Page 40 - Journal of Special Operations Medicine - Spring 2017

balloon into the aorta to occlude blood flow proximal Participants
to an injury has been developed and shown to be ef- US Army Special Operations Command medical person-
fective as an alternative to thoracotomy. Resuscitative nel with no prior experience of endovascular techniques
5–8
endovascular balloon occlusion of the aorta (REBOA) were included in this study. All participants received
can delay life-threatening hemorrhage, allowing more didactic instruction of the Basic Endovascular Skills
time for triage, transport, and definitive surgical treat- for Trauma (BEST) Course together, with individual
™
ment. REBOA is currently being used and studied in the evaluation of technical skills. Of the four participants,
civilian trauma clinical setting. Military enthusiasm for two were nonsurgeon physicians (one was an emergency
9
this adjunct has been demonstrated in its inclusion in medicine and the other, a family medicine physician),
the June 2014 Joint Trauma System Clinical Practice one physician assistant, and one Special Operations
Guidelines: it “is recommended as an adjunct to control Combat Medic. Before this training, none of the partici-
life-threatening hemorrhage in the setting of truncal and pants had any experience with REBOA. The evaluators
extremity injury,” but is currently authorized only at were all physicians on staff at the University of Mary-
10
Role 3 facilities. land Shock Trauma who had clinical experience placing
REBOA.
Analysis of battlefield deaths confirms that earlier con-
trol of hemorrhage decreases mortality. One of the main Simulator
impediments to deployment of this adjunct into the field The VIST-C (Mentice, http://www.mentice.com) uses
is that, until recently, the procedure required long plat- computer software coupled with equipment that uses
form guidewires and a large-bore arterial sheath. These haptics when devices are inserted or manipulated. Hap-
devices are awkward when deployed and require a sur- tics uses force feedback to provide tactile feedback,
geon’s intervention for removal, which is not feasible in which is essential to the performance of endovascular
the forward setting. A smaller bore device has recently skills. This is of critical importance in this situation
gained Food and Drug Administration approval in the because the endovascular insertion of devices, as with
United States and has seen success in its initial clinical REBOA, is largely based on feel. This tactile feedback
use. This smaller device requires fewer procedural steps, is reinforced with static fluoroscopic images, which are
can be easily upsized from a percutaneously placed arte- used to confirm wire placement.
rial line, and requires only direct pressure for hemostasis
upon device removal. Unlike the far more invasive tho- BEST Course and Testing Scheme
racotomy and laparotomy, which are often performed The BEST course is a structured, day-long course con-
after the patient has had a hypotensive cardiac arrest, sisting of 4 hours of instructor-led didactics followed by
the minimally invasive REBOA device has the potential a simulation session and then cadaver laboratory ses-
to be placed preemptively in patients who are at risk of sion. A pretest was administered before the didactic por-
decompensating during their prolonged extraction. tion of the course. This was followed by several lectures
describing indications, insertion, and pitfalls of REBOA,
Although REBOA remains an adjunct used solely in the and an individual demonstration of the procedure by an
armamentarium of specialized physicians, its efficacy instructor.
will remain limited to only those patients who survive
to arrival at a Role 3 medical treatment facility. With Immediately after the didactic sessions, participants were
the changing landscape of military operations and the familiarized with the equipment and the procedure was
shift to smaller teams in disparate locations, arrival to demonstrated once. REBOA was then performed a total
a physical Role 2 or 3 facility may no longer be feasible of six times: three times each at a simulated aortic level
within the golden hour. Additional methods for tempo- for the distal thoracic aorta (zone 1) and proximal to
rizing noncompressible torso hemorrhage and junctional the iliac bifurcation (zone 3) (Figure 1). Each task, from
hemorrhage must be moved forward into the field. Our the insertion of the guidewire to inflation of the REBOA
hypothesis is that nonsurgeon physicians and high-level balloon, was performed as quickly as possible without
military medical technicians (i.e., Ranger Medics, Special compromising safe use of the endovascular equipment.
Forces Medical Sergeants, Pararescuemen, and Indepen- Each step of the procedure was evaluated by the instruc-
dent Duty Corpsmen) can learn the technical skills re- tors and assigned a score from 1 to 5. No interruption
quired for REBOA and the theory behind the procedure. or evaluation was provided between the attempts. The
time to complete the procedure and correct performance
of each step were recorded on a standardized evaluation
Materials and Methods
form (Figures 2 and 3). Because REBOA is performed
Ethical approval was obtained from the institutional in the resuscitation area with the use of only digital
review board at the University of Maryland School of x-ray imaging, when the trainee reached the portion
Medicine. of the procedure where confirmation of the guidewire

18 Journal of Special Operations Medicine Volume 17, Edition 1/Spring 2017