Page 139 - JSOM Spring 2018

Prehospital Medicine and the Future

Will ECMO Ever Play a Role?

2
David Macku˚ , MSc, MD ; Pavel Hedvicˇák, MSc ;
1
John Quinn, MD ; Vladimir Bencko, MD 4
3*

ABSTRACT
Due to the hybrid warfare currently experienced by multiple Introduction
NATO coalition and NATO partner nations, the tactical com-
bat casualty care (TCCC) paradigm is greatly challenged. One TCCC practiced in traditional and special operations repre-
of the major challenges to TCCC is the ad hoc extension phase sents prehospital trauma care guidelines customized for the
1–4
in resource-poor environments, referred to as prolonged field battlefield. Clinical evidence from hybrid war and hybrid
care (PFC) and forward resuscitative care (FRC). The nuanced tactics is still under review from current conflict, but warfight-
clinical skills with limited resources required by warfighters ing mortality and morbidity data from Iraq and Afghanistan
and auxiliary health care professionals to mitigate death on are well documented and TCCC takes its lessons learned from
the battlefield and prevent morbidity and mortality in the PFC these conflicts to influence clinical practice. The challenge
phase represent a balance that is still under review. The aim of new concepts and potentially far forward treatment once
of our article is to describe the connection between extracor- found only in the hospital may be innovative as it addresses
poreal membrane oxygenation (ECMO) or the extracorporeal the issues proposed by hybrid warfare experienced today by
life support (ECLS) treatment and its possible improvement in warfighters in new theaters. The TCCC guidelines emphasize
prehospital trauma care, at a Role 1 or 2 facility and, more three objectives: treat the patient, prevent additional casual-
provocatively, in the PFC phase of care in the future through in- ties, and complete the mission. It also describes three phases
novative technology and how it connects with FRC. We report of care: care under fire, tactical field care, and casualty evacu-
and describe here the primary components of ECMO/ECLS ation care. These objectives center on preventing the three
and present the main concept of a human extracorporeal cir- major, potentially survivable causes of death: extremity hem-
culation cocoon as a transitional living form for the cardiopul- orrhage exsanguination, tension pneumothorax, and airway
1,4–6
monary stabilization of wounded combatants on the battlefield obstruction. In challenging and resource-poor environ-
and their transportation to higher echelons of care and treat- ments, where MEDEVAC (medical evacuation) may be de-
ment facilities (to include damage control resuscitation [DCR] layed, field medics must provide PFC, which might be seen as:
and damage control surgery [DCS]). As clinical governance,
these matters would fall within the remit of the Committee on “Field medical care, applied beyond ‘doctrinal planning
Surgical Combat Casualty Care (CoSCCC) and the Commit- time-lines’ by an NSOCM (NATO Special Operations
tee on Enroute Combat Casualty Care (CoERCCC), and it is Combat Medic), in order to decrease patient mortality
within this framework that we propose this concept piece of and morbidity. Utilises limited resources, and is sus-
ECMO in the prehospital space. We caution that this report tained until the patient arrives at the next appropriate
is a proposed innovation to TCCC but also serves to push the level of care.”7–9
envelope of the PFC and FRC paradigm. What we propose will
not change the practice this year, but as ECMO technology This differs from FRC, which is defined by the US Department
progresses, it may change our practice within the next decade. of Defense as:
We conclude with proposed novel future research to save life
on the battlefield with ECMO as a major challenge and one “Care provided as close to the point of injury as possible
worth the focus of further research. Medicine is controversial based on current operational requirements to attain sta-
and constantly changing; for those who work in prehospital bilization, achieve the most efficient use of life-and-limb
and battlefield medicine, change is the only constant on which saving medical treatment, and provide essential care so
we rely, and without provocative discussion that makes our the patient can tolerate evacuation which is known as
systems and practice more robust, we will fail. Role 2 care in the North Atlantic Treaty Organization
doctrine.” 10
Keywords: NATO; TCCC; prolonged field care; forward re- ECMO/ECLS can provide cardiac and respiratory support for
suscitative care; extracorporeal membrane oxygenation; patients whose heart and lungs cannot perform their functions
extracorporeal life support
adequately. This equipment can be understood as being the ar-
tificial heart and lungs, standing outside the patient, connected

*Address correspondence to cuinne@gmail.com
1 Dr Macku˚ is from the Department of Cybernetics, Czech Technical University in Prague, Prague, Czech Republic; and from the Department of
Biomedical Engineering, Na Homolce Hospital, Prague, Czech Republic. Mr Hedvicˇák is an clinical perfusiologist at the Department of Car-
2
diovascular Surgery, Motol University Hospital, Prague, Czech Republic; and an Application Specialist for ECLS therapy at MAQUET Czech
3
Republic s.r.o., Prague, Czech Republic. Dr Quinn is from Charles University and General University Hospital, Institute of Hygiene and Epide-
miology, Prague, Czech Republic; and from the Emergency Department, Northwick Park Hospital, London Northwest Trust (LNWH), London,
UK. Dr Bencko is from Charles University and General University Hospital, Institute of Hygiene and Epidemiology, Prague, Czech Republic.
4
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