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Patient Transportable Tactical Combat Casualty Care Documentation Capability



OBJECTIVE: Army Medicine, MRMC, and the Military Health System requires a persistent, durable non-paper patient transportable tactical combat casualty care documentation capability for transport and transfer of medical care information into the currently fielded Department of Defense electronic health record in the absence of a reliable communications link. This technology would enable the facilitation of medical information exchange, thereby improving clinical outcomes. 

DESCRIPTION: The current capabilities for documentation of patient care in the pre-hospital environment by the combat medic (Emergency Medical Technician) is to utilize a paper Tactical Combat Casualty Care (TC3) Card. While paper-based cards offer ease of use and rapid deployability, they also have significant limitations as a form of medical documentation. These limitations include vulnerability to the elements, ease of marring or destruction, and may be lost during patient transfer (Killeen) or rendered illegible by blood or fluids (Garner). Studies show that the loss of medical information in the pre-hospital environment is significant and trauma patients’ outcomes are directly impacted by failures in communications. Dr. Frank Butler, Chairman, DoD Committee on Tactical Combat Casualty Care highlighted in the Tactical Combat Casualty Care Update 2009 that less than 10% of the 30,000 casualties in Iraq and Afghanistan had any form of documentation in their records. He also further states that only 1% of the patients have sufficient pre-hospital documentation. This low rate of pre-hospital documentation is alarming when considering studies that highlight that 67% of sentinel events for Trauma patients can be attributed to result of errors in communication (Stahl). This high rate of sentinel events occurred within a single Trauma I Facility which is in direct contrast to the geographically dispersed tactical pre-hospital environment with patient multiple hand-offs. Casualties in the military operational environment will be transferred between care providers at multiple hand-offs as they are evacuated to a military hospital. These hand-offs offer additional opportunity for loss of record of care for the patient. According to Dr. Emily Patterson, Editorial Advisory Board member for The Joint Commission Journal on Quality and Patient Safety, “the impacts of less-than-ideal hand-offs likely include adverse events, delays in medical diagnosis and treatment, redundant communications, redundant [medical] activities.” This study focused on credential providers within a medical facility and did not delve into the issues of the lack of pre-hospital documentation. However, the salient point is that failures in medical information exchange impacts patient care and therefore impacts patient outcomes. The future potential capabilities are highly reliant upon network connectivity and cloud computing to facilitate the exchange of information as a patient is being evacuated to a military hospital. However, these advanced capabilities have not yet been realized in the pre-hospital environment for the medic treating casualties. In a networked environment that is degraded through enemy denial of service attacks, the exchange of medical information through communication networks may not be feasible. This desired capability will allow for the transfer of patient information through a persistent and durable mechanism that can be easily maintained with the patient through multiple patient hand-offs as the patient transitions through the continuum of care from the Point of Injury (Role I) to a Combat Support Hospital (Role III). This mechanism will feature a minimal risk of loss of the information or the medium on which it is conveyed. This capability would need to be compatible with Nett Warrior End User Devices (EUDs) that utilizes Samsung Galaxy S5 phones loaded with securely configured Android 5.0 operating system. The capability will need to interface with the currently deployed Electronic Health Record. Information must be transferrable between Nett Warrior EUDS through an interface, as well as DoD’s currently deployed Electronic Health Record. Capability concepts with smaller footprints and lower consumption of supplies are preferred. Capability concepts that do not require modification of the Nett Warrior End User Device hardware will also be given preference. 

PHASE I: Design and develop an innovative concept for a capability that allows for the medical information exchange of pre-hospital care in military operational environment that persists throughout multiple patient exchanges and the continuum of care to a deployed military hospital in theater. The capability should be compatible with mobile Nett Warrior Android-based EUDs and be able to interface with the currently deployed Electronic Health Record. Produce a conceptual design and breadboard of the patient transportable tactical combat casualty care documentation capability to identify measures and predicted performance in Phase II. Explore commercialization potential with civilian emergency medical service systems development and manufacturing companies. Seek partnerships within government and private industry for transition and commercialization of the production version of the product. 

PHASE II: Finalize the design from Phase I. Complete component design, fabrication and laboratory characterization experiments. Develop, demonstrate, and validate a ruggedized prototype and evaluate end to-end functionality without a transmission over an Internet Protocol-based military tactical radio/cellular network. At the end of Phase II, demonstrate a field testable prototype the in a government sponsored military exercise and without requirement for connection to a military tactical network. The prototype system will be evaluated by operational medics and clinicians in a relevant operational field environment; such as at a USA Army TRADOC Battle Lab. Flesh out commercialization plans contained in the Phase II proposal for elaboration or modification in Phase III. Firm up collaborative relationships and establish agreements with military and civilian end users to conduct proof-of-concept evaluations in Phase III. 

PHASE III: Continue development and refinement of the prototype in Phase II to develop a production variant of the application. The production variant may be evaluated in an operational field environment such as Marine Corps Limited Objective Experiment (LOE), Army Network Integration Exercise (NIE), etc. depending on operational commitments. Present the prototype project, as a candidate for fielding, to applicable Army, Navy/Marine Corps, Air Force, Coast Guard, Department of Defense, Program Managers for Combat Casualty Care systems along with government and civilian program managers for emergency, remote, and wilderness medicine within state and civilian health care organizations, and the Departments of Justice, the Department of Homeland Security, the Department of the Interior, and the Department of Veteran’s Affairs. Execute further commercialization and manufacturing through collaborative relationships with partners identified in Phase II. 


1: Butler, Frank K. "Tactical combat casualty care: update 2009." Journal of Trauma and Acute Care Surgery 69.1 (2010): S10-S13.

2:  Garner, Alan. "Documentation and tagging of casualties in multiple casualty incidents." Emergency Medicine 15.5-6 (2003): 475-479.

3:  Killeen, James P., et al. "A wireless first responder handheld device for rapid triage, patient assessment and documentation during mass casualty incidents." AMIA annual symposium proceedings. Vol. 2006. American Medical Informatics Association, 2006.

4:  Patterson, Emily S., and Robert L. Wears. "Patient handoffs: standardized and reliable measurement tools remain elusive." The joint commission journal on quality and patient safety 36.2 (2010): 52-61.

5:  Stahl, Kenneth, et al. "Enhancing patient safety in the trauma/surgical intensive care unit." Journal of Trauma and Acute Care Surgery 67.3 (2009): 430-435.

KEYWORDS: Pre-Hospital Care, Documentation, Role I, Tactical Combat Casualty Care Capability, Medical Information Exchange, Electronic Health Record 


James Beach 

(301) 619-8912 

Ronald Yeaw 

(301) 619-2079 

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