Page 75 - JSOM Summer 2019

Development of a
Field-Expedient Vascular Trauma Simulator

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Cedric J. Martin, BSHS ; Timothy P. Plackett, DO, MPH *;
Robert M. Rush Jr, MD 3

ABSTRACT
The past few years have noted significant declines in combat have self-reported an increased confidence in trauma manage-
casualty exposure over the course of a deployment. As a re- ment skills over the course of a deployment. The underlying
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sult, overall confidence and comfort in performing potentially presumption is that the continual exposure fostered this skill
life-saving therapies may wane during a deployment. Devel- development. However, more recent surveys from these rela-
opment of training simulators provides a method for bridg- tively slower deployments suggest lower levels of confidence in
ing this gap. Herein, a field-expedient vascular trauma trainer managing these critical injuries. 11
for noncompressible torso hemorrhage is described. A low-
fidelity simulator was created using a Penrose drain, intrave- Procedural simulation provides a means to limit or reverse skill
nous tubing, suture, and a cardboard box. A higher-fidelity erosion and decreasing confidence associated with a slower
simulator was created using an aortobifemoral bypass graft, operative tempo. When patient exposure is more limited, sim-
double-lumen endotracheal tube, suture, and an upper torso ulation offers a mechanism to focus on clinical skills and team
mannequin. The two trainers were successfully used to train dynamics. Although there are numerous high-fidelity commer-
for peripheral shunt placement and definitive vascular repair. cial products available for this type of training, their financial
The trainer makes use of supplies readily found at most Role cost and the inherent restrictions of a resource- limited envi-
2 and 3 facilities and that are obtainable for Role 1 facilities ronment questions their practicality. Instead, field-expedient
providing damage control surgery. It provides a just-in-time solutions making use of available supplies are needed. We de-
way to develop and sustain confidence in the damage control scribe the development of a practical multi-use vascular injury
principles applicable to vascular injuries. trainer made from commonly found medical supplies.

Keywords: noncompressible torso hemorrhage; training sim- Trainer Construction
ulator; vascular trauma trainer
The initial vascular trainer was constructed using expired
medical equipment and a medium-size cardboard box (Figure
1). A vascular structure was simulated using a Penrose drain
Introduction
(Figure 2). Intravenous tubing was sutured to the proximal
There has been a shift in the epidemiology of combat trauma and distal ends of the drain, thereby permitting the infusion
over the past decade. Whereas during the height of the previ- of expired units of packed red blood cells. This was later re-
ous operations in Iraq and Afghanistan, medical teams were fined to infusion of normal saline that had been dyed red. Bags
exposed to a robust variety and volume of severe traumatic of saline were placed within the box to simulate the presence
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injuries, this exposure has dwindled over the past 5 to 7 years. of small and large intestine overlying the blood vessel. The
Case volumes have shifted from Role 2 facilities performing trainer was successful used for several iterations and allowed
care for hundreds of patients and Role 3 facilities caring for for individual and team training on placement of intravascular
thousands of patients over a 9- to 12-month deployment to shunts (Figure 3).
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more recent experiences where the provision of care is much
less and unequally distributed among the various medical ele- Over time, a higher-fidelity trainer was also constructed (Fig-
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ments. Teams can now go an entire deployment with caring ure 4). The exterior of the patient was constructed using an
for fewer than a dozen combat-injured patients. upper body mannequin with a U-shaped mold constructed out
of fiberglass casting material to create a retroperitoneum and
A potential consequence of this decreased exposure to trauma flank. Moleskin was circumferentially applied to create skin
patients is a degradation of clinical skills. Not surprisingly, and affix the fiberglass molding to the mannequin (Figure 5).
during times of peak combat casualties, military providers The internal vascular anatomy was recreated using an expired
*Correspondence to Timothy Plackett, DO, MPH, FACS, 759th Forward Surgical Team (Airborne), A-6631 Gorham Street, Fort Bragg, NC
28310; or timothy.p.plackett.mil@mail.mil
1 SSG Martin is the Perioperative Nursing Services noncommissioned officer in charge for the US Army Institute of Surgical Research Burn Center.
He also serves on the Joint Trauma System’s Committee on Surgical Combat Casualty Care. SSG Martin has deployed twice to Afghanistan; his
first rotation was to Camp Dwyer with the 115th Combat Support Hospital ISO OEF 11-12 and his second rotation was at Kandahar Airfield
with the 555th Forward Surgical Team/Golden Hour Offset Surgical Treatment Team supporting Special Operations Task Force Afghanistan
ISO OEF 15 and Operation Freedom’s Sentinel in Support of Resolute Support Mission. LTC Plackett is a trauma surgeon currently assigned
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to Womack Army Medical Center, Fort Bragg, NC. COL (Ret) Rush is the Trauma and Acute Care Surgery medical director at PeaceHealth St
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Joseph Medical Center, Bellingham, WA. He retired from military service after a 35-year career with numerous overseas deployments.
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