Background

The U.S. Military has been testing telemedicine solutions for nearly 30 years.7 It was not until 2017, however, that telemedicine was recognized as an operational requirement by the Special Operations community.8 Although Joint- and Service-specific requirements for telemedicine remain undefined, it is clear from experience and research that OVH can enhance management of complex casualties in austere and operational environments.3,6,9-11

Importantly, OVH provides clinical expertise to the point of need. When caregivers managing casualties reach the limit of their KSAs, two options exist for ensuring a patient receives optimal care: evacuate or call for help. Calling for help has been identified as best practice when it is uncertain if a casualty needs evacuation or when evacuation is not possible. Using TC alters evacuation plans of local caregivers in more than half of cases2,3,12 and saves the U.S. Military millions of dollars annually. More importantly, these consultations have improved the care provided to casualties while simultaneously enhancing the LC’s KSAs through education during the consultation and the RE’s through increased understanding of austere and operational contexts.9

TC’s major limitation is that it requires network resources; if the network is not available, then it is not possible to conduct TC. Still many misperceptions about this limitation exist that need to be dispelled:

- TC is widely accessible and used daily in all environments without specialized communications equipment. It uses available technology: cellular, radio, satellite phone or computer via voice, text, email, internet web portals. Encryption may enhance security or protect patient information but is not a requirement for most medical applications (see below).13
- Synchronous voice using radio or phone call is sufficient for most consultations. Voice calls plus asynchronous file transfer (i.e. images) is a highly flexible and adaptable solution for delivering consultation in very austere locations.14-15 Video TC is most beneficial when LCs require tele-mentoring assistance by a RE to complete a procedure (e.g., fasciotomy, external fixation).16-17
- TC is a skill set and a tool that requires training, practice, and a PACE plan (Primary, Alternate, Contingent and Emergent). A team training in TC is able to adapt to conditions on the ground and optimize care for their patient. Last TC use when recorded sets the stage for future technologies like artificial intelligence and machine learning to produce decision support solutions that do not require network resources.
- Lastly TC takes more time than you think. Conveying information to a RE about the patient to ensure the RE has a clear understanding of the casualty’s problems and the clinical questions the LC needs answered are not always straight forward. The efficiency of TC may be improved by following the best practices outlined in this CPG.

Many clinicians fear TC because of concerns about a RE who may be unfamiliar with local context may be critical of care rendered in the operational setting. While this is a valid concern, it has not born out in case reviews and after-action reports. Feedback collected from real-world and training calls about LC experience with REs has been overwhelmingly positive.3 Remote military experts understand operational constraints and try hard to provide consultation in context to LCs who are often faced with nearly impossible challenges to overcome.