury to a hollow viscus that requires surgical repair.
Concern for stomach or intestinal injury (based on
clinical signs) warrants IV antibiotics, which should
be continued through definitive surgical care.
A nasogastric tube can be therapeutic if there is a gastric or intestinal injury, and can be diagnostic if there
is a diaphragmatic injury and the tube is seen diverging into the chest on radiograph. Gastric decompression also helps prevent aspiration.
Blind drain placement was considered in this case,
but it is not a substitute for surgical management and
could potentially be harmful. Although image-guided
drain placement via ultrasound for a bowel injury has
the potential to control peritoneal sepsis, it will likely
result in an enterocutaneous fistula, and is not recommended. All surgical options should be explored
and exhausted before such an approach could be
112
Lessons Learned
This was a quick and robust response to a complicated
clinical scenario in a remote area with a multidisciplinary team of providers to assist with management.
All parties made contact with the provider in-country
within 1-2 hours after initial contact.
Use of initial e-mail with images of the patient provided complete and concise information regarding the
case, which was able to be forwarded to various specialists to assist in management plan.
There is continued difficulty regarding availability of
secret methods of communication for providers who
are on call for VC3.
Providing a list of potential subspecialty physicians
on call for this consult service could reduce delays in
consultative care for patients downrange.
References
1. Brierley J, Carcillo JA, Choong K, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal
septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med. 2009;37:666688.
2. Como JJ, Bokhari F, Chiu WC, et al. Practice management
guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma. 2010;68:721733.
Disclaimer
Medical Department, Department of the Army, Department of the Air Force Department of Defense or the U.S.
Government.
Disclosures

CPT Ellis is with the 528th Sustainment Brigade (SO) (A),

SFC Karnopp is with the 528th Sustainment Brigade (SO)
(A), Fort Bragg, North Carolina.
Capt Dellavolpe is at San Antonio Military Medical Center,
LTC Gurney is at the US Army Institute for Surgical Research, San Antonio, Texas; and Uniformed Services University, Bethesda, Maryland.
COL Edwards is at San Antonio Military Medical Center,
COL Keenan is at SOCEUR, Stuttgart, Germany.
Antonio, Texas.
San Antonio, Texas.
MAJ Powell is with the Office of Special Warfare, 3rd Special

Forces Group (Airborne), Fort Bragg, North Carolina.
Resus Pack

San Antonio, Texas.
Maj Matos is at San Antonio Military Medical Center, San

LTC Pamplin is at the US Army Institute for Surgical Research, San Antonio, Texas; and Uniformed Services University,
Bethesda, Maryland. E-mail: jeremy.c.pamplin@gmail.com.
The i-gel from Intersurgical is an innovative second

generation supraglottic airway widely used during
resuscitation of the unconscious adult patient.
It has a soft, gel-like, non-inflating cuff that is
designed to provide an anatomical, impression fit
over the laryngeal inlet, accurately mirroring the
perilaryngeal framework. The non-inflating cuff
means there is no need for a syringe, no need for
cuff deflation prior to insertion and no need for cuff
inflation after placement to secure a seal, thereby
shortening and simplifying the preparation and
insertion procedure. i-gel is known for its ease
and speed of insertion, reduced trauma, superior
seal pressures, gastric access, integral bite block
and non-inflating cuff. The new i-gel O2 has been
designed to facilitate ventilation as part of standard
resuscitation protocols, such as those designated
by the American Heart Association (AHA). However,
the i-gel O2 also incorporates a supplementary
oxygen port, so that it can also be used for the
delivery of passive oxygenation, or Passive Airway
Management (PAMTM), as part of an appropriate
CardioCerebral Resuscitation (CCR) protocol.
Evidence Based Airway

Management
The i-gel O2 Resus Pack is available in 3 adult sizes and includes:
i-gel O2 supraglottic airway

