Page 90 - JSOM Spring 2020

performed a second attempt at gaining vascular access and access in unstable patients in austere environments is challeng-
REBOA placement and were compared with the QRT-FF. All ing for providers without a surgical skillset and should be the
QRT-FF improved their procedure time, as were four of the focus of further training.
five medics (Table 4).
Teeter et al. described US Army Special Operations Com-
16
TABLE 2 Procedure Time (Needle in Hand to Balloon Insufflation) mand medical personnel without prior endovascular experi-
at First Test ence who were included in the BEST course, with findings
™
Firefighters SOF Medics similar to our own—that procedure time after basic training
Expert Level (n = 6) (n = 11) P Value* of medical personnel of various backgrounds and limited prior
Time sheath, 2:04 3:59 endovascular experience can be improved. In another study on
median [IQR] (min:sec) [1:54–2:12] [1:55–4:21] NS the subject, Pasley et al. concluded that independent duty mil-
17
Time total, 3:23 5:05 NS itary medical technicians can be effectively trained to perform
median [IQR] (min:sec) [2:59–4:13] [3:07–5:38] the procedure for REBOA placement accurately and rapidly.
Abbreviations: IQR, interquartile range; min:sec, minutes:seconds; In a similar fashion, we confirm in our study that personnel
SOF, Special Operations Forces. with no prior endovascular training can be trained in perform-
*Mann-Whitney U test.
ing this procedure in a task training model. Similarly, in case
of extracorporeal membrane oxygenation cannulation is not
TABLE 3 Difference in Procedure Time Between First and Second only performed by vascular surgeons but also by trained non-
Attempts physicians such as perfusionists. Recent programs on remote
First Second
Procedure Time Attempt Attempt Difference P Value* cannulation and transport have also shown good patient out-
18
Firefighters (n = 6) comes. A recent Delphi consensus paper stated that REBOA
can be safely and effectively performed in a variety of settings
Time sheath, 2:04 1:48 –0:16 NS and by providers of various clinical background, provided that
mean [SD] (min:sec) [0:18] [0:39] they have appropriate training and local protocols for use. 19
Time total, 3:32 3:07
mean [SD] (min:sec) [0:40] [0:57] –0:25 NS
Medics (n = 5) Prompt bleeding control and advanced resuscitation in a pre-
hospital environment are essential to improve outcome of
Time sheath, 2:32 2:38 +0:06 NS trauma victims with major hemorrhage. Although medical
mean [SD] (min:sec) [1:04] [2:33] treatment is not the primary skillset for QRT-FF, providing
Time total, 3:54 3:27 –0:27 NS
mean [SD] (min:sec) [1:04] [2:42] them with effective training and tools for early hemorrhage
Abbreviations: min:sec, minutes:seconds; SD, standard deviation. control has apparent potential advantages. Currently, how-
*Paired t test. ever, these critical first responders have limited options in their
toolkit in this regard. Depending on the zone they are oper-
ating in, presently available hemorrhage control adjuncts in-
TABLE 4 Procedure Time (Needle in Hand to Balloon Insufflation)
Retest for Firefighters Versus Medics clude only the use of pressure bandages, hemostatic dressings,
20
Firemen SOF Medics and tourniquets. Availability of additional treatment options
Expert Level (n = 6) (n = 4) P Value* for advanced bleeding control in the warm zone, as commonly
Time sheath, 1:38 1:19 NS used by QRT-FF, could improve outcome in trauma patients
median [IQR] (mm:sec) [1:18–2:12] [1:09–2:04] because extraction times can be longer than formally accepted
Time total, 2:44 2:07 timeframes for medical care. Analysis of the Bataclan attack
median [IQR] (mm:sec) [2:25–3:54] [1:46–2:53] NS showed that when the conventional rescue teams received
Abbreviations: IQR, interquartile range; mm:sec, minutes:seconds; clearance to enter the warm zone, all living casualties had al-
SOF, Special Operations Forces. ready been extracted. The final evacuation was performed 4.5
*Mann-Whitney U test. hours after the start of the attack. One could argue that only
4,5
victims with deemed survivable injuries were extracted before
conventional teams were allowed in. When advanced bleeding
Discussion
control options are implemented in the hot/warm zone, more
This feasibility study provides evidence that vascular access injuries could be triaged as survivable and therefor extracted
training and REBOA placement of QRT-FF with no endovas- sooner. Properly trained and equipped, these first responders
cular experience is possible via a formalized and comprehen- could bring advanced bleeding control kits into the warm zone
sive curriculum using a task training model. Our results show and at least assist forward surgical teams and other medical
that QRT-FF were able to perform REBOA placement on a professionals in performing advanced bleeding control pro-
task training model with similar and acceptable procedure cedures including REBOA when legislation does not permit
times compared with medics. these professional first responders to perform these acute care
measures. Several gap analyses have revealed groups of casu-
All six participating QRT-FFs were able to improve their proce- alties with NCTH that could have benefitted from advanced
dure times in the posttest, indicating that this training program bleeding control options, such as REBOA, both in military and
delivers consistent results and improvements in procedure in civilian settings. Obviously, the number of amendable casu-
times are to be expected with more exposure to training. alties in civilian settings is lower than in the military settings.

This is an important finding considering that QRT-FF and In civilian public mass shootings (CPMS), the probability of
medics only have a 4-month medical training program that death is based on the firearm type used, with handguns associ-
currently does not cover these topics. Although insertion is ated with a higher percentage killed compared with when a rifle
relatively straightforward, achieving percutaneously arterial is used. Wounding with a handgun was significantly associated

84 | JSOM Volume 20, Edition 1 / Spring 2020