Introduction

In a harsh or remote environment, there may be times when access to the patient is not feasible.[1] Access can be limited for various reasons, such as an active shooter, barricaded subjects, distance, or any obstructions. These obstructions vary based on location and terrain. These limitations should not prevent a tactical medical provider from trying to provide the best medical care they can in these less-than-optimal conditions. These situations make a tactical medical provider's knowledge set unique because they may need to provide care in less than optimal circumstances and utilize the actual patient or partner to provide the care until the situation is safe. This is completely different from how EMS and medical care are provided in a "normal" environment, where one gets to interact immediately with the patient verbally and physically. The remote can range from verbal instructions to the patient to complete medically oriented tasks to change location for better access.[2][3][4]

Issues of Concern

The concern for the medical care provider is the safety (of the patient and themselves). The concern for the patient is access to care promptly. Remote assessment needs to be utilized with these issues to get as much information as possible to lead to an educated medical decision that leads to the best outcome for the patient. 

Remote assessment can be accomplished in various ways, depending on the type of environment and equipment available. Remote assessment can be done directly by a line of sight, either a straight line or an advanced line of site (binoculars and scopes). Vision is paramount as it provides additional information to what is being communicated verbally and can give clues to the medical provider that the patient may not have verbalized or noticed. Binoculars should be part of every tactical medical provider's equipment. If not, observer/sniper scopes can be used instead of regular binoculars. The recent addition of "body cams" or body cameras and the "live-streaming" ability of some of these devices can also be used. 

Regardless of the ability to obtain a visual assessment, verbalizing and talking to the patient or someone nearby can provide additional valuable information. Both verbal and visual abilities exponentially increase information, but this is not always feasible. Similarly, depending on the situation, remote treatment may be the only option. Giving specific commands to the injured person or an uninjured partner may provide the necessary treatment to temporarily stabilize the injury until more definitive care can be provided. Some of these commands may be simple reminders of what is already known. Still, with the surge of catecholamines along with a high-stress environment, these basic things (cover from additional injuries, pressure for bleeding) may be forgotten but can easily be brought to the attention of the patient with minimal prompting.

After arriving on the scene and performing the initial (visual and verbal) assessment and treatment, you should know which physical exam must be performed to complete the assessment and which portions may be skipped or abbreviated due to the conditions. The focused physical exam is reserved for just these types of patients since they are trauma patients who have a limited number of body systems involved. The time saved can be paramount in patient outcomes. The parts of the physical exam that were skipped' can be done while waiting for transport or 'en route.'  The provider must perform a focused exam and potentially save a detailed exam when the conditions are safer (yellow or green zone).

The following is a suggested approach to providing focused, detailed physical examinations. The physical exam needs to be done. It can be whole-body or focused, but the first decision is to decide where and when to perform the exam. This must consider the safety of the provider, patient, and surrounding environment. The full physical exam should be done in the green zone, whereas a focused exam can be done in the yellow zone. 

• A multisystem trauma patient may have life-threatening injuries; delaying treatment and transport to perform an exam on scene may not be appropriate.
• If life is threatened, extricate the patient as soon as practical and perform a detailed exam during transport.
• When determining where and when to assess the patient, account for all factors at the scene.
• If there is a long delay expected in transport due to prolonged extrication, it may not be advisable to delay the assessment
• An inconsistent physical exam approach makes an injury more likely to be missed, and the most serious injuries may not be the most obvious.
• When performing a detailed physical exam, the easiest way to avoid missing something is to be methodical. Start at the patient’s head and work down, always remembering to prioritize the CBAs. 

A detailed physical exam in a dangerous setting may require rapid communication with the patient. Like most police and EMS systems have adopted 'plain language,' keep the information exchange in plain language as much as possible to gain as much information from the patient as possible. You are on the right track if something is incorrect or leads to more questions. 

Like any medical interaction, documentation needs to be performed. This does not mean taking detailed notes in the warm zone. In a dangerous field setting, completing documentation after the fact may be necessary. Documenting findings can help hospital staff understand the mechanism of injury and may guide further assessment and treatment of definitive care. 

Clinical Significance

Remote medical assessment and treatment can be life and limb-saving in the tactical environment. This usually occurs in less-than-optimal conditions when emergency management professionals cannot treat the patient themselves. Using verbal cues, self-treatment, cognitive reminders, and instructions can all help stabilize a life-threatening emergency until the medical providers can deliver more advanced care.[5][6][7][8]