12 Essential Capabilities of Austere Emergency Care

MARCH 2020
A newly formed International Committee for Austere Emergency Care (IC-AEC), comprised of medical-specialty subject matter experts, has as its mission to develop and translate military best-practices from Prolonged Field Care guidelines to broader civilian use.  The following list is an adaptation of the PFC capabilities and suggests that medical providers consider the below list of capabilities when preparing their EMTs and medics to manage patients in austere settings.  It is presented in a “minimum, better, best” format.  The intent is to demonstrate those basic skills, with adjunctive skills and equipment that may be employed when considering what to train for Austere Emergency Care.  It is tiered to reflect not only increased equipment availability, but also escalating provider skill levels and scopes of practice.  This list is presented as medical subject matter expert opinion and does not supersede individual provider or service scope of practice or accepted protocols.
At first glance, the list may seem somewhat simple, but it emphasizes basic medical skills, that, when put together, allow for a more comprehensive approach to critical patient care in an austere setting.  Of note, equipment is relatively de-emphasized since medical skills and training should be the focus of preparing the remote provider for providing this care.
AEC requires the following capabilities in at least some capacity.  If you can provide these 12 capabilities in at least the minimum requirements, you are on your way to being prepared for AEC. The recommendations are detailed below:
1.  Monitor the patient in order to create a useful vital sign trend
                  a.  Minimum – blood pressure cuff, stethoscope, pulse oximetry, a means to measure urine output, mental status, and an understanding of vital signs interpretation.  Use a method to accurately document vital signs trends.
                  b.  Better – add capnometry; Foley catheter
                  c.  Best – automated vital signs monitor in order to provide hands-free vitals at regular intervals
2.  Resuscitate the patient for various causes of hypoperfusion/shock
                  a. Minimum – Administer replacement/resuscitation fluids via intravenous, intraosseous, oral and/or rectal routes.
                  b. Better – use of fresh whole blood (FWB) or blood products (packed RBCs, plasma, etc.); be prepared for a major burn and/or closed head injury resuscitation (adequate amounts of LR or PlasmaLyte A; hypertonic saline); have adequate replacement and maintenance fluids; Fluid warmer
                  c. Best – maintain a stock of blood products (cold-stored Whole Blood; pRBCs, FFP, and have type-specific donors identified for immediate FWB draw) for hemorrhagic shock resuscitation; multiple other forms of resuscitation fluids.

3.  Ventilate/oxygenate the patient
                  a. Minimum – provide positive end-expiratory pressure (PEEP) via bag-valve-mask (BVM) device
                  b. Better – provide supplemental O2 via oxygen concentrator or other source
                  c. Best – portable Ventilator with supplemental O2

4.  Gain definitive control of the patient’s airway with an inflated cuff in the trachea (and be able to keep the patient comfortable)
                  a.  Minimum – supraglottic airway or cricothyrotomy
                  b.  Better – add ability to provide long-duration sedation
                  c.  Best – add a responsible rapid sequence intubation (RSI) capability with subsequent airway maintenance skills, in addition to providing long term sedation (to include suction and paralysis with adequate sedation)
5.  Use pain control/sedation (as allowed by practice guidelines/protocols)
                  a.  Minimum – provide over the counter and/or controlled analgesics administered PO/PR
                  b.  Better – provide opiate analgesics and/or ketamine titrated IV/IO (and adjunctive midazolam or other medications as indicated by protocol)
                  c.  Best – experienced with and maintains currency in long term sedation practice using IV morphine, ketamine, midazolam, fentanyl, etc.
6.  Use physical exam/diagnostic measures to create a Problem List and treatment plan
                  a.  Minimum – using physical exam without advanced diagnostics – maintain awareness of potential unseen injuries (abdominal bleed, head injury, etc)
                  b.  Better – trained to use advanced diagnostics – ultrasound, point-of-care lab testing, etc.
                  c.  Best – experienced clinician
7.  Provide nursing/hygiene/comfort measures
                  a.  Minimum – ensure the patient is clean, warm, dry, positioned, padded, has a plan for bowel and bladder needs, and provides documentation of all care
                  b.  Better – advanced wound care to include: debridement, perform washouts, wet-to-dry dressings; decompress stomach; catheterized; and adequate plan and monitoring of in- and out-puts over time
                  c.  Best – experienced nursing staff member with transport training
8.  Perform advanced surgical interventions (as allowed by scope of practice)
                  a.  Minimum – cricothyrotomy, needle or finger thoracostomy
                  b.  Better – escharotomy, fasciotomy, wound debridement, amputation completion, tube thoracostomy, lateral canthotomy, etc.
                  c.  Best – experienced emergency, critical care or surgical provider
9.  Perform telemedicine consult
                  a.  Minimum – Designate Medical Control; establish & test multiple modes of communications; document & detect trending vital signs & patient’s response to treatment; present a patient using an organized call script
                  b.  Better – Exercise with dedicated Medical Control; add photos of labs, equipment, patient injuries, and any available diagnostic imaging (ultrasound, ECG, etc.)
                  c.  Best – video teleconference or other synchronous medical direction
10.  Package and prepare the patient for movement
                  a.  Minimum – provide splinting, immobilization and movement to the non-ambulatory patient using improvised or light-weight stretchers or similar devices
                  b.  Better – trained in critical care transport and air transport
                  c.  Best – regularly participate in critical care transport, air transport, and adjunctive equipment
11. Planning for austere care (evacuation chain, referral center for patient destinations, medical/environmental threats in area, logistic considerations)
a.  Minimum – Understand the chain of care and evacuation; identify the referral medical center; understand most common medical and environmental threats; plan for logistics requirements
                  b.  Better – Understand and practice evacuation, visit and establish points of contact at referral centers, pre-mission visiting to area of operations, have a good supply and re-supply plan
                  c.  Best – regularly practice and operate in austere environments with first-hand knowledge of operational area
12. Establish reliable communication within the team and for operational and medical control
a.  Minimum – Voice communication with at least one redundant system for basic data (text) established with equipment to support
                  b.  Better – PACE (Primary, Alternate, Contingency, Emergency) Plan developed and exercised for voice and data.
                  c.  Best – Multiple redundant systems for voice, data and video communications