Sachet of lubricant for quick and easy lubrication of the i-gel O2 prior to insertion
Airway support strap to secure the i-gel O2 in position
Child With Penetrating Abdominal Trauma
www.i-gel.com
113
Embedded Fragment Removal and Wound Debridement

in a Non-US Partner Force Soldier
Robert D. McLeroy, MD; Sloan Spelman; Eric Jacobson, MD; Jennifer Gurney, MD;
Sean Keenan, MD; Doug Powell, MD; Jamie Riesberg, MD; Jeremy Pamplin, MD
Objective: Review application of telemedicine support

for removal of fragment and wound management.
Clinical context: Special Forces Operational Detachment-Alpha deployed in Central Command area of responsibility operating out of a small aid station (house
phase of prolonged field care)
Organic expertise: 18D Special Operations Combat medic
Closest medical support: Combined Joint Special Operations Task Force (CJSOTF) surgeon located in another
country; thus, all consults were either via telephone or
over Secret Internet Protocol Router e-mail.
embedded in between the lateral border of his right

scapula and the humeral head. The embedded fragment
was removed and the wound tract was opened medially-to-laterally to allow for further wound debridement
with removal of devitalized tissue (Figure 1). No evidence of vascular or neurologic complication was noted.
A second dose of ertapenem 1g IV was given.
Figure 1 (A) Initial removal of fragment and debridement
from right posterior shoulder. (B) Image of fragment piece.
A
Earliest evacuation: NA
emergency treatment; patient transfer; combat casualty care
Introduction
A Special Operations Medical Sergeant deployed in the
Central Command area of operations and working in a
small aid station with limited communications (telephone
and secret Internet protocol router e-mail) was challenged
by a partner force patient who presented with retained
fragment in a wound secondary to a mortar blast. No
evacuation was possible. A telemedicine consult was obtained to seek guidance about wound management.
Case Presentation
An 18-year-old non-US partner force soldier sustained
penetrating-fragment trauma with the entrance wound
located at the right lateral triceps muscle near the level
of the axilla from a mortar blast. Point-of-injury management by the partner force included suturing the entrance wound and dressing. The next day, the patient
was evaluated at a small aid station, where he underwent suture removal; wound-tract irrigation with minor
debridement; and dressing change. He also received ertapenem 1g intravenously (IV).
On postinjury day 2, he was reevaluated by an18D
who discovered that the patient had retained fragment
The patient remained clinically and hemodynamically

stable throughout his treatment course. He was due to
leave the aid station in 6 days and would be moving to
a remote combat outpost (COP) with no running water
or medical care, and no possibility of returning to the
station (or house) for continued follow-up care of the
injuries he sustained.
Clinical Questions
The concern is that with no medical care at the COP
and no ability for follow-up, what is the preferred
method of healing for this patients wound: secondary
intention or delayed closure?
How should this wound be bandaged and dressed
given the consideration of minimal medical supplies
or clean water once at the COP?
Should all retained foreign bodies such as a fragment
be removed? Should this one? What are indications
to remove or not remove this fragment in an austere,
resource-limited environment?
Consultation(s)
Local: No local assets, CJSOTF surgeon located in
nearby area of operation.
Telemedical: The Virtual Critical Care Consultation
(VC3) Service.
Initiated with e-mail to the VC3 e-mail distribution list.
114
Followed up by telephone within 10 minutes to VC3

intensivist on call.
Three attempts to contact VC3 on call provider were
unsuccessful; thus, 18D contacted the Institute for
Surgical Research Burn Unit at San Antonio Military
Medical Center (SAMMC) and was immediately answered. Case information was then relayed to the oncall VC3 provider who then contacted 18D to provide
guidance.
Due to technical surgical aspects of the teleconsultation, an on-call trauma surgeon at SAMMC was
brought into the teleconsultation loop to provide direct guidance to and answer questions from the 18D.
Consultation Recommendations
Partial closure of ends of exit wound to facilitate linear
and rapid healing of wound while allowing the overall wound to heal by secondary intention Aggressive
wound care: cleaning the wound daily, dressing changes
two or three times daily to encourage microdebridement
and lowering the bacterial burden of the wound.
Aggressive surgical wound care will facilitate faster healing of contaminated wounds only. Most contaminated
wounds will, nevertheless, still heal, albeit more slowly, if
they are kept clean with dressing changes and irrigation.
Partially closing a wound (i.e., turning a mostly circular/elliptical wound into a more linear wound) will
facilitate a more cosmetic and rapid closure. A pitfall
of this approach, however, is that by creating potential space under the partial closure, it becomes more
difficult to effectively pack the wound. This may lead
to infection. It is better not to close or partially close
a wound if it will impede proper wound care; instead,
pack with wet-to-dry dressing changes.
Not all fragments should be retrieved. Large fragments that impede function, particularly joint range
of motion, can be cautiously retrieved. Any fragments that affect vascular flow or neurologic function
should be evaluated at a level of care, if possible, that
can perform vascular repairs and/or further vascular
imaging. We recommend a surgical consultation prior
to retrieving most fragments.
Follow-up
Lessons Learned
After following the recommendations provided by the

