Page 42 - Journal of Special Operations Medicine - Spring 2017

186 ± 18.7 seconds to 83 ± 10.3 seconds (p < .001), The participants’ knowledge and comprehension were
a mean improvement difference of 104 ± 12.3 seconds significantly improved after the course; they performed
from the first to the sixth trial. The mean time difference better on the posttest by approximately 14%. A similar
between trials was most marked between the first and rate was seen in the previous group with an improve-
second trial, with a 51 ± 8 second reduction in time ment in test performance of approximately 13.7%
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compared with the second trial (p = .011). After a de- (p = .97). This evaluation was identical to that used
crease in trial time of 21 ± 12 seconds to the third trial, previously and demonstrates our hypothesis that non-
the performance times shortened a further 3 ± 9, 11 ± surgeon physicians and advanced nonphysician practi-
10, and 18 ± 4 seconds at each subsequent trial, respec- tioners exhibit similar comprehension and knowledge of
tively (all p > .16). endovascular techniques after formal training.

All participants demonstrated safe handling of the en- Due to the small sample population, this case series is
dovascular equipment, and correctly verbalized the submitted as a white paper with the goals of establishing
indications of and need for REBOA placement, and the a proof of concept and beginning the discussion of the
indications for discontinuation. This trend continued available literature. Herein, we have described the feasi-
through all six tasks. The performance of all five proce- bility of military nonsurgeon and nonphysician prehos-
dural tasks over the six trials was judged by the evalu- pital providers learning the steps to perform REBOA
ator as 4 of 5 on the Likert scale for each participant. after arterial access is established. However, the results
There was no variation observed from this trend across of this case series should not be generalized to all pre-
the trials or participants. All balloon inflations were at hospital personnel, because these practitioners are all
the correct level within the aorta. particularly trained in the management of traumatic
hemorrhage, which may not necessarily be in the skillset
There was significant improvement in comprehension of every provider.
and knowledge between the pretest and posttest for the
study group. The participants’ average performance im- Furthermore, two major skills were not evaluated in this
proved significantly from 67.6 ± 7.3% to 81.3 ± 8.1% cohort: the ability to determine who needs a REBOA
(p = .039). and to obtain common femoral artery (CFA) access, both
which are essential to the success of the procedure. The
indications for REBOA may be straightforward in the
Discussion
setting of traumatic amputation not amenable to tourni-
The improvement seen from trial 1 to trial 6 is similar to quet placement; however, patients with intra-abdominal
our initial published study on REBOA. In that study, hemorrhage or severe pelvic hemorrhage may present a
12
participants improved their times by a mean of 148 ± diagnostic dilemma in the field where ultrasound and
44.8 seconds. The current group did not improve its other imaging modalities are not readily available.
12
times as dramatically (p = .08), but the participants’
initial starting times were significantly faster during the Although the technique of inserting balloon catheter
first trial—186 ± 18.7 seconds, compared with the 277 for REBOA is relatively straightforward, cannulation
± 54.7 seconds reported for a group of acute-care sur- of the CFA can be technically difficult and, when per-
geons (p =.006). Through all six trials, this study group formed incorrectly, can result in damage to the superfi-
12
improved at a significantly faster rate, with the scores of cial femoral artery or femoral bifurcation. In the clinical
five of six trials being significantly different. Although setting, acute-care surgeons who are not able to access
this may seem to suggest that nonsurgeon and nonphysi- the CFA percutaneously are required to perform a groin
cian military medical personnel may be able to perform cut-down. This underscores the importance of nonsur-
the procedural tasks more quickly, there was a low level geon providers becoming extremely facile with the use
of variation within the dataset due to the small number of ultrasound-guided CFA access, because the inability
of participants tested. In fact, the improvement from to access percutaneously is prohibitive for REBOA in
trial to trial was similar to that of the previous group, providers without a surgical skillset.
12
despite significant differences in trial times for five of six
performance repetitions. The procedural times between This study demonstrates that nonsurgeon and nonphysi-
the two groups’ trends are consistent with logarithmic cian providers can learn the steps required for REBOA
improvement in skill times, meaning performance im- placement after arterial access is established and can
proved to a plateau, with time reaching a minimum. perform the procedure correctly and rapidly as assessed
These data suggest that the compressed learning curve by virtual reality simulation. It is certainly the first step
for REBOA is applicable to nonphysicians, indicating in driving REBOA beyond the confines of hospitals.
that the technique is readily trainable and teachable to In countries such as Japan and the United Kingdom,
forward care providers. REBOA has been placed in the prehospital setting by

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