Real Time Battlefield Casualty Care Decision Support

Abstract

Tactical combat casualty care (TCCC) involves care for casualties in armed conflict from one’s own service (e.g., U.S. Marine Corps), other services (i.e., U.S. Army, Air Force,), allied forces, adversaries, and civilians. To minimize injury and preserve life, medics perform TCCC which includes casualty retrieval, stabilization and documentation, transport, triage, and treatment. In future scenarios, delays in evacuation are expected to require extended care including prolonged field care (PFC) over hours to days, increasing the potential for complications such as bloodstream infection (sepsis). Most medics have only simple equipment and essential medications and will need assistance at point of care to make decisions on how to treat more complex cases and perform procedures in an austere setting.We describe a project for the Defense Health Agency (DHA) over 3 years to develop and evaluate the Trauma Triage Treatment and Training Decision Support (4TDS), a real-time decision support system (DSS) to monitor casualty health. The operating 4TDS prototype uses the Samsung smart phone and tablet certified for use in the Department of Defense (DoD) Nett Warrior program. Connection to a simple VitalTag (Pacific Northwest National Laboratory, Richland, WA) vital signs monitor placed on a casualty at point of injury (PoI) will stream patient data including heart rate, respiration rate, peripheral oxygen saturation (SpO2), and diastolic and systolic blood pressure. Nurses, technicians, and physicians can use the tablet to display an expanded data set including lab values while providing care at a Battalion Aid Station (BAS) and Field Hospital (FH).4TDS includes a Machine Learning (ML) model to indicate shock probability, risk of internal hemorrhage, and probability of the need for a massive transfusion. The shock model was trained on Mayo Clinic Intensive Care Unit (ICU) patient data, then evaluated in a 6-month “silent test” comparing shock prediction with actual clinician diagnoses. The model only uses 6 vital signs, which is suited to battlefield care, while other published results include lab tests (e.g., lactate), and produces a Receiver Operator Characteristic Curve (ROC) of 0.83 for shock detection. The model only decreases by 0.05 90 minutes, identifying shock probability well before its onset. Medic reviews indicate a 30-minute advanced warning would be more than sufficient to initiate treatment.Medics who provide PFC may need to perform life-critical procedures such as shock management, cricothyroidotomy intubation, and transfusion that may not have been used for an extended period. 4TDS includes refresher training in how to perform such a procedure, as well as whether to perform the procedure. Usability assessments with healthcare providers from the Army, Navy, and Air Force at Joint Base San Antonio, TX have demonstrated 4TDS and its capabilities align with TCCC practice. This work is supported by the US Army Medical Research and Materiel Command under Contract No. W81XWH‐15‐9‐0001.