Page 64 - JSOM Fall 2020

Airway Management in the Prehospital, Combat Environment

Analysis of After-Action Reviews and Lessons Learned

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Steven G. Schauer, DO, MS *; Jason F. Naylor, PA-C ; Denise M. Beaumont, CRNA ;
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Michael D. April, MD, DPhil, MSc ; Kaori Tanaka, DO ; Darren Baldwin, RN ;
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Joseph K. Maddry, MD ; Tyson E. Becker, MD ; Robert A. De Lorenzo, MD, MSM, MSCI 9
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ABSTRACT
Introduction: Airway compromise is the second leading cause Introduction
of potentially survivable death on the battlefield. Studies show
that airway management is a challenge in prehospital combat Airway compromise is the second leading cause of potentially
care with high error and missed opportunity rates. Lacking is survivable death on the battlefield and accounts for approxi-
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user information on the perceived reasons for the challenges. mately 1 in 10 preventable deaths. Lairet et al. prospectively
The US military uses several performance improvement and evaluated prehospital interventions performed in Afghanistan
field feedback systems to solicit feedback regarding deployed and reported that military healthcare providers incorrectly
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experiences. We seek to review feedback and after-action re- performed 8.9% of airway interventions. Blackburn et al. de-
views (AARs) from end-users with specific regard to airway scribes airway interventions occurring during the early stages
challenges noted. Methods: We queried the Center for Army of care at or near the point-of-injury finding a high rate of
Lessons Learned (CALL), the Army Medical Department Les- mortality with after-action reviews noting challenges with
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sons Learned (AMEDDLL), and the Joint Lessons Learned both equipment and training. In a previous study published
Information System (JLLIS).Our queries comprised a series of by several of these authors, we found that 1 in 20 casualties re-
search terms with a focus on airway management. Three mil- quired a prehospital airway intervention with the overwhelm-
itary emergency medicine expert reviewers performed the pri- ing majority of interventions consisting of intubations and
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mary analysis for lessons learned specific to deployment and cricothyrotomies. Moreover, another case series published by
predeployment training lessons learned. Upon narrowing the these authors on the use of prefabricated cricothyrotomy kits
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scope of entries to those relevant to deployment and prede- in combat suggests that improvements are still needed.
ployment training, a panel of eight experts performed reviews.
The varied nature of the sources lent itself to an unstructured The Committee on Tactical Combat Casualty Care (CoTCCC)
qualitative approach with results tabulated into thematic cat- lists improvements in methods for prehospital airway man-
egories. Results: Our initial search yielded 611 nonduplicate agement as a top priority. During the recent conflicts in Iraq
entries. The primary reviewers then analyzed these entries to and Afghanistan, significant advancements in methods for
determine relevance to the project—this resulted in 70 de- hemorrhage control were made and improved casualty sur-
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ployment-based lessons learned and four training-based les- vival rates. However, the data indicate a commensurate
sons learned. The panel of eight experts then reviewed the improvement inprehospital airway management has not oc-
74 lessons learned. We categorized 37 AARs as equipment curred during the same time period. To develop more targeted
challenges/malfunctions, 28 as training/education challenges, advances in airway management, first we must better under-
and 9 as other. Several lessons learned specifically stated that stand the challenges that the end-users experience in the pre-
units failed to prioritize medic training; multiple comments hospital, combating setting.
suggested that units should consider sending their medics to
civilian training centers. Other comments highlighted equip- Goals of This Project
ment shortages and equipment malfunctions specific to cer-
tain mission types (e.g., pediatric casualties, extreme weather). We sought to review feedback and AARs from end-users with
Conclusions: In this review of military lessons learned systems, specific regard to airway management and associated prob-
most of the feedback referenced equipment malfunctions and lems reported.
gaps in initial and maintenance training.This review of AARs
provides guidance for targeted research efforts based the needs Methods
of the end-users.
Ethics
Keywords: prehospital; combat; airway; review; lessons As this project was conducted for the purpose of military per-
formance improvement in which we sought records submitted
*Correspondence to Steven.g.schauer.mil@mail.mil
1 MAJ Schauer is affiliated with the US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX; Brooke Army Medical Center, JBSA
Fort Sam Houston, TX; Uniformed Services University of the Health Sciences, Bethesda, MD; and 59th Medical Wing, JBSA Lackland, TX. LTC
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Naylor is affiliated with the Madigan Army Medical Center, Joint Base Lewis-McChord, Washington. COL Beaumont is affiliated with the US
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Army Medical Center of Excellence. MAJ April is affiliated with the Brooke Army Medical Center. Dr Tanaka is affiliated with the University
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of Texas Health San Antonio, TX. Mr Baldwin is affiliated with the US Army Institute of Surgical Reseach. LtCol Maddry is affiliated with the
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Brooke Army Medical Center; Uniformed Services University of the Health Sciences, Bethesda, MD; US Army Institute of Surgical Research; and
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59th Medical Wing, JBSA Lackland, TX. COL Becker is affiliated with the Brooke Army Medical Center. Dr De Lorenzo is affiliated with the
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University of Texas Health San Antonio, TX.
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