Page 52 - JSOM Winter 2018

The Biggest Challenge—Getting an ARC Capability Close in a Special Operations unit that has far-forward medical el-
(within 15–30 minutes) to the Point of Injury ements that routinely conduct complex medical procedures in
In caring for a casualty with severe truncal injury, suspected austere environments. Experience gained in this initial rollout
ongoing NCTH, and shock—every minute counts. 21,22,28 Get- will help to identify challenges that will need to be addressed
ting casualties with NCTH to a resuscitative team with an in the event that ARC is subsequently implemented on a larger
ARC capability as soon as possible is the challenge, since scale in the US military.
many casualties in this category will not survive their “Golden
Hour.” The optimal treatment for these casualties would be Potential Civilian Applications for ARC
immediate surgical repair of the noncompressible bleeding site ARC has important implications for the civilian sector as well
and immediate replacement of blood loss, but the surgical re- as the military. In a mass casualty incident, local trauma cen-
sources of the US military are already severely strained trying ters may be overwhelmed with critically injured trauma pa-
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to achieve casualty evacuation times to a surgical capability tients. Having an ARC capability with hospital-based WBBs
that are less than 60 minutes in combat theaters. 23,74 With the to provide LTOWB and clinicians trained to perform REBOA
time and location at which casualties will be sustained un- would enable critically injured patients with abdominopelvic
known until the event occurs, how can an ARC capability be NCTH to be kept alive until they can be taken to surgery. This
made available within a very short time span (15–30 minutes)? would also be an important new capability for the everyday
This is the time frame within which peak mortality occurs in management of trauma that occurs in rural settings, where
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severe NCTH and within which prehospital blood products long transports are often required to reach surgical care. Per-
have been observed to improve survival. 28,51 haps the most important application for the ARC concept in
the civilian sector would be for the initial stabilization of the
In some operational settings, this may simply not be possible. everyday hypotensive urban trauma patient who needs a lapa-
In other scenarios, however, operational planners will be able rotomy—whose current mortality is 46%. 13,14
to identify missions that entail a high risk of casualties. In those
instances, planners have a number of options for placing a Summary
resuscitation team with an ARC capability close to where ca-
sualties are likely to be sustained. Possible options include a loi- In summary, adding an Advanced Resuscitative Care capa-
tering CH-47 or CV-22; an ARC vehicle that follows a unit on bility to TCCC has the potential to reduce mortality from
a ground assault operation; a dedicated ARC vehicle on convoy NCTH—the largest remaining cause of preventable prehos-
operations; and a CH-47 or CV-22 based ARC platform with pital death—with currently available technology in 3 ways:
WB and REBOA capability on call for TACEVAC Missions. 1. Early whole blood resuscitation from hemorrhagic shock
will benefit all casualties with NCTH and may enable those
Operationalizing Advanced Resuscitative Care casualties who would not otherwise have survived for 60
TCCC is now mandated as the standard for battlefield trauma minutes (the Golden Hour) to reach the care of a surgeon
care in the DoD by DOD Instruction 1322.24, but ARC is alive;
a new capability for TCCC. Now that this change has been 2. For casualties in immature combat theaters who are not
approved by the CoTCCC, what is the best approach to tran- able to reach a surgical capability within 60 minutes, the
sitioning it into use in the DoD? ARC Zone 1 Intermittent REBOA technique—as described
by Kuckelman and modified by Rasmussen—offers the
One option would be definitive action undertaken at the OSD potential to extend their survival time well beyond 60
level, as was done with Secretary Gates’ Golden Hour Man- minutes, even in the presence of life-threatening abdomi-
date. This would be the most direct path to implementation nopelvic NCTH;
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throughout the US Military and has the advantage of im- 3. Having a REBOA catheter in place in Zone 1 in casual-
pacting the entire Department of Defense with one directive, ties who arrive at a surgical capability with suspected ma-
but new innovations in battlefield trauma care have not histor- jor abdominal or pelvic hemorrhage is of great potential
ically been directed at the SecDef level. benefit, even if the balloon is deflated, in that it provides
the surgeon a ready option for proximal aortic control.
An alternate course of action for implementation of ARC During trauma laparotomy, the balloon may be inflated
could be as follows: long enough for the operating surgeon to remove collected
1. The CoTCCC/JTS documents the need for ARC, provides blood from the abdomen, identify major vascular injury,
an estimate of how many lives could be saved with this obtain more selective vascular control, and manage the in-
initiative, and defines the desired capability; jury without having to contend with both the physiological
2. Senior line and/or operational medicine leaders are briefed instability and the operative exposure difficulty imposed by
on the ARC concept and—if desired—statements of need massive ongoing bleeding (personal communication, Col
and operational requirements are prepared. Jeff Bailey, June 2018).
3. Training programs for ARC teams are identified.
4. A pilot program is undertaken to demonstrate the feasibil- To evaluate the potential impact of adding an ARC capability
ity of ARC and the outcomes that it produces. The USSO- to Tactical Combat Casualty Care, an estimate is needed of the
COM/USAISR TCCC Transition Initiative is an excellent number of lives that could be saved by better prehospital inter-
model for how new innovations in battlefield trauma care ventions for torso hemorrhage. Figure 5 provides this estimate
can be expeditiously fielded. 151 based on the data reported in COL Brian Eastridge’s landmark
2012 paper. This paper noted that NCTH caused 67% of po-
Execution of the latter course of action is presently underway. tentially preventable prehospital hemorrhagic deaths, with
The first operational implementation of ARC has occurred abdominopelvic hemorrhage causing 64% of the deaths from

50 | JSOM Volume 18, Edition 4 / Winter 2018