Page 141 - JSOM Spring 2018

of stabilizing and preparing casualties for strategic aero- academies that provide processes of credentialing (and de-
medical evacuation (AE). velop certification guidelines). In the United States, the Ameri-
can Society of Extracorporeal Technology and the American
Role 3—Hospital Response Capability. A hospital response Board of Cardiovascular Perfusion have developed minimal
capability provides secondary health care at the theater standards for perfusionists in clinical practice as a checklist,
level. This role must provide all the capabilities of Role 2 monitoring significant events and parameters of each clinical
and be able to conduct specialized surgery, care, and ad- procedure. The technician and advanced technician levels of
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ditional services. practice can be learned by medics and assistants.

Role 4—Definitive Hospital Response Capability. A defini- The use of ECMO/ECLS in prehospital care on the battlefield
tive hospital response capability offers the full spectrum of is underestimated in the military theater. Advanced ECMO/
definitive medical care that cannot be deployed to the the- ECLS technology allows cardiopulmonary stabilization and
ater or will be too time-consuming to be conducted in the aeromedical evacuation for critically ill combatants with lung
theater. Role 4 normally provides definitive care specialist injuries. It also occurs in casualty transportation from Role
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surgical and medical procedures, reconstructive surgery, 3 to Role 4. The use of this device may be more wide rang-
and rehabilitation ing. The deployment of ECMO/ECLS technology with trained
specialists closer to the battlefield is possible and should be
The organization of tactical field care and enhanced field care explored in a far more aggressive and rapid fashion.
rendered by combat lifesavers, combat medics, medics, phy-
sicians, and their assistants firmly stands on these roles. But ECMO has been already used to support trauma and burn
where would ECMO fit within this paradigm—and where patients in hospital settings. There were reported applications
would it be feasible to deploy, implement, and feed evidence of ECMO in severe trauma patients with resistant cardio-
back into the medical lessons learned system? pulmonary failure and coexisting bleeding shock. ECMO
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therapy has proved to be a valuable option when conven-
The Joint Theater Trauma System (JTTS) and Joint Theater tional therapies for polytrauma/multitrauma patients with
Trauma Register (JTTR) were developed and implemented refractory cardiopulmonary failure and refractory shock
by US military forces, using US civilian trauma system mod- are insufficient. Experiences in the application of ECMO
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els with the intent of improving outcomes after battlefield in- in burn patients with inhalation injuries have also been well
jury. The data from JTTR help to improve tactical algorithms described. 25
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and guidelines for higher combat casualty survival, based on
evidence-based practice. Any new device, drug, or process sug- There are many companies that produce heart–lung support
gested for improving combat casualty survival should include systems with various components (ECMO/ECLS) of all shapes
the use of this register for benchmarking between old stan- and sizes; as technology advances, these systems become smaller,
dard procedures and new innovative ones, especially through easier to use, and more versatile for the prehospital and austere
the NATO Military Medical Center for Medical Excellence environment. A perfect solution for our purpose is represented
(MilMED COE) lessons learned process and information by the CARDIOHELP System (Maquet Gettinge Group; https://
sharing. The only way that a new intervention such as ECMO www.maquet.com/int/products/cardiohelp-system/). This device
could be discussed is through providing an evidence base via can be easily carried by one person; it is small and lightweight
these networks. (310mm × 250mm × 430mm and about 10kg). It is rugged and
comes with a battery and a wide range of power supply. The
Life-saving interventions (LSIs) within the TCCC framework system can operate with two fully charged lithium ion batteries
are defined as advanced airway, needle or tube thoracostomy, for at least 90 minutes. The necessary system components are
tourniquet, and hypotensive resuscitation with Hetastarch or a medical gas supply and cannulas. The CARDIOHELP sys-
another agent. An early and reasonable application of this tem is designed for extracorporeal respiratory support and for
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intervention should prevent potentially survivable causes of simultaneous cardiovascular and respiratory support for up to
death as based on warfighting morbidity data presented to the 30 days.
Committee of Tactical Combat Casualty Care (CoTCCC). A
combat lifesaver’s mission is to stabilize the casualty for the Ambulatory ECMO on the Battlefield
evacuation to the next appropriate level of care. The com- When ECMO/ECLS is applied out of the hospital, it can be
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bat lifesaver is a bridge between the self-aid/buddy aid (first called ambulatory ECMO/ECLS. We assume a positive effect
aid) training given to all Soldiers during basic training and the of ambulatory ECMO/ECLS on the survival of combatants
medical training given to the combat medic. Combat med- wounded in combat. We in particular expect that ECMO/
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ics are often first responders who triage, treat, and evacuate ECLS can help in the following situations:
the wounded from the frontlines of battle, many times with
limited resources and in violent and austere environments. • Battlefield trauma, major hemorrhage/catastrophic bleed-
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Combat medics face unconscionable challenges and obstacles ing, and heart failure
in providing care in the PFC phase; would ECMO be able to • Chemical attacks, lung injuries, and respiratory failure
help save lives? Could FRC, still in preliminary workshop
phases, be a place for ECMO? And where would the clinical Guidelines
governance remit of the CoSCCC and/or the CoERCCC ad- Guidelines and clinical practice pathways should prevent time
dress the concept of ECMO in the prehospital space? delays and describe the process in detail to best serve the pa-
tient. The draft of guidelines for the ECMO/ECLS use in cases
Perfusionists are specialists who operate extracorporeal tech- of severely wounded warfighters on the battlefield could be
nology (ECMO/ECLS, CPB). There are societies, boards, and listed as follows (Figure 2):

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