Page 51 - JSOM Winter 2018

Teams with an ARC capability could be unit-based or assigned A recent study of 1,399 emergency department thoracotomies
to support combat units when indicated for specific opera- (EDT) performed at 28 centers compared high-volume with
tions. Medical leaders in the military services or combat unit low-volume centers. The overall survival of patients in this
commanders will decide whether or not to establish teams study was 6.8% with survival being over 4.5 times greater if
with an ARC capability and would determine the composi- EDT was performed at a high-volume center. There is not
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tion, training, and employment plan for these teams. In addi- yet a comparable study for REBOA outcomes, but it should
tion to having completed an approved training course, every be expected that high- volume experience with this procedure
effort should be made for individuals who will be performing will also result in greater procedural success. This suggests
REBOA on combat casualties to maintain an ongoing experi- that teams who will be performing ARC should spend sub-
ence in this procedure using simulators or as part of a trauma stantial time in high-volume trauma centers or training with
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team in a civilian trauma center. Procedural fluency is the key high-fidelity simulators.
to success.
Once baseline training has been accomplished, organizations
Options for Fielding an ARC Capability with teams that will be performing ARC must develop a sus-
While an organized effort to incorporate routine use of whole tainment program that will maintain competency. Ideally, this
blood to resuscitate casualties in hemorrhagic shock and the would include ongoing experience with trauma patients in ad-
use of prehospital REBOA is a new concept, all of the services dition to simulation or perfused cadaver-based training as well
have organizational entities already in place that could serve as a training and clinical experience that allows the individu-
as teams through which ARC concepts could be employed: als performing ARC to function as a team. There are multiple
venues that could provide training in ARC. To list a few:
– USMC—Shock Trauma Platoons/Squads
– Special Operations Forces—Special Operations Resusci- – the Air Force C-STARS programs
tation Teams 146,147 – the Army Trauma Training Center
– Conventional Army—Battalion Aid Stations – the Navy Trauma Training Center
– Maritime—Shipboard-based care on vessels – the Army Center for Prehospital Medicine
– Special Operations Forward Operating Bases – the Defense Medical Readiness Training Institute
– Advanced Capability Evacuation Platforms (eg—UK – Military trauma centers such as the San Antonio Mili-
Medical Emergency Response Team—Enhanced; 160th tary Medical Center
Special Operations Aviation Regiment Tactical Evacua- – Civilian trauma centers
tion teams; and USAF Tactical Critical Care Evacuation – Commercial training vendors
Teams) – Individual military units who set up courses using or-
ganic assets
Some of these potential users of ARC already have Emergency
Medicine and/or Critical Care physicians included in the Documenting Care in ARC
teams. It is also worthy of note that, in some locations and Recording the injuries sustained, vital signs, interventions and
situations, austere surgical teams might function in a resus- responses to ARC interventions is an absolute requirement.
citation capacity enroute to a higher level of care and could This information will be vital for the providers at the next
make use of the ARC intermittent REBOA protocol outlined level of medical care and to JTS-led performance improvement
above in order to delay the need for laparotomy. For casualties efforts as experience is gained with this new capability. ARC
with abdominopelvic NCTH and shock, early resuscitation should not be undertaken without the commitment to docu-
with whole blood and REBOA may well improve the results ment these details of care precisely. Required documentation
of surgical intervention when that becomes feasible. includes:
Training for Advanced Resuscitative Care – Time and mechanism of injury
Preparing surgeons—and other combat medical providers— – Time of arrival at the ARC capability
– Vital signs on arrival
to care for the casualties of war requires that lifesaving skills – Diagnostic measures and interventions performed and
needed for the combat environment be mastered in noncombat the times at which they were performed
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settings. Both the American College of Surgeons (ACS) and – Transfusion products and amounts administered
the US military have REBOA training programs. Likewise, – Balloon location, volume infused and total balloon in-
whole blood administration training is available in a number flation or “up” time
of venues. Training for teams that will be performing ARC – Response to interventions
must include either a single course that incorporates all of the – Time and clinical condition when the casualty leaves the
skills enumerated above or a combination of courses that do ARC location
so—and provides assurance that these skills have been suc- – Time of arrival to a Role 2 or Role 3 facility
cessfully learned by the provider. Northern noted that USAF – Eventual outcome
Special Operations Surgical Team physicians were all trained
using the Basic Endovascular Skills for Trauma (BEST) course As recently as June 2018, many users of LTOWB are not doc-
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offered by the American College of Surgeons. This training umenting the care provided to their casualties and are not for-
enabled these Air Force teams to successfully perform 19 of warding it to the JTS for incorporation in the DoD Trauma
20 attempted REBOA procedures in austere environments Registry. Failure to document prehospital care detracts from
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with good short term hemodynamic results and no major pro- the US military’s efforts to optimize care both for the individ-
cedural complications, although the long-term outcomes for ual casualty and for other casualties throughout the DoD. This
these patients (who were not US casualties) was not able to be documentation is especially important when using new battle-
determined.
field trauma care innovations such as LTOWB and REBOA.

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