VC3 staff, the 18D continued to debride and irrigate the
wounds and dress them with wet-to-dry dressings; however, three-times-daily wound irrigation and dressing
changes were not possible because of logistical constraints,
so a second debridement was performed on postinjury day
4 (Figure 2). By postinjury day 5, the patient felt better
and was beginning to use his right upper extremity for
daily activities. He was then counseled to continue to keep
the wound clean and dressed while at the COP.
Teleconsultation with experienced critical care physicians and surgeons can improve the care provided
to and outcomes of medical and surgical casualties
in austere environments with limited to no access to
definitive care.
Key elements needed for teleconsultation are reliable
voice link and the ability of the provider downrange
to send an e-mail with images. Image transmission
proved beneficial because the VC3 staff could provide
recommendations and plan of care based on a more
comprehensive picture of the patient and wound characteristics, available supplies, and operational environment than that provided by voice description alone.
More reliable access to secret communication may be
beneficial because secure communication allows deployed providers more liberty to elaborate about the
clinical scenario, especially with respect to the context
of logistical constraints they may have that could impact treatment plans; however, lack of secure communications should not be a barrier to teleconsultation.
A redundant call system, including a central call center
with 24/7 staffing, would be beneficial; the provider
in this case was unable to reach on-call VC3 physician
because of cell-phone dead zones. The alternate VC3
contact plan, contacting the SAMMC Burn Center,
was used in this case and succeeded in connecting the
remote provider with the on-call intensivist.
Figure 2 (A) Wounds postinjury day 5 after partial closure

of lateral edges. (B) Image of anterior (entry) and posterior
(surgical) wounds.
A
Teaching Points
Wound Management1-4
Basic wound care: frequent irrigation (with showers if
possible), dressing changes with wet-to-dry dressings
(microdebridement); removal of any gross contamination or devitalized tissue from the wound (sharp debridement with a scalpel or substitute), and repeated
wound examination will result in healing of most soft
tissue wounds.
Case Report: Telemedicine Support for Wound Care
Disclaimer
115
Medical Department, Department of the Army, Department of Defense or the U.S. Government.
Disclosures
References
1. Cubano MA, Lenhart MK. Emergency war surgery. 4th ed.
Washington, DC; Government Printing Office: 2014.
2. Joint Theater Trauma System Clinical Practice Guideline. Initial
management of war wounds: wound debridement and irrigation. 24 April 2012. Accessed from http://www.usaisr.amedd.
army.mil/cpgs/Mgmt_of_War_Wounds_25_Apr_12.pdf on 8
August, 2016.
3. Townsend CM, Beauchamp D, Evers M, Mattox K. Sabiston
textbook of surgery: the biological basis of modern surgical
practice. 20th ed. Philadelphia, PA: Elsevier; 2016.
4. Covey DC. Blast and fragment injuries of the musculoskeletal
system. J Bone Joint Surg Am. 2002;84:12211234.

