Page 62 - JSOM Winter 2023

(1/10), and higher procedural confidence (1/10). The top three Based on the open-ended responses, the ALD design should
major concerns were excessive time spent (6/10), possibility be improved to possibly increase its practical clinical applica-
of over-insertion/patient injury (1/10), and risk of needlestick tion. Based on several users’ concerns regarding inadvertent
injury (1/10). Only one subject in the SOF group suggested damage to surrounding structure, the optimal needle length
changing the ALD to a shorter needle. The rest of the partic- should be determined in order to increase comfort levels with
ipants were not interested in offering suggestions to a device the ALD beyond its current design.
they did not want to use in the future.
Finally, determining the procedural adjuncts and training are
11
necessary to improve success rates and user comfort. One
Discussion
possibility is to harness portable technology via smartphone or
SC is a low-volume procedure for most prehospital providers head-mounted device apps or programs. While the hands-on
but plays a critical role in addressing traumatic airway obstruc- component would be reduced, high-fidelity review programs
1
tion, the second-most common cause of battlefield mortality. may be a more portable, efficient way to deliver this critical
When SC is indicated, it is a time-sensitive, high-consequence, training. Studies investigating augmented reality visualization
and high-stress intervention. Increasing the accuracy of SC lo- and procedural guidance are already underway and showed
cation with an ALD and increasing the provider confidence preliminary promise. 12–14
with optimized refresher training may lead to increased SC
success when it is most needed. The open responses suggest the importance of soliciting feed-
back and suggestions from the end user that can guide future
The ALD can help localize the airway as well as deliver med- research and product development. We need feedback from
ications such as local anesthetic or medications used in the the field to determine which procedural adjuncts, training
ACLS algorithm that can be absorbed by the tracheal mucosa. techniques, and devices are the most helpful. While SC is in-
The ALD was favored by the HMs although design sugges- frequently used, it plays a critical role in time-sensitive and
tions were made in the open-response questions, which if catastrophic conditions.
implemented, would likely increase the ALD acceptance. The
ALD was not favored by most SOF participants, mainly out Conclusion
of concern for the extra procedural time. It is possible that the
additional time may not be clinically significant as the airway This SC study analyzed the effects of ALD on the TCCC-
was secured in under four minutes, when anoxic brain injury approved Control-Cric SC device. Procedural times were in-
starts to occur. However, in an actual airway emergency, other creased with ALD when compared with those without ALD,
factors impact morbidity such as patient factors or opera- although it may have no clinical significance. User confidence
tional considerations, including shock, patient status, duration in their ability to successfully perform an SC increased after
of airway obstruction or loss, and operational context. The two procedures using an airway model.
SOF group was faster overall, which may indicate a greater
appreciation for the urgency of SC intervention. The protocol Presentation
did not reveal urgency or stress during the SC procedure and Presented at the Special Operations Medical Association
the less-operationally experienced HM group tended to move (SOMA) 2022 Scientific Assembly, Raleigh, NC; 3 May 2022.
more slowly.
Author Contributions
Limitations All authors conceived the study and drafted the IRB protocol.
The modest SOF sample size indicates difficulty in recruit- CS obtained funding. CS, SG, and BB recruited participants
ing SC-trained SOF personnel who had no refresher training and coordinated and collected the data. CS analyzed the data
within the last 12 months as the SOF training cycles included and wrote the first draft. All authors read and approved the
maintenance of skill. The study was conducted under low- final manuscript.
stress conditions and did not incorporate external stressors
that replicated the high-stress scenario of an actual SC. The Acknowledgments
mannequin model does not reflect human tissue characteris- The authors acknowledge the support of the Combat Trauma
tics that make SC more difficult in actual patients presenting Research Group (CTRG) – San Diego and Gregory Zarow,
with bleeding or thicker subcutaneous tissue that can obscure PhD for his mentorship, support, and assistance with statisti-
landmarks. The only SC method used was the CricKey, which cal analysis and review.
was favored the least in a study of three different SC methods.
7
Other studies have used other techniques, such as scalpel and Disclosure
bougie-assisted SC. 8,9,10 Finally, no long-term follow-up of par- None
ticipants’ SC performance was conducted in future real-world
exercises or deployments. Funding
The work was supported by an intramural Naval Medical Re-
Areas for Future Research search and Training Command, San Diego Clinical Investiga-
This study should be replicated and extended to include larger tion Department (CID) grant that paid for needed supplies.
and more diverse samples, such as medics and SOF from dif-
ferent military branches. More realistic, higher-stress study References
conditions may also improve simulation conditions. Cadaver 1. Eastridge BJ, Mabry RL, Seguin P. Death on the battlefield (2001–
and other live tissue models, although expensive and more 2011): Implications for the future of combat casualty care. J
Trauma Acute Care Surg. 73(6 Suppl 5):S431-7.2.
logistically complicated to coordinate, would also improve 2. Mabry RL, Frankfort A. An analysis of battlefield cricothyrotomy
training under real-world conditions. in Iraq and Afghanistan. J Spec Oper Med. 2012;12(1):17–23.

60 | JSOM Volume 23, Edition 4 / Winter 2023