Page 112 - JSOM Winter 2023

Time for the Department of Defense

to Field Video Laryngoscopy Across the Battlespace

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Steven G. Schauer, DO, MS *; Brit J. Long, MD ; Andrew D. Fisher, MD, MPAS ; Peter J. Stednick ;
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Vikhyat S. Bebarta, MD ; Adit A. Ginde, MD, MPH ; Michael D. April, MD, DPhil, MSc 7
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he New England Journal of Medicine recently published Currently, the Medic Enhancement Set (MES) for the BAS
a prospective, randomized controlled trial by Prekker Role 1 does not include VL technology. Neither do Brigade
Tet al., “Video versus direct laryngoscopy for tracheal in- and Area Support Medical Companies (BSMC, ASMC) com-
tubation of critically ill adults,” funded by the Defense Health prising Role 2 facilities for maneuver forces. The MES for For-
Agency. Patients presenting to emergency departments and in- ward Resuscitative Surgical Detachments in the Army includes
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tensive care units requiring emergent tracheal intubation were video laryngoscopes as Associated Support Items of Equip-
randomly assigned to either video laryngoscopy (VL) or di- ment. However, these items remain strictly as developmental
rect laryngoscopy (DL) on the first attempt. The trial stopped line-item numbers. To the authors’ knowledge, there has yet
early after a pre-planned interim analysis demonstrated clear to be an established timeline for full procurement and fielding
superiority of VL over DL for first-pass success (final results across the Force. Current modified tables of organization and
[n=1,417]: 85.1% VL vs. 70.8% DL, p<.001). The accompa- equipment (MTOE) for contemporary Role 3 organizations
nying invited editorial suggests that VL should be available in (e.g., Field Hospitals) are in the same situation. Historical VL
all treatment areas with intubation capability. This is not the device materiel solutions (e.g., GlideScope) are no longer ser-
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first clinical trial to assess these two emergency airway man- viceable by the manufacturer; as the technology malfunctions,
agement interventions, but it does represent the largest and no replacement exists. Even if we identify a solution to replace
most robust to date. the aging GlideScope devices, that only solves the challenge
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for Role 3, which already has assigned residency-trained emer-
According to the North Atlantic Treaty Organization (NATO) gency medicine physicians, anesthesiologists, and certified
definitions, most data show that tracheal intubation is the registered nurse anesthetists (as the authors and others have
most common airway intervention in the Role 1 phase of care described). 5,13
(including temporary, forward-staged aid station settings), far
outpacing cricothyrotomy and extraglottic airway placement Role 1 field and semi-fixed facility staffing pose distinct chal-
(as we previously reported). While it is not feasible to ran- lenges that increase the need for VL capability. The providers
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domly assign combat casualties to immediate versus delayed and configuration of the Role 1 aid station vary based on the
intubation, the authors’ best available data demonstrated service, unit, mission, and operational environment. A Role 1
higher mortality among those undergoing intubation in the aid station typically has one medical officer leading the team.
Battalion Aid Station (BAS) Role 1 setting; our finding per- This guideline may be modified, leaving only enlisted med-
sisted when adjusting for confounders, including mechanism ical personnel trained at the level of an emergency medical
of injury and injury severity score. 9–11 The authors could not technician. The training of the medical officer varies, ranging
determine the success rates of Role 1 endotracheal intubation from a newly trained physician assistant to general medical
or if there was a requirement to transition to supraglottic air- officers (one-year general internship post-graduate) or a non-
way for failed endotracheal intubation attempts. These pre- emergency medicine residency-trained physician (family med-
vious studies suggest that if we implement an intervention to icine or pediatrics trained). The common thread within these
improve outcomes for casualties requiring airway interven- staffing models is a lack of medical officers with advanced air-
tions, the BAS Role 1 setting offers the greatest opportunity way training. The American College of Graduate Medical Ed-
for improving patient outcomes, given the critical nature and ucation (ACGME) requires that emergency medicine residents
need for early intervention. Further, the authors’ recent assess- have at least 35 successful intubations to graduate; however,
ment of trends suggests that they have not materially affected data suggest that 50 is a reasonable volume for competency (as
outcomes among casualties requiring prehospital intubation in noted by others and authors in a recent opinion). 14,15 ACGME
nearly two decades of combat. 12 does not have direct requirements for sustainment training,
*Correspondence to sgschauer@gmail.com
1 LTC Steven Schauer is a physician affiliated with the Uniformed Services at the University of the Health Sciences, Bethesda, MD, and the Univer-
sity of Colorado Anschutz Medical Campus and Anschutz Center for COMBAT Research, Aurora, CO. MAJ Brit Long is a physician affiliated
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with the Uniformed Services University of the Health Sciences, Bethesda, MD, and Brooke Army Medical Center, JBSA Fort Sam Houston, TX.
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3 MAJ Andrew Fisher is a physician affiliated with the University of New Mexico Hospital, Albuquerque, NM. MSG Peter Stednick is a Combat
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Medic affiliated with the Capabilities and Development Integration Directorate, JBSA Fort Sam Houston, TX. COL Vikhyat Bebarta is a physi-
cian affiliated with the University of Colorado Anschutz Medical Campus and Anschutz Center for COMBAT Research, Aurora, CO. Dr Adit
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Ginde is a physician affiliated with the University of Colorado Anschutz Medical Campus and Anschutz Center for COMBAT Research, Aurora,
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CO. LTC Michael April is a physician affiliated with the Uniformed Services at the University of the Health Sciences, Bethesda, MD.
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