Page 140 - JSOM Spring 2018

by tubing, and helping patients to survive when their injury FIGURE 1 Schematic of basic ECMO/ECLS and patient. DA, drug
and wound pattern would otherwise make survivability im- administration; P, pump; O, oxygenator; HE, heat exchanger.
possible. ECMO/ECLS stabilizes a patient´s circulation and
oxygenation. We assume that ECMO/ECLS can maintain ad-
equate perfusion and respiration and promote basal metabo-
lism and thus can help to overcome many PFC challenges and
to transport a wounded warfighter to a secondary or tertiary
facility or Role 4 hospital safely. ECMO has been used in sur-
gical theaters and at the intensive care unit (ICU) level of care
in hospitals for many decades with specialized training and
equipment.

Objectives that we considered include:

• Does ECMO have a place in the TCCC, DCR/DCS ,and
NATO Role 1-3 system?
• If ECMO can play a role, what changes in care and
training need to take place? is available for DCS in the presence of battlefield trauma, and
• How can the paradigm of current battlefield medicine such studies will shed light on the practical solutions of ECMO
be challenged with ECMO to mitigate preventable in the prehospital space and their benefits, if any.
death, if at all?
• ECMO will never replace DCR/DCS, but where can this Four Roles of Care From the Battlefield to the Hospital
clinical tool be placed in the phases of care? To place this concept within the paradigm of TCCC, PFC,
• Will ECMO technology advances and innovation affect and FRC, we discuss fundamental characteristics of orga-
the prehospital medical space? nizing modern health service support through echelons of
care—not to make a false connection across these phases of
Because this a proposal challenging the status quo, our methods care but rather to describe de facto phases of care for opera-
detail what is ECMO and the basic components to be used in tional needs in general. The distribution of medical resources
DCR/DCS phases, and we put forth the idea of its use in the and capabilities to facilities at various levels of command
PFC and FRC. Please note that PFC is not a doctrinal conduit across NATO and NATO partner nations, including ungov-
with PFC and other phases of care, but we wish to not silo these erned or austere locations, and progressive capabilities of-
concepts and rather refer to patient care on a continuum in bat- fers challenges for PFC for all practitioners. Indeed, adding
tlefield and prehospital medicine. For more details on ECMO more equipment to basic medical loads is not in anyone’s
and core principles, please refer to the many references listed. interest, unless the benefits far outweigh the risks. No one
wants to carry more medical resources than are needed, and
Extracorporeal Circulation Systems PFC is based on subtraction of technology and the need for
ECMO is commonly known as a tool for delivering oxygen- less burdensome adjuncts. However, in World War II, it may
ated blood to tissue and organs and removing carbon dioxide have been considered burdensome to pack a bag-valve-mask,
(CO ) from tissue and organs when the heart and lungs have tranexamic acid (TXA), intravenous fluids, or a quick tra-
2
stopped or have been damaged. Another term for this device cheostomy or cricothyroidotomy kit, all of which are now
is ECLS. Cardiac surgeons use this equipment for the replace- standard practice for the advanced practitioner. To aid in the
ment of lungs and heart functioning during cardiac surgeries; description and placement of such clinical interventions, it is
this is referred to as cardiopulmonary bypass (CPB). Some helpful to list the four roles of care accepted by military prac-
complicated operations are performed in deep hypothermia, titioners (Roles 1–4). 14,15
and the time spent on CPB may reach up to 6 hours or more
when clinically indicated and patient condition can sustain. Role 1—Medical Response Capability. This focuses on pro-
These patients receive perfusion of tissue and the brain with vision of primary health care, specialized first aid, triage,
a stopped heart and unventilated lungs, with a body tempera- resuscitation, and stabilization.
ture of 26°C (Figure 1).
Role 2—Initial Surgery Response Capability. Initial sur-
After cardiac surgery, patients are subsequently heated, and gery response capability is characterized by the ability to
their hearts and lungs reanimated. With a functional heart- perform surgical interventions in addition to perform re-
beat and assisted breathing, patients are successfully weaned ception/triage of casualties; includes resuscitation and
off CPB after cardiac and other required damage control sur- treatment of shock to a higher level than Role 1 facilities.
gery. Other components that are inserted in extracorporeal cir-
cuits are heating/cooling units and a dialysis capsule to ensure • There are two main types of Role 2: Role 2 Basic (Role
best clinical outcomes. Perfusionist skills and technical abilities 2B) and Role 2 Enhanced (Role 2E, also sometimes ref-
are required for successful administration and management of erenced as a “Role II+”). Role 2B must provide the sur-
CPB and ECMO. Cardiac and other damage control surger- gical capability, including DCS and surgical procedures
ies performed in deep hypothermia states are associated with for emergency surgical cases, to deliver life-, limb-, and
a greater risk of coagulopathy and bleeding. 11–13 As is clearly function-saving medical treatment.
described in the literature related to trauma, the fatal triad is Role 2E must provide all the capabilities of the Role 2B
coagulopathy, acidosis, and hypothermia. Many cardiac proce- but has additional capabilities as a result of additional
dures with CPB are performed in normothermia; little evidence facilities and greater resources, including the capability

134 | JSOM Volume 18, Edition 1/Spring 2018