Page 67 - JSOM Winter 2024

Validation of a Training Model for Austere Veno-Venous
Extracorporeal Membrane Oxygenation Cannulation and Management

1
2
Elizabeth K. Powell, MD *; Tyler S. Reynolds, MD ; James K. Webb, CRNA ; Rishi Kundi, MD ;
4
3
8
6
5
Meaghan Keville, MD ; Douglas H. Anderson, DO ; Ann E. Matta, CRNP ; Sarah Juhasz, RN ;
7
Bradley S. Taylor ; Samuel M. Galvagno Jr., DO, PhD ; Thomas M. Scalea, MD 11
9
10
ABSTRACT
Introduction: Veno-venous extracorporeal membrane oxygen- Introduction
ation (VV ECMO) is used in trauma patients with pulmonary
injury in the acute setting. The United States Military has Veno-venous extracorporeal membrane oxygenation (VV
an advanced ECMO transport and management capability; ECMO) is used for patients with respiratory failure and acute
however, future conflicts may require forward prolonged ca- respiratory distress syndrome (ARDS) who have failed con-
1
sualty care (PCC). Special Operations Surgical Teams (SOSTs) ventional ventilator management. VV ECMO facilitates rapid
provide damage control surgery, resuscitation, and PCC in correction of hypoxemia and respiratory acidosis from hy-
2,3
forward, unregulated, multidomain environments. We hy- percarbia while also reducing injurious ventilator settings.
pothesize that SOSTs can be trained to cannulate and manage Use of VV ECMO increased during the H1N1 epidemic and
patients requiring VV ECMO. Methods: We developed a 2.5- COVID-19 pandemic and is also commonly used for a wide
4–6
day course using knowledge assessments (25 questions), self- variety of other pulmonary illnesses. More recently, VV
assessments (5-point Likert scale, moderate confidence=3), ECMO has been used for trauma patients as part of a sta-
and instruction checklists. The instruction checklists were bilization strategy to correct pulmonary-related laboratory
7–9
used to assess performance during final evaluation with York- derangements thus facilitating interventions for injuries. Re-
shire swine (Sus scrofa) models. Data were tested for normal- gardless of the underlying pulmonary etiology, the use of VV
10,11
ity, and statistical significance was defined as P<.05. Results: ECMO is increasing in civilian centers.
Twelve qualified SOST personnel completed the training.
Four participants reported previous ECMO clinical exposure, The United States Military has an experienced ECMO trans-
and none reported formal ECMO training. When comparing port and management team that allows worldwide, regulated
12,13
pre- and post-course knowledge assessment scores, there was access to ECMO. Future conflicts may necessitate pro-
a significant improvement in overall scores (12.5 vs. 20.6, longed casualty care (PCC) and holding in forward, austere
P<.001). The number of participants who self-reported at environments. With the current military ECMO capability and
least moderate confidence in cognitive (2.8 vs. 11.3, P<.001), operational environment, time from notification to patient
14
technical (1.2 vs. 11.6, P<.001), and behavioral (2 vs. 12, contact could be 48 hours. Contested airspace requiring un-
P<.001) aspects of VV ECMO set-up, cannulation, and man- regulated movements could make time to patient contact even
agement increased. Each team successfully set up, cannulated, longer. Gaps in VV ECMO capabilities could lead to delays
9,15
and managed models with lights on and in darkness. Conclu- in cannulation and potentially increased morality. Forward
sions: