Military Telemedicine: The Future is Telesonography in Prolonged Field Care
ACEP Ultrasound Military and Tactical Subcommittee
Military telemedicine in recent conflicts
In 2004, a modern-day military telemedicine platform was created to provide an asynchronous consultation service to support the medical units deployed during the wars in Iraq and Afghanistan. The capabilities of this service expanded between the years of 2004 and 2017 to include over 20 subspecialties such as dermatology, ophthalmology, infectious disease, trauma, cardiology, neurology and orthopedics.1 This email-based service, with an average response time of 5 hours, has facilitated the continued medical care of over 14,000 deployed service members from the years 2004 to 2018, with the majority of the consultations pertaining to Disease, Non-battle field Injury (DNBI) cases.2
Extending the hand of the military physician into Prolonged Field Care
Over the past decade, military medicine has become accustomed to operating in an environment where patient evacuation to definitive care with surgical intervention within the “golden hour” is possible.3,4 This, in conjunction with advancements in military trauma care published in the Clinical Practice Guidelines by the Joint Trauma System, has led to the unparalleled survival of U.S. combat casualties in Iraq and Afghanistan. However, it is likely that future conflicts may lack large infrastructure, and thus will inhibit the ability to evacuate patients expeditiously. Medical professionals will therefore need to rely on far forward combat medics and other health professionals, such as physician assistants and nurse practitioners, to provide “Prolonged Field Care” (PFC) prior to evacuation for definitive care. This new treatment algorithm requires training on a set of medical capabilities and competencies that allow the provider on the ground to care for a patient in an austere environment for an extended duration.5 The ten capabilities of PFC are as follows: continuous monitoring, resuscitation, establishing a definitive airway, ventilation/oxygenation, sedation/pain control, continued physical exam with real-time diagnostic measures, nursing/hygiene/comfort measures, surgical interventions, telemedicine consultations and flight preparation/in-flight care.5
As above, a key core competency in PFC is utilization of telemedicine consultations. With the already established aforementioned military telemedicine platform, the goal is for the PFC provider to develop proficiency in requesting emergent assistance in real-time from a medical expert. With proper training, telemedicine can facilitate appropriate triage and avoid delays in diagnosis and medical management for patients during their initial trauma evaluation.6 It allows a tele-intensivist to virtually connect with a medic at the point of injury to provide real-time guidance and augment their limited skill set when managing a complex critical patient. To perform an adequate assessment and initial treatment at the first echelon of medical care, the medic or advanced practice provider will also require basic knowledge of real-time diagnostics and procedural guidance using point-of-care ultrasound (POCUS). This is feasible given the development of inexpensive, hand-held, durable ultrasound devices. POCUS is also cost-effective and versatile: qualities that are essential in remote military operations requiring a small footprint and a high level of maneuverability. With the utility of POCUS being well established in Emergency Medicine and Critical Care, the use of telesonography will become a critical clinical decision and management tool in PFC.7
A multitude of emergency medicine POCUS modalities have been proven to be useful in austere environments, including civilian pre-hospital or remote battlefield environments where X-ray or CT are not readily available.8,9 These applications include fracture identification and reduction, evaluation of the inferior vena cava for resuscitation, optic nerve sheath diameter assessments for intracranial pressure evaluation in the setting of head trauma, procedural guidance for venous access, regional anesthesia, pericardiocentesis, cricothyrotomy and foreign body detection as well as the extended focused assessment with sonography for trauma (e-FAST) for patients with blunt or penetrating trauma.10 Given that the majority of battlefield deaths are from exsanguination or tension pneumothorax, the ability to perform the e-FAST will be essential for these far forward medical providers in conducting appropriate triage decisions as well as performing life-saving initial medical interventions. In the aftermath of the Boston bombing in 2013, the use of eFAST by an emergency physician provided invaluable triage decisions to determine which patients required immediate operative interventions, given that the use of conventional radiography processes were unavailable.11 However, to have an emergency medicine physician on the military frontlines in Prolonged Field Care is not likely.
