Page 51 - JSOM Summer 2023

Leveling the Battlefield

Development of a Pre-Deployment Vascular Access Curriculum
for the Nonsurgical Provider

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Skyler Walker *; Olivia Agree ; Rachel Harris ; Taylor DesRosiers, MD 4

ABSTRACT
Introduction: Timely vascular access is critical, as hemorrhage of analgesics and prophylactic antibiotics. The Resuscitative
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is the number one cause of death on the battlefield. Anecdotal Endovascular Occlusion of the Aorta (REBOA) device in the
evidence in the Military Health System identified an opera- prehospital setting further serves as a newer lifesaving method
tionally relevant procedural skills gap in vascular access, and of vascular access on the battlefield. 8,9
data exist in civilian literature showing high rates of iatro-
genic injuries when lack of robust procedural opportunity Other methods for gaining vascular access in the combat setting
exists. Multiple pre-deployment training courses are available include intraosseous (IO) devices, central and peripheral intra-
for surgical providers, but no comprehensive pre-deployment venous (IV) access, and arterial line access. 10,11 It is therefore
vascular access training exists for non-surgical providers. paramount that combat medics, nurses, mid-level providers,
Methods: This mixed-method review aimed to find relevant, and physicians are appropriately trained and practiced via an
operationally focused, vascular access training publications. A effective, standardized vascular access curriculum to perform
literature review was done to identify both relevant military this lifesaving skill quickly and with minimal complications.
clinical practice guidelines (CPGs) and full text articles. Re-
viewers also investigated available pre-deployment trainings Military treatment facilities (MTFs) primarily cater to a
for both surgeons and non-surgeons in which course adminis- healthy, active-duty population. In low-acuity civilian settings,
trators were contacted and details regarding the courses were estimated iatrogenic injuries from central line access such as
described. Results: We identified seven full-text articles and infection, pneumothoraces, and great vessel damage are esti-
four CPGs. Two existing surgical training programs and Army, mated to be between 5–19%. The low acuity of MTFs places
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Navy, and Air Force pre-deployment training standards for providers at this same risk; however, iatrogenesis cannot exist
non-surgeons were evaluated. Conclusion: A cost-effective and as the focus of military medical readiness shifts toward the
accessible pre-deployment curriculum utilizing reviewed litera- possibility of a near-peer threat. Medical providers must be
ture in a “learn, do, perfect” structure is suggested, building on prepared to manage a higher volume of patients at a higher
pre-existing structures while incorporating remotely accessible acuity and be able to give care for prolonged periods in the
didactics, hands-on practice with portable simulation models, field. Proficiency in rapidly and accurately obtaining periph-
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and live-feedback training. eral and central vascular access is paramount and must be em-
phasized in pre-deployment training now more than ever.
Keywords: vascular access; military medicine; arterial access;
arterial line; central venous access; central line; IV; intrave- Currently, both Emergency War Surgery (EWS) and Advanced
nous; literature review; training, military; deployed medi- Surgical Skills for Exposure in Trauma (ASSET) provide
cine; simulation training; austere environments; emergency pre-deployment training opportunities for surgical providers
medical care to practice their surgical skills. However, there is presently no
comprehensive vascular access training course for the non-
surgical provider within the United States military, represent-
ing a large gap in the pre-deployment milieu of preparation.
Introduction
This article outlines a mixed methods review to guide the cre-
Immediate vascular access in trauma patients is essential in ation of an ideal, standardized, and effective pre-deployment
treatment of battlefield wounds. The leading cause of prevent- training/skills maintenance vascular access curriculum for the
able death on the battlefield is hemorrhage, with one in five nonsurgical military provider.
injuries during the Global War on Terror (GWoT) requiring
hemorrhage control. Thus, rapid resuscitation serves as a crit- Methods
ical lifesaving intervention. During the conflicts in Iraq and
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Afghanistan, 5% of all patients required either venous or arte- A mixed-methods review of the literature was conducted
rial access, and in some cases, crucial blood resuscitation and via PubMed, Embase, and Cochrane research databases in
administration of tranexamic acid and calcium led to improved July 2021. The systematic review management software
outcomes for patients that met prehospital transfusion crite- COVIDENCE (Veritas Health Innovation, https://www.
ria. Vascular access can also be utilized for administration covidence.org/) was utilized via a three-reviewer process (SW,
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*Correspondence to skyler.d.walker2.mil@mail.mil
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1 ENS Skyler Walker and LDCR Taylor DesRosiers are affiliated with the U.S. Navy. 2LT Olivia Agree is affiliated with the U.S. Marine Corps.
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3 2LT Rachel Harris is affiliated with the U.S. Army. LDCR Taylor DesRosiers is a physician affiliated with the U.S. Navy. All authors are affil-
iated with the Uniformed Services University of the Health Sciences, Bethesda, MD, and the Combat Trauma Research Group of the U.S. Navy.
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