Page 41 - JSOM Fall 2021

TABLE 4 Self-Assessment of Trainees According to Likert Scale with a mannequin, 73% of the practitioners had already
Before After managed to correctly place a REBOA, leaving little room to
training training demonstrate significant progression. The reduction in time
(n = 15) (n = 13) p-value for insertion of the introducer is not significant. On the other
I am comfortable with: hand, the 108-second reduction in the duration of REBOA
the internal aortic clamping 2 [2–3]* 4 [4–4] < 10 –3 placement was significant. This shows that the training has an
the material required for internal –3 impact on success, but also on speed, which corroborates the
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aortic clamping 3 [1–3] 4 [4–5] < 10 results of other studies on the subject. As shown in Table 2,

the sequence of steps for internal –3 the values are globally less dispersed after training, with a more
aortic balloon placement 2 [1–3] 5 [4–5] < 10 uniform speed among the practitioners. The median post-train-
the US-guided access technique 2 [1–3] 4 [4–5] < 10 –3 ing time is very encouraging. Certainly, the installation of such
the surgical access technique 1 [1–3] 3 [3–4] 0.005 a device in a mannequin is not the same as in pre-hospital con-
the choice I made regarding the ditions, which may explain our times being far below those
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placement area and locating the 3 [1–3] 5 [4.5–5] < 10 –3 of the study of Ross and Redman. In their study, the success
cutaneous area rate was 85.9% with the percutaneous or surgical approach,
inflating the balloon and 1 [1–2] 5 [4–5] < 10 –3 and the median duration for placement was 439 seconds (IQR
controlling the effectiveness 429–657). Their study was perhaps closer to actual conditions,
the physiologic consequences of –3 as trainees sometimes had to place the REBOA while in a heli-
internal aortic clamping 2 [1–3] 4 [4–4,5] < 10 copter or moving ambulance. This duration is a central element
the intermittent and partial –3 in the use of REBOA. The device must not waste of time in the
internal aortic clamping technique 1 [1–2] 3 [3–4] < 10 evacuation of the patient to the trauma center. The 222-second
the deflation and the tolerance –3 duration is compatible with fast evacuation.
estimation 1 [1–2] 4 [4–4] < 10
the hemostasis of the puncture 2 [2–2] 4 [4–5] < 10 –3 The fact that 73% of trained practitioners succeeded in de-
point ploying a REBOA after only half a day of theoretical training
the potential secondary is interesting. Training as accomplished as ours seems diffi-
complications related to the 2 [1–3] 4 [4–4.5] < 10 –3
placement of a balloon for cult to reproduce regularly and massively in order to train all
internal aortic clamping emergency practitioners in the French Armed Forces. It may be
US = ultrasound interesting to develop shorter training, targeting the steps that
*Median value [interquartile range]. most physicians fail to emphasize, so that the same success
rate as the one we obtained with this training can be achieved.
FIGURE 1 Star chart: The dotted line is the median notation before From Table 2, it appears that the three points causing most of
thee training, and the continuous line is the median notation after the
training. Students are designated from 0 to 5. the failures were the ultrasound-guided puncture, placement
of the guidewire, and placement of the sheath introducer.
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These points are also described in the literature and can be
explained by the fact that deep venous access is used less and
less in prehospital care, particularly with the development of
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intraosseous perfusion. Intraosseous perfusion has made it
easier for emergency physicians to find venous approaches in
patients for whom perfusion is difficult, by avoiding the instal-
lation of a central line. If the emergency physicians no longer
see any interest in recycling and maintaining their knowledge
of deep access, it seems that the practice of REBOA is insep-
arable from the technical ease of such access. This point is all
the more important as a rapid approach to the femoral artery
would increase survival. 13

The significant improvement in all items after training shows Study Limitations
that the trainees’ attitude and confidence in the various proce- Our study has some limitations. Only one criterion signifi-
dures increased during the training. Increasing self-confidence cantly improved (the duration of REBOA installation), which
in a procedure reduces the risk of failure the day the procedure can be explained by the small number of participants. In ad-
is to be conducted in real-life conditions. Stress related to the dition, the overall success rate is not significantly different
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rarity of this procedure may be present in real conditions, es- before and after training. This can be explained by the high
pecially the first time it is performed. Therefore, our training success rate on the first test, achieved only after a demonstra-
to gain self-confidence could reduce this stress and increase the tion of REBOA installation. Our hypothesis is that the train-
chances of success. ees were emergency physicians already experienced, and thus
were a priori more comfortable with the gestures of emergency
This training appears to be an effective way to train military medicine, such as central venous access.
practitioners in the REBOA technique. A success rate of 93%
seems particularly satisfying for carrying out such a procedure,
especially in a rescue framework. The absence of a significant Conclusion
result concerning the progression to installation of the device Our training appears to be a good way of training emergency
can be explained by several hypotheses. First, having only fol- physicians but is very expensive because it requires pigs and
lowed the half-day theoretical training and the demonstration cadavers. In addition, we trained the physicians over two days.

REBOA Course for Internal Aortic Clamping | 39