Page 42 - JSOM Spring 2018

use of human cadavers for research, development, test and codified to include standardizing the equipment, a protocol
evaluation, education, or training. Research funding was for the conversion from percutaneous to open vascular access,
provided by the Defense Medical Research and Develop- the creation of a basic vascular access surgical instrument kit,
ment Program. and development of a team placement approach, the partici-
pants advanced to more challenging environments (Table 1;
The participants for this experiment were two board-certified Figures 1 and 2). The next four procedures were performed
active duty military emergency medicine physicians with no on the floor of the laboratory with the specimen on a Talon
prior endovascular surgery exposure or prior use of REBOA. II Assault Litter Carrier (North American Rescue, http://www
Both providers were proficient at ultrasound-guided vascular .narescue.com) under normal- and low-light conditions.
access before the start of the project. Both providers also had
experience working in austere environments as well as train- TABLE 1 Minimum Recommended Equipment List for Battlefield
ing in providing medical care aboard military aircraft. The REBOA
participants would need to learn the procedure and success- 1 Case for equipment: Pelican M2450
fully perform it with the newer-generation US Food and Drug 1 Monitor with invasive pressure monitoring capability
Administration–approved REBOA catheters (ER-REBOA) in 1 Set invasive pressure monitor cables
various austere environments. The project comprised three
phases: skill acquisition, skill proficiency in austere environ- 1 Pressure infuser bag
ments, and operational implementation. 1 Set invasive pressure monitoring tubing
1 Portable ultrasound device
Phase 1: Skill Acquisition 1 Bottle ultrasound gel
Both providers attended two nationally recognized REBOA 2 Chloraprep swabs
courses: the Basic Endovascular Skills for Trauma (BEST) 1 Standard 7F central venous catheter Cordis set
course offered in Baltimore, Maryland, which is currently the 2 7F ER-REBOA compatible catheter introducer sheaths
REBOA skills course recommended by the American College 1 Needle, 18 gauge 7cm
of Surgeons; and the REBOA course offered through the De- 1 10mL syringe
partment of Surgery at University of California, Davis Medical
Center. Both courses used various REBOA simulation mod- 1 30mL syringe
19
els, including perfused human cadavers, the Mentice VIST G5 1 5F catheter clamp
(http://www.mentice.com) endovascular simulator, and vari- 1 Package of clear chest seals
ous nonproprietary, custom-made endovascular simulation 2 Packages of sterile gloves
models. The basic skills for percutaneous and open vascular 1 Package of 4×4 gauze
access were discussed and performed, and basic endovascular 1 Rapid access surgical instrument set
concepts for overwire placement of catheters were discussed 1 ER-REBOA catheter
™
and placement was performed. 1 Abdominal Aortic Junctional Tourniquet (AAJT)
1 500mL bag of normal saline
After training course completion, it was determined a new en-
dovascular model was needed to complete the current feasi-
bility study. The investigators performed a medical literature FIGURE 1 Battlefield REBOA protocol.
review, conducted interviews with subject matter experts,
and visited the Centre for Health Sciences in Spring Branch,
Texas; the Basic Endovascular Skills in Trauma laboratory in
Baltimore, Maryland; the Fresh Tissue Dissection Laboratory
in Los Angeles County, California; and the Keck School of
Medicine of University of Southern California, Los Angeles,
California. 21–23 Design goals were to create a simple, easily re-
producible, and realistic model to simulate placing REBOA
in the field and austere conditions. A novel perfused cadaver
model was created using items currently available at most mili-
tary medical departments. Before beginning the cadaver fea-
sibility study, both participants placed 10 REBOA catheters
in a porcine model of hemorrhagic shock as part of ongoing
research efforts to ensure they were proficient in the skill.

Phase 2: Skill Proficiency in Austere Environments
The participants progressed in the common crawl-walk-run
fashion of skill development. The initial 12 procedures (n = Final Study Protocol
6 specimens) were performed in a well-lighted surgical-skill For the study protocol, the timed procedure begins with turn-
laboratory to ensure techniques were performed correctly and ing on the ultrasound machine, followed by using a ChloraPrep
the model performed as desired. Vascular access was obtained pad (BD, https://www.bd.com) to clean the groin. Next, percu-
using ultrasound-guided percutaneous placement or open vas- taneous vascular access is attempted first by using ultrasound
cular cutdown if the wire or catheter could not be passed per- guidance. If, after 5 minutes, this is unsuccessful, a femoral
cutaneously. Placement was confirmed by demonstrating with artery cutdown is performed. After vascular access is achieved
transabdominal ultrasound the presence of an intraaortic wire and the 7F introducer sheath is in place, the REBOA cath-
at the level of the celiac trunk. After the techniques had been eter is measured on the body, using the appropriate anatomic

38 | JSOM Volume 18, Edition 1/Spring 2018