Page 145 - JSOM Spring 2018

Editorial Response

Sean Keenan, MD

would like to commend Drs Macku, Hedvicak, Quinn, and for initiation are, and will continue to be, refined. Like any
I Bencko for their provocative article, “Prehospital Medicine new technology, however, it may be overused before finding its
and the Future: Will ECMO Ever Play a Role?” Their review of proper place in resuscitative care. I suspect it will be some time
the technology and its application to current military doctrinal before the trauma community can correctly define the subset
concepts offers an opportunity for reflection. It also provokes of patients who would benefit from this technology.
this editorial response in order to present concepts that can be
applied to the application of any new and emerging technol- At first review of the report by Quinn and colleagues, some
ogy into the most austere and challenging environments. obviously significant hurdles must be overcome for prehospi-
tal use, not the least of which are the cost of the technology,
There is no doubt that the use of ECMO or ECLS is of abso- trained staff, and resources (power and outside medications
lute benefit to a subpopulation of critical medical and trauma and supplies). Perhaps the most obvious hurdles for imple-
patients. In fact, as we seek to decrease morbidity and cer- mentation of ECMO or ECLS in the prehospital space are the
tainly mortality on the battlefield, considering any technology technical aspects. From a first blush, adding more “lightweight
or novel approach to resuscitation of patients is a worthwhile equipment” will immediately meet resistance. Any new tech-
exercise. nology must either work with what an Operator already car-
ries (see our PFC telemedicine discussions in previous JSOM
As an emergency physician and a member of the editorial staff editions) or prove to be so valuable as to warrant reducing
to consider prolonged field care (PFC) applications, I take a another critical resource. Such obvious limitations mentioned
viewpoint that may differ from that of other medical profes- in the article include an example of a portable machine that
sionals. I do, however, believe that my analysis will align with has a battery life of “only” 90 minutes and requirements for
the considerations of applying advanced technology to oper- additional medications and vascular cannulas.
ational utilization in the field. PFC represents the challenge
of diagnosing and managing complex patients in a resource- Some steps in the implementation of ECMO as presented are
limited environment. The entire premise hinges on a prehos- troubling at best and frankly dangerous or lethal in the hands
pital provider presented with a challenging, and many times of the inexperienced practitioner. These steps are identified
overwhelming, problem, with limited resources, personnel, only so they may be classified as potential training hurdles:
and knowledge.
1. Ensuring adequate hemostasis before implementation
When considering any new technology, implementation, al- 2. Proper resuscitation before implementation
though possible, must be feasible and correct application 3. Anesthesia (and not just sedation or dissociation with
should be deemed at least probable in the providers’ hands. ketamine)
Ultimately, when seeking to “triage” new techniques and pro- 4. Heparinization
cedures, one must at least have a concept as to what subpop- 5. Potential cooling
ulation would this indication definitively help. For instance,
if the technology were present at the right place and time, This discussion so far has considered only the technical aspects
which patients who died would otherwise have lived? If this, of implementation. Perhaps most importantly, the consideration
in turn, is a potentially significant percentage, can the average should now focus on the clinical aspects of implementation.
provider apply this technology properly from a technical as-
pect (e.g., resources, training, education)? And, perhaps more Just because a technology can be taught, does not mean it
importantly, can we (as policy-makers) differentiate who it should be taught. This is perhaps one of the biggest challenges
would benefit and, conversely, who it might harm? Further, if in forming the education and training agendas with any SOF
there is a potential for harm, can this morbidity be minimized, medical curriculum. Some technologies that are common
and how lethal could the misapplication potentially be? Put practice in any medical center are best not implemented in
simply, placed in a provider’s hands, will it harm more people the prehospital space. Any new treatment modality must be
than it could potentially help? If so, we should stop consider- analyzed to ensure it is both reproducible and safe. If the po-
ing it at this point. tential morbidity of improperly implementing the technology
unknowingly can lead to the patient’s death (a “clean kill”),
I will fully submit that the application of ECMO, once con- control measures must be considered. A common discussion
sidered a fringe technology for the management of trauma pa- of a similar concept is the consideration of rapid-sequence
tients, is presenting itself as a viable option, and the indications intubation (or induction), and the PFC Working Group’s

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