SSG Spelman is with the 5th Special Forces Group, Fort

Campbell, Kentucky.
MAJ Jackobson is with the 5th Special Forces Group, Fort
Campbell, Kentucky.
HAMILTON-T1
Transport ventilation for armed forces
LTC Gurney is at the US Army Institute for Surgical Research, San Antonio, Texas.
Performance of a full-featured ICU

ventilator
COL Keenan is with Special Operations Command Europe,

Stuttgart, Germany.
For use in helicopters, airplanes,

ambulances, ships, combat support
hospitals, and battalion aid stations
MAJ Powell is with the Office of Special Warfare, 3rd Special

Forces Group (Airborne), Fort Bragg, North Carolina.
Advanced ventilation modes including

automated ventilation using ASV
Independence from compressed air
Over 9 hours of battery operating time
NATO stock number

NSN 6515-01-648-5814

LTC Pamplin is at Madigan Army Medical Center, Joint Base

Lewis-McChord, Washington; and the Uniformed Services
University, Bethesda, Maryland.
E-mail: jeremy.c.pamplin@gmail.com.
www.hamilton-medical.com/HAMILTON-T1military
116

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An Ongoing Series

Prolonged Field Care for the Winter 2016 Edition

s the winter months approach, the community has

Included in this edition is a second Clinical Practice

We hope that you find these articles informative and

Additionally, we have the beginning of a relevant series

Management of Burn Wounds Under Prolonged Field Care

Patients with smoke inhalation injury may

Figure 1 Severe facial burns with airway secured.

Burns covering >20% of the total body surface

Note: Significant over- or underestimation of

Best: Isotonic crystalloids (e.g., lactated Ringers, Plasma-Lyte IV [Baxter, http://www.baxter

Journal of Special Operations Medicine Volume 16, Edition 4/Winter 2016

Figure 2 First-degree burns. (Do not include these wounds in

the TBSA estimate!)

example, if the burn size is 30%: 30 10 =

The principles of hypotensive resuscitation

PFC Guideline: Burn Management

Figure 3 Second-degree burns.

Figure 4 Third-degree burns.

(A) Second-degree burn with intact blisters.

(A) Third-degree burn with eschar.

(B) Third-degree burn before cleaning and debridement of loose, dead

(C) Third-degree burn after cleaning and debridement and escharotomy.

(D) Extensive third-degree burns with eschar formation.

Journal of Special Operations Medicine Volume 16, Edition 4/Winter 2016

300mL/h, increase IV rate by 0.25 300 =

PFC Guideline: Burn Management

MAJ Powell, MC, USA, is an intensive care physician cur-

rently serving as the 4th Battalion 3rd Special Forces Group

COL (Ret) Cancio, MC, USA, is the senior burn surgeon at

the US Army Burn Center. He directs the Multi-Organ Support

Surgeon, 82d Airborne Division, Operation Just Cause and

Journal of Special Operations Medicine Volume 16, Edition 4/Winter 2016

Appendix A Escharotomy incisions

Figure A1 Photograph of a patient undergoing escharotomy

Figure A2 Photograph of a patient undergoing escharotomy

of the leg, using electrocautery. The goal is to go through the

of the leg and foot, using a scalpel. When using a

PFC Guideline: Burn Management

Appendix B Lund and Browder Burn Wound Calculation Worksheet

Burn Estimate and Diagram (Age vs. Area)

Appendix C Rule of Nines Burn Wound Calculation

Journal of Special Operations Medicine Volume 16, Edition 4/Winter 2016

PFC Guideline: Burn Management

Date and Time of Injury

Calculate Rule of Tens

Calculate max 24hr

BAMC/ISR Burn Team DSN 312-429-2876: Yes No

*Titrate LR hourly to maintain adequate UOP (30-50mL/hr) and tissue perfusion

Initial Treatment Facility

Total Fluids: (Use adjuncts if >24hr max)

Appendix D Joint Trauma System (JTS) Burn Resuscitation Flow Sheet

Appendix E Fluid and equipment planning considerations

Fluids: IV fluid (lactated Ringers solution or

Fluids: IV fluid (lactated Ringers solution or

Journal of Special Operations Medicine Volume 16, Edition 4/Winter 2016

Appendix F Summary Table

Assess Burn Size

For initial estimate: Rule of 9s

For large burns: Rule of 9s

Use isotonic crystalloid (lactated Ringers or Plasma-Lyte)

Oral resuscitation with electrolyte solution (avoid plain water)