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FIGURE 2 Procedural training pyramid of skills acquisition training. Additional benefits of the live tissue training include
and perfection. practice operating under stress and managing realistic hemor-
rhage scenarios. However, ethical and moral considerations
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when utilizing animal or cadaver models must be weighed,
and models that maximize training opportunity must be par-
amount. Hence, live patients can be utilized for this final step,
under a high level of supervision and active ready assistance.

To maximize successful cannulation even in difficult to ac-
cess (e.g., hypovolemic) patients, US must be utilized even in
a deployed setting. Corpsmen, nurses, and non-surgical physi-
cians displayed increased success in US-guided cannulation at
the conclusion of a training program with just 30 minutes of
video didactics, followed by supervised hands-on training on
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live patients. The technique, proficiency, and lack of patient
Phase 3: Skills Perfection and Maintenance via wet skill perfection complications in this study illustrate that a vascular access train-
with vivarium, cadaver, or live patient practice. ing program involving live patients is both safe and feasible. Re-
• Pinnacle step translating knowledge and practice to live tissue gardless of the tool, full preceptorship with feedback, skills and
with standardized checklists, 360-degree feedback, and merit competency checklists, and post-procedural debriefing are es-
based (not numerical based) sign-offs
• Can modify based on wet resource availability, and can revisit sential to maximize learning opportunities and skills perfection.
simulation for novel procedures or troubleshooting
Phase 2: Initial Procedural Skills Acquisition via mobile hands-on Strengths of this analysis and proffered solution lie in this
skills trainers and simulation models. being the only review of its kind, supplementing the mixed
• Create standardized checklists to ensure high reproducibility methods review with a scaffold for future training. Limitations
across standard task trainers
• 3D print atypical trainers (such as subclavian or brachial include a low number of studies that were found to be rele-
access) into mobile deployable models vant, as well as offering a model that has yet to be formally
Phase 1: Functional Knowledge Acquisition via computer or created or validated. Next, as there is no central repository for
mobile device. all vascular access training opportunities within the Depart-
• Virtual aspect increases availability of training regardless of
location ment of Defense, it is highly probable that smaller programs
• Consistency in widely available training eliminates variance were entirely missed. Lastly, even the larger branch-specific
and increases both precision and accuracy programs were not assessed in a peer-reviewed manner, as
curricula access was dependent on each individual point of
contact. While specific requests for both quantitative numer-
less obvious benefits include improving team performance, as ical data as well as qualitative themes and goals of each pro-
SIMs have been shown to improve dynamics and cooperation gram were requested, the amount and quality of information
between team members. Last, non-traditional models can be received was widely variable. However, this further proves that
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created through 3D printing to represent difficult access or less future studies and development of this critical training is nec-
familiar areas, such as an axillary model for brachial arterial essary for a battle-ready force in potential near peer threats.
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cannulation.
Conclusion
The third tier—skill perfection—should occur in a wet model,
such as a vivarium, cadaver, or a live patient experience. This As the United States military creates new iterations to pre-
pinnacle training experience addresses the tactile feedback and deployment training to prepare for the possibility of a peer-
finetuning required to minimize injury and troubleshoot vari- to-peer threat, medical personnel must be prepared for the
ations. Few studies have assessed the efficacy between human prolonged field care of casualties, which may include central
SIM models, cadavers, and live tissue animal models. How- venous and arterial access. In a setting in which air superiority
ever, two studies have illustrated that training with live ani- and rapid evacuation is not guaranteed, expertise in vascular
mal tissue models improved trainees’ confidence and technical access to administer medication drips, sedation, antibiotics, or
skills compared to those that utilized a SIM model. 25,26 One re- monitor blood pressure via arterial line becomes even more
view concluded that all methods (live tissue, SIM, and cadaver essential. The training techniques found in this review can be
training) improved technical skills in medical providers. 27 utilized as a framework to guide these new pre-deployment
curricula.
Each of the three options carries risks and benefits. Simula-
tors, which despite becoming more advanced and available in A pilot program would be the next step toward this goal to
recent years, do not provide a realistic model for advanced validate this training model prior to rolling out across all
surgical/emergency interventions. Human cadavers provide a branches of the military. Ample evidence shows that minimiz-
more accurate depiction of anatomy, but dead tissue does not ing variation and streamlining training efforts into a single
respond in the same manner as live patients. Live animal tissue process improves outcomes and performance. This ideal cur-
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models provide a more realistic simulation of hemorrhage, an riculum holds great potential toward preserving the lives of
ideal tool for complex surgical or emergency interventions in a warfighters who require vascular access in a deployed setting.
combat environment. Seventy-five medics from the Canadian
Combat Forces trained on SIM plus live tissue felt significantly Disclosure
more prepared while deployed in Afghanistan; 94% stated The authors have indicated they have no financial relation-
live tissue practice should be available for all pre-deployment ships relevant to this article to disclose.

Pre-Deployment Vascular Access Curriculum for Non-Surgeons | 53