Introduction

This Role 1, prolonged field care (PFC) Clinical Practice Guideline (CPG) 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 CPG is meant to provide medical professionals who treat severely injured or sick patients in austere environments with recommendations for documentation that will allow them and subsequent providers along the evacuation chain to optimally manage complex, often unstable casualties. Recommendations follow a “minimum,” “better,” “best” format that provides alternate methods when optimal hospital options are unavailable.

PFC frequently involves the care of complicated, critically injured or sick casualties who are normally managed in medical treatment facilities. For patients that survive the initial trauma or sickness, the biggest risk of death is from circulatory shock and its complications. All severely injured and sick patients must be closely monitored for signs of shock and decompensation because the best treatment for shock is early recognition, treatment of the cause, and resuscitation. One method used by intensive care units to monitor critical patients is trending vital signs, physical exams, and fluid outputs recorded on a flowsheet that facilitates recognition of changes that could mark the early signs of decompensation.

In the PFC environment, one of the few techniques available to the medical provider that is identical to those used in hospitals is documentation of key clinical trends. It is critical that Medics are trained on the interpretation of clinical trends. It is also essential that Medics cross-train nonmedical teammates to take and record vital signs, outputs, key exam findings, and interventions to free the medic to do other tasks as well as to sleep if care of the casualty is especially prolonged.

Documentation that can help the medic and successive caregivers manage complicated patients includes:

• TCCC Card, DD1380
• PFC flowsheet
• Telemedicine guide
• Handoff report

Finally, completion of the PFC after-action report (AAR) will contribute greatly to performance improvement to develop training, tools, and techniques for improving the care of casualties in austere environments.

While some casualties will be unable to provide name, identification number, date of birth (DOB), or other identifying information, every effort should be made to collect and document this information in order to facilitate the inclusion of prehospital documentation into the patient’s medical record. This information not only helps the longitudinal care of casualties as they progress through the evacuation chain, it also provides the vital link to connect prehospital treatments delivered to survival and long-term outcomes in order to guide recommendations for improving trauma care.

NOTE: Medical treatment facilities use pseudo names assigned when a patient’s real name is unknown. In such cases, every effort should be made to continue the same pseudo name through transfers of care. Prehospital documentation submitted after patient transfer, to include AARs, should use the same name or pseudo name assigned at the first treating MTF.

Goals

• Transmit important medical information to the next level of care
• Permanently record information vital to service members injured in combat
• Contribute to performance improvement in prehospital care.

Minimum: TCCC Card DD1380

• The DD1380 is organized as a MIST (Mechanism, Injuries, Signs and Symptoms, Treatments) report (Appendix A).
• Note the time casualty is received and include time of injury (if known and different from when received) and time of all key interventions (e.g., tourniquet, blood transfusion, tranexamic acid [TXA] dosing).
• List injuries and annotate on the diagram. Tourniquets and tourniquet times are also annotated on the diagram.
• Vital signs, including mental status AVPU (alert or responsive to voice, pain, or unresponsive) and pain scale, should be recorded to the greatest extent possible—up to four sets of vital signs can be recorded on the TCCC card.
• Document treatments to include external hemorrhage control, airway, breathing, fluids, medications, and other interventions on the reverse side of the TCCC card.

Better: PFC Flowsheet

As a follow-on to the TCCC card, the PFC flowsheet is used to document trends over time and is the most useful tool to recognize important clinical changes in complex casualties such as decompensation, response to resuscitation, development of complications, effectiveness of medications, etc. The PFC flowsheet is one of the most effective ways to improve the level of care provided in PFC situations.

• When prehospital care transitions to PFC, documentation should transition from the TCCC card to the PFC flowsheet. There is no exact time for this transition to occur; however, once all of the available time blocks on the TCCC card are filled and evacuation to higher level of care is not imminent, then documentation can transition to the PFC flowsheet (Appendix B).
• The PFC flowsheet not only serves to document care and identify trends but also contains a checklist of interventions that may be needed through the included patient care and nursing care checklists. Such checklists can greatly aid task-saturated, fatigued Medics by providing a quick point of reference for important tasks that should be performed regularly to improve care and reduce the risk of complications to their patients.

• The PFC flowsheet also includes:
• Vital signs
• Fluid input and output
• Medication times, route, dose
• Physical exam findings
• Problem list
• Treatment plan
• Telemedicine call script

Best: AAR

• An AAR should be completed after patient handoff. In addition to the TCCC card and PFC flowsheet, a structured AAR is used to collect lessons learned and improve care. In cases where documentation is not able to be completed before patient handoff or was lost after handoff, the AAR can also serve as a supplement to the medical record.
• TCCC and PFC AARs are available at http://jts.health.mil/index.cfm/PI_CPGs/cpgs
• TCCC or PFC AARs, along with any medical documentation not completed before patient handoff, should be completed within 24 hours of patient handoff and summited to the Joint Trauma System (JTS) prehospital organizational email box: usarmy.jbsa.medcom-aisr.list.jts-prehospital@mail.mil
• The unclassified medical AAR should be accomplished in addition to unit-required classified AARs.

Goal

Goal: Facilitate communication between prehospital provider and telemedicine consultant.

