PROLONGED FIELD CARE DOCUMENTATION RECOMMENDATIONS

AUGUST, 2014

The need for more robust patient care documentation while caring for a patient over an

extended period of time has been proven through exercises, scenarios and incidents to be the most

effective way to provide prolonged field care. Despite this, many medics continue to fall short by

attempting to improvise by using cardboard, multiple strips of tape, or even writing on the wall or

patient while in a crisis situation in order to document. Any medic can greatly improve the morbidity,

as well as mortality, of their respective patients post-recovery through the use of an organized and

efficient flow-sheet. Through much trial and error, consulting, editing, and revising the local PFC

working group has agreed upon certain attributes that a single patient care document should contain

for the purpose of prolonged field care. While we have also made available our product, we would like

to emphasize that if you do not use ours, having something ready and familiar pre-incident is better

than neglecting this aspect of care until a crisis arises.

Nowhere is the need for documentation more important than during the hand off of patients

between medical providers. In a remote, austere environment it is likely that during a lengthy

evacuation a patient will be transferred multiple times between medics and providers. The sheer

amount of information accumulated during a prolonged field care event will not be manageable,

recalled or relayed in the short time during hand-off. Properly relaying injuries, treatments rendered

and drugs administered to the next echelon, team or lone medic can be the difference between a

patient dying, living or living with lifelong difficulties. We owe it to our patients to continue providing

first world care despite the circumstances and properly documenting that care is an easy way to

improve patient outcome which will make all the difference to our brothers-in-arms and their families.

The first things mentioned and agreed upon is that the document should be a single page

utilizing both sides and able to cover as much time as safely possible. This will prevent multiple pages

from becoming separated during movement or transfer of the patient. Several sizes and types of

paper have been used but the most common and easily accessible 8.5”x11” laminated page is being

recommended and a much larger version has also been used successfully in an aid station-like setting

demonstrating its utility. Having both and transferring data between the two is a viable option, using

the smaller size during the initial stages of care and transferring data to the larger once in a more static

position. Either can travel with the patient and be transferred to the receiving medical treatment

facility.

The first side of the flow sheet will be referred to as Side A and should contain all necessary

data pertinent to patient identification, safety, security and tracking by the organization. The version

12 document we have available for use is in Excel format for ease of editing and customization. Known

patient allergies should be clearly visible, along with tourniquet application time, which was proven

crucial during the most recent incident in South Sudan. The MIST report (Method of illness or injury,

Injuries, Stable or Unstable, and Treatments rendered) should be easily identifiable for anyone relaying

information to telemedical support as well as a current set of vitals is usually requested and

appropriate to relay here.

While most first rate medics may not be familiar with all labs and the consequences of the

values, it is worth adding them to the sheet for the purpose of consulting and perhaps going a step

further and adding the local conversion for the country one is operating in. If one can run a couple

vials of blood to the local host nation clinic, or run it through an iStat, one should be able to relay that

info, which will greatly improve the clinical picture to another provider on the other side of the world.

Keeping the normal ranges for these labs can alert even an untrained team member that the result is

out of range and should be brought to the attention of the necessary personnel.

Drugs and fluids administered, or Ins, will be important in the short term but also very

important when working with multiple providers, an unfamiliar team or anytime there is a hand-off or

transfer. If you are tracking Ins then tracking Outs nearby will be as important. I cannot possibly go

over all of the implications of properly recording and trending urine output here, but of initial concern

in shorter term patient management, properly tracking urine output serves as a surrogate measure of

adequate resuscitation in many patient populations. Other Outs include chest tube drainage, stomach

contents via NG/OG tube and feces, which can all add pieces to the puzzle. An area for clinical notes is

usually useful for other info that does not fit into one of the other categories. We have also adopted

the pictogram from the TCCC card for another visual reference, and will likely add the GCS criteria and

possibly, a revised trauma score in a future version in the notes section.

Side B started out with a visual trending chart that can be used for a multitude of different vitals

using different symbols and connecting those symbols like connect the dots. This will make easier the

instant recognition that a patient’s health is in decline or if they are improving. In order to trend a

patient throughout a PFC incident more information will be needed over a longer period of time than is

normally anticipated for. Using a customizable grid with blanks for recording hours and minutes will

give the user the flexibility to take vitals as needed for either a stable or unstable patient without

skewing the trend line much at all. Our chart is easily used over a 10 hour period taking vitals every 15

minutes before needing to move to a second sheet and can be used far longer than this if time

between vitals is increased. Other vital signs which are difficult to trend due to the small change in

number should still be recorded for comparison, such as core temperature, pain scale or GCS and

output of drains other than urine.

Due to the nature of small unit operations, taking even one or two casualties can be extremely

stressful as well as time and resource intensive for the medic and team as a whole. A single medic

caring for a casualty will likely experience an initial rush of adrenaline as the patient is stabilized, and

depending on the duration of the operation and time to evacuation may also experience extreme

fatigue. This fatigue, if not managed properly can lead to mistakes by highly trained and experienced

SOF medics. Therefore, a chronological checklist of nursing care reminders is recommended in order

to remind the medic of procedures beneficial to the patient. Since not all patients present with the

same injury symptom, every effort should be made to anticipate as many procedures and treatments

common to the majority of patients seen due to both trauma and illness. These reminders therefore,

may appear to be random or generic depending on the presentation of the patient but can easily be

crossed out when not applicable.

All team members should be educated on the use of this new flow sheet prior to

deployment or even a training scenario. Once demonstrated and explained it becomes much easier for

the non-medical person to understand what is going on with the patient, making them an asset in care

as opposed to a hindrance or worse, a liability. The medic and non-medic alike will now be able to

anticipate through trending, the health of the patient in the near future. This will enable a proactive

approach to planning the procedures and care the patient receives as opposed to constantly reacting

to patient crises, possibly when it is too late.