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 a variety of reasons such as an active shooter, barricaded subjects, distance, or any type of 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 providers 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 than the way EMS and medical care is provided in a "normal" environment, when one gets to interact immediately with the patient, both verbally and physically. The remote can range from verbal instructions to the patient to complete medically oriented tasks to change in location for better access.[2][3][4]

Issues of Concern

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

Regardless of the ability to obtain a visual assessment, verbalization and talking to the patient or someone close by can provide additional valuable information. Having both verbal and visual abilities exponentially increases information, but this is not always feasible. Along similar lines, remote treatment may be the only option depending on the situation. 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, but 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 have a sense for which physical exam needs 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 type 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 for a time 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 the whole body or focused, but the first decision is to decide where and when to perform the exam. This must keep in mind the safety of the provider, patient and surrounding environment. The full physical exam should be done in the green zone where 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 the detailed exam during transport.
• Account for all factors at the scene when making the determination of where and when to assess the patient.
• If there is a long delay expected in transport due to prolonged extrication, it may not be advisable to delay assessment
• An inconsistent physical exam approach makes it more likely that an injury will be is missed. 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, starting at the patient’s head and working down while always remembering to prioritize the CBA's. 

A detailed physical exam in a dangerous setting may require rapid communication with the patient. Just like most police and EMS systems have gone to 'plain language,' keep the information exchange in plain language as much as possible as to gain as much information from the patient as possible. If something doesn't sound correct or leads you to more questions, that means you are on the right track. 

Like any medical interaction, documentation needs to be performed. This does not mean to take detailed notes in the warm zone. In a dangerous field setting, it may be necessary to complete documentation after the fact. The importance of documenting findings is so it can help the 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 with less than optimal conditions when emergency management professionals cannot actually treat the patient themselves. The use of verbal cues, self-treatment, cognitive reminders, and instructions all can help stabilize a life-threatening emergency until more advanced care can be delivered by the medical provider themselves. [5][6][7][8]