Rehearsal of telemedicine consultation between prehospital providers and remote physician consultants has shown that communication is optimized when the caller completes a telemedicine guide or script before calling the consultant and uses it during the consultation. In addition to transmit- ting medical information to the consultant, it is important for the caller to provide information about the care context and a summary of capabilities currently available. An image of the casualty and an image of the care environment are helpful for remote consultants to understand the operational constraints faced by the local caregiver. Capabilities that are important to convey to remote consultants may include the training level of the provider, available medications, medical supplies, monitoring, ultrasound, etc. Reading or sending a photograph of a written capabilities list will more quickly orient the consultant to the operational environment of the caller and reduce time spent asking the caller for items that are not available. If urgent teleconsultation is needed, do not delay calling to fill out a guide sheet or send e-mails. For additional details, see Teleconsultation in prolonged field care position paper.¹

Minimum: Read from TCCC card.

Better: Use telemedicine report incorporated in the PFC flowsheet.

Best: Use the Virtual Critical Care Consultation guide (Appendix C) and send a picture of casualty, capabilities, and vital sign trends to the consultant via email or text using appropriate operational security and protections of patient privacy.

Goal: Ensure safe transition to the next level of care.

Adverse events may occur due to poor handover of a patient from one level of care to another. The PFC provider’s job is not done until the receiving team understands the patient’s condition and can begin to manage the patient appropriately.

Summarize in organized format:

1. Overall condition of the patient: stable or unstable; better, same, or worse.
2. Mechanism of injury or illness
3. Injury(ies), current physical exam
4. Vital signs to include trends and urine output
5. Treatments (procedures, dressings, airway management, fluids, blood products, medications)

Minimum: Written handoff report that follows the MIST format (e.g., TCCC Card).

Better: Add the PFC flowsheet.

Best: Add a dedicated handoff sheet (e.g., SBAR handoff report2, PFC handoff report3).

Electronic documentation is the standard in hospitals and advanced field medical facilities. Devices such as the Tempus Pro (Remote Diagnostic Technologies LTD, United Kingdom) and BATDOK (USAF, 711 Human Performance Wing, OH) are devices designed for the operational environment that can compile detailed patient records that support many of the recommendations in this CPG. These and other similar devices and applications may improve the accuracy of patient records, reduce the burden of data entry for the prehospital provider, and provide other features to improve patient care such as critical value alarms and telemedicine communication. Where such devices are fielded and supported with network connectivity, their use for austere PFC environments is encouraged.

JTS hosts a variety of fillable forms at http://jts.health.mil/index.cfm/documents/forms_after_action

1. Vasios W, Pamplin JC, Powell D, et al. Teleconsultation in prolonged field care. J Spec Oper Med. 2017:17(3);141–144.
2. Air Force Instruction 48-307, Volume 1, En Route Care and Aeromedical evacuation Medical Operations, 9 Jan 2017. 
3. Prolonged Care MTF Handover Sheet. https://prolongedfieldcare.org Accessed 28 Dec 2017.

Purpose

The purpose of this Appendix is to ensure an understanding of DoD policy and practice regarding inclusion in CPGs of “off-label” uses of U.S. Food and Drug Administration (FDA)–approved products. This applies to off-label uses with patients who are armed forces members. 

Background

Unapproved (i.e. “off-label”) uses of FDA-approved products are extremely common in American medicine and are usually not subject to any special regulations.  However, under Federal law, in some circumstances, unapproved uses of approved drugs are subject to FDA regulations governing “investigational new drugs.” These circumstances include such uses as part of clinical trials, and in the military context, command required, unapproved uses.  Some command requested unapproved uses may also be subject to special regulations. 

Additional  Information  Regarding  Off-Label  Uses  in  CPGs

The inclusion in CPGs of off-label uses is not a clinical trial, nor is it a command request or requirement. Further, it does not imply that the Military Health System requires that use by DoD health care practitioners or considers it to be the “standard of care.” Rather, the inclusion in CPGs of off-label uses is to inform the clinical judgment of the responsible health care practitioner by providing information regarding potential risks and benefits of treatment alternatives. The decision is for the clinical judgment of the responsible health care practitioner within the practitioner-patient relationship.

Additional  Procedures

Balanced  Discussion

Consistent with this purpose, CPG discussions of off-label uses specifically state that they are uses not approved by the FDA. Further, such discussions are balanced in the presentation of appropriate clinical study data, including any such data that suggest caution in the use of the product and specifically including any FDA-issued warnings.

Quality  Assurance  Monitoring

With respect to such off-label uses, DoD procedure is to maintain a regular system of quality assurance monitoring of outcomes and known potential adverse events.  For this reason, the importance of accurate clinical records is underscored.

Information  to  Patients

Good clinical practice includes the provision of appropriate information to patients.  Each CPG discussing an unusual off-label use will address the issue of information to patients. When practicable, consideration will be given to including in an appendix an appropriate information sheet for distribution to patients, whether before or after use of the product. Information to patients should address in plain language: a) that the use is not approved by the FDA; b) the reasons why a DoD health care practitioner would decide to use the product for this purpose; and c) the potential risks associated with such use.