Therefore, prolonged field care training focuses on combat medics as the primary provider. Numerous studies have demonstrated that non-physician providers and pre-hospital medics can obtain adequate POCUS images for diagnosis of pneumothorax and pericardial effusion after a brief training session.12–14 An additional study, using synchronous telesonography, showed that physicians at a distant medical facility can provide accurate virtual feedback to a non-physician performing the e-FAST real-time, in order to obtain US images that direct critical patient care actions in an ICU setting.15 This evidence reveals that telemedicine could greatly enhance a forward-deployed medic’s skill set and allow them to perform critical trauma care while simultaneously safeguarding the military physician, a commodity that is irreplaceable. Thus, developing a reliable, secure telesonography platform and then training the non-physician military medical providers in ultrasound will be essential to continue the delivery of exceptional trauma care to critical wounded service members and virtually extend the hands of the military physician into future remote resource constrained battlefields.
The views expressed herein are those of the author(s) and do not reflect the official policy or position of Brook Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, the Department of Defense, or the U.S Government.
- Lappan CM. The US Army medical department email teleconsultation program. US Army Med Dep J. 2016.
- Nettesheim N, Powell D, Vasios W, et al. Telemedical support for military medicine. Mil Med. 2018. doi:10.1093/milmed/usy127
- Palm K, Apodaca A, Spencer D, et al. Evaluation of military trauma system practices related to damage-control resuscitation. J Trauma Acute Care Surg. 2012. doi:10.1097/TA.0b013e3182754887
- 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. 2016. doi:10.1001/jamasurg.2015.3104
- Ball JA, Keenan S. Prolonged field care working group position paper: prolonged field care capabilities. J Spec Oper Med. 2015.
- Marsh-Feiley G, Eadie L, Wilson P. Telesonography in emergency medicine: A systematic review. PLoS One. 2018. doi: 10.1371/journal.pone.0194840
- Nelson BP, Chason K. Use of ultrasound by emergency medical services: a review. Int J Emerg Med. 2008. doi:10.1007/s12245-008-0075-6
- El Sayed MJ, Zaghrini E. Prehospital emergency ultrasound: A review of current clinical applications, challenges, and future implications. Emerg Med Int. 2013. doi:10.1155/2013/531674
- Gharahbaghian L, Anderson KL, Lobo V, et al. Point-of-care ultrasound in austere environments: A complete review of its utilization, pitfalls, and technique for common applications in austere settings. Emerg Med Clin North Am. 2017. doi: 10.1016/j.emc.2016.12.007
- Nations JA, Browning RF. Battlefield applications for handheld ultrasound. Ultrasound Q. 2011. doi:10.1097/RUQ.0b013e31822b7c14
- Kimberly HH, Stone MB. Clinician-performed ultrasonography during the Boston marathon bombing mass casualty incident. Ann Emerg Med. 2013. doi: 10.1016/j.annemergmed.2013.05.014
- Monti JD, Younggren B, Blankenship R. Ultrasound detection of pneumothorax with minimally trained sonographers: a preliminary study. J Spec Oper Med. 2009.
- Chin EJ, Chan CH, Mortazavi R, et al. A pilot study examining the viability of a prehospital assessment with ultrasound for emergencies (PAUSE) protocol. J Emerg Med. 2013. doi: 10.1016/j.jemermed.2012.02.032
- Bhat SR, Johnson DA, Pierog JE, et al. Prehospital evaluation of effusion, pneumothorax, and standstill (PEEPS): Point-of-care ultrasound in emergency medical services. West J Emerg Med. 2015. doi:10.5811/westjem.2015.5.25414
- Biegler N, McBeth PB, Tiruta C, et al. The feasibility of nurse practitioner-performed, telementored lung telesonography with remote physician guidance - “a remote virtual mentor.” Crit Ultrasound J. 2013. doi:10.1186/2036-7902-5-5.
Amie Billstrom, PA-C, MAJ Melissa Myers, MD
Army Physician Assistant
Emergency Medicine Ultrasound Fellow at the San Antonio Military Medical Center.