Page 46 - JSOM Spring 2018

Feedback from our operational implementation was over- anatomy outweighs the risk of minor procedure complications
whelmingly positive. The most common request was for more directly related to the model.
perfused cadaver training. Participants appreciated the real-
ism of having the patient bleed. During training, we routinely Conclusion
mixed perfused cadavers and simulation mannequins (RATT
Pulsatile Simulator; Prytime Medical Devices, http://prytime This study clearly demonstrates that with proper training,
medical.com/) to allow participants greater numbers of place- nonsurgical providers can properly place REBOA catheters in
ments and attempts at vascular access. Vascular access remains austere prehospital settings at speeds and with an effectiveness
the longest and most challenging portion of this procedure. similar to that seen in the hospital setting.

Endovascular management of trauma is an emerging trend in Acknowledgments
trauma management and resuscitation. The role of REBOA, as We gratefully acknowledge the men, women, and families of
part of the resuscitation strategy, is currently viewed as a short those who donated their earthly bodies to medical research.
bridge to definitive operative management. Several studies are Without their gift, untimely death and needless suffering
looking at some unanswered critical questions, including the would be the norm. We also thank the University of Texas
following: How long can a balloon be safely inflated within Southwestern Willed Body program and staff for their tire-
each zone? Can partial REBOA or intermittent REBOA de- less efforts, which truly enhance the medical arts. A special
crease the risk of the resulting metabolic insult of prolonged thanks to Bill Baxter at ISR, Mike Minneti at the Keck School
balloon inflation? Does REBOA improve the quality of cardio- of Medicine of University of Southern California, along with
pulmonary resuscitation in traumatic cardiac arrest patients? Scotty Bolleter and Jennifer Stubbe at The Centre for Emer-
Does REBOA exacerbate traumatic brain injury in the poly- gency Health Sciences in Bulverde, Texas, for their help and
trauma patient? 14,29,30 Many of the answers to these questions guidance. Additionally, we would like to thank the Texas
are just over the horizon and will help guide implementation Army National Guard for their support. Finally, we thank Col
of this resuscitation tool. Chetan Kharod and the Military EMS and Disaster Medicine
Fellowship for prioritizing and unyielding support of prehos-
Limitations pital research efforts.
Our study has limitations. First, this study only examined the
performance of two providers. Future studies would benefit Funding
from training and testing a larger cohort to see if there is truly This study was supported by the Defense Medical Research
a significant provider variation, because we did not see one in and Development Program.
this study.
Disclaimer
Second, the age of the specimens predisposes the models to The views expressed in this article are those of the author(s)
have calcified arteries and tortuous anatomy. These challenges and do not necessarily reflect the official policy or position of
in the anatomy of the older population are the reason most the Department of the Navy, the Department of the Army, De-
vascular surgeons will recommend against using this procedure partment of Defense, or the US Government. “I am a military
without fluoroscopy in the population older than 65 years. 31 Servicemember. This work was prepared as part of my official
duties. Title 17, USC, §105 provides that ‘Copyright protection
Third, the procedures performed were not done while wear- under this title is not available for any work of the US Govern-
ing the full combat personal protective gear often worn by ment.’ Title 17, USC, §101 defines a US Government work as a
military providers practicing in this austere prehospital and en work prepared by a military service member or employee of the
route care environment. The bulk and weight of this gear may US Government as part of that person’s official duties.”
dramatically affect the speed at which these procedures can
be performed. Future studies should assess performance while
in full combat gear as part of full mission profile training ex- Disclosures
ercises. This may better identify limitations of the procedure. The authors have nothing to disclose.

Fourth, although the protocol was to convert to open vascular Author Contributions
access if the vascular introducer sheath was not in place after 5 EMR and TTR are responsible for the design, resource man-
minutes, the individual provider could choose to convert early agement, data collection, analysis and writing. The authors
on the basis of on poor ultrasound image quality or late if they approved the final version of the manuscript.
felt continued percutaneous attempts were likely to be success-
ful. The protocol was designed to meet expected standard time References
points found in the civilian hospital setting but to also prevent 1. Eastridge BJ, et al. Death on the battlefield (2001–2011): im-
the provider from becoming target fixated on continued per- plications for the future of combat casualty care. J Trauma
cutaneous attempts. This selection bias may have affected the Acute Care Surg. 2012;73:S431–S437.
total time to balloon inflation. 2. Moore LJ, et al. Implementation of resuscitative endovascular
balloon occlusion of the aorta as an alternative to resuscita-
Finally, our model can be very challenging to gain access, as tive thoracotomy for noncompressible truncal hemorrhage.
J Trauma Acute Care Surg. 2015;79:523–532.
mentioned, leading inexperienced providers to believe the pro- 3. Teeter WA, et al. Smaller introducer sheaths for REBOA may
cedure is more difficult than it is. Placement of the vascular be associated with fewer complications. J Trauma Acute Care
sheaths and advancement of the catheters in the animal model Surg. 2016;81:1039–1045.
is much simpler. This may introduce some training scars from 4. Brenner M. REBOA and catheter-based technology in trauma.
the challenge of the model. We believe the value of the human J Trauma Acute Care Surg. 2015;79:174–175.

42 | JSOM Volume 18, Edition 1/Spring 2018