The practice of military emergency medicine and civilian emergency medicine frequently overlap, often in a symbiotic relationship1,2. The hard-won lessons from the operational environment are often incorporated into civilian practice time and time again (triage, tourniquets, whole blood etc etc). Within the military there is an emerging emphasis on the concept of prolonged field care3–5. This is the scenario in which rapid transport to definitive care (think Chinook/MERT) is not available, and casualties may have to spend a prolonged period of time in a semi-hostile environment. My random musings have translated this into an analogy for what is seen day-in day-out across emergency medicine departments due to exit block. Emergency departments are now expected to care for patients for periods of time in excess of 12 hours.
This is not what the emergency department was designed nor resourced to do. Sadly though, prolonged waits in the ED are common6,7 and it is common for things to get missed. In the ED we are often good at determining the next few hours of care in the expectation that the patient will have been clerked and admitted by the time ‘our’ plan has finished. This does not happen and if we are not wise to this our patients may miss important aspects of their care (Ed – this problem has been a feature of many complaints and a few high level incidents over the last decade).
Whilst trauma is the leading pathology in the military context, there are also standard medical presentations – sepsis, asthma, infectious diseases etc. So, how are the military preparing to look after patients when they are logistically stuck in a suboptimal environment? There is a mnemonic (that sounds more sinister than it is) that is in essence an aide memoire for the ongoing care of patients. H.I.T.M.A.N. (I definitely promise it sounds more sinister than it is) stands for Hygiene/Hydration, Infection, Tubes, Medication, Analgesia, and Nutrition8. These are the core needs of the patient, and ones that must be addressed to achieve even a basic level of care. I have no doubt that these are obvious to many delivering care in the emergency department; H.I.T.M.A.N. merely represents a nice way of formalising these needs into a package of care. If you want to H.I.T.M.A.N. your patients, please feel free to print off the checklist below.
Remember to HITMAN your patients!
- 1.Bailey ColJA, Morrison MajJJ, Rasmussen CTE. Military trauma system in Afghanistan. Current Opinion in Critical Care. November 2013:1. doi:10.1097/mcc.0000000000000037
- 2.Remick K, Shackelford S, Oh J, et al. Surgeon preparedness for mass casualty events: Adapting essential military surgical lessons for the home front. Am J Disaster Med. 2016;11(2):77-87. https://www.ncbi.nlm.nih.gov/pubmed/28102530.
- 3.Corey G, Lafayette T. Preparing for Operations in a Resource-Depleted and/or Extended Evacuation Environment. J Spec Oper Med. 2013;13(3):74-80. https://www.ncbi.nlm.nih.gov/pubmed/24048994.
- 4.Get Started Here . ProlongedFieldCare.org. https://prolongedfieldcare.org/2018/05/11/welcome-to-somsa-2017/. Published May 11, 2018. Accessed May 7, 2019.
- 5.Smith M, Withnall R. Developing prolonged field care for contingency operations. Trauma. September 2017:108-112. doi:10.1177/1460408617728536
- 6.Carley S. Studying for FCM (Fellow of Corridor Medicine) at St.Emlyn’s • St Emlyn’s. St.Emlyn’s. http://www.stemlynsblog.org/studying-fcm-fellow-corridor-medicine-st-emlyns/. Published December 19, 2014. Accessed May 7, 2019.
- 7.A&E waiting times. The Nuffield Trust. https://www.nuffieldtrust.org.uk/resource/a-e-waiting-times#background. Published October 16, 2018. Accessed May 7, 2019.
- 8.O’Kelly A. Prolonged Field Care. Remote Medicine. http://remotemedicine.blogspot.com/2012/08/prolonged-field-care.html. Published 2019. Accessed May 7, 2019.
1 thought on “Prolonged Field Care…in the ED. St Emlyn’s”
Hi, I’d like to add one more point to your HITMAN acronym:
a) collect all the necessary information
medical history, details necessary for both surgery and anaesthesia.
It often happens that a caring family member(i.e. a parent) waits for hours in the ED and has to leave at some point; just after that you find out, no one has handed the patient the anaesthesia questionaire and the patient is not fully oriented about his medical past. Or your patient deteriorates and you don’t recollect that pharmacy allergy he mentioned when he was still oriented.
b) informed consent
Tell the patient what you think is going on with him and what you are planning for him. This includes obtaining informed consent!
Being ill or injured is not a nice situation to be in, and even worse if noone tells you how long you are still going to lie alone on that stretcher while your are feeling sicker and sicker.
It’s also an annoying situation if there finally is a surgery room ready for a patient and you can’t send the patient because noone obtained informed consent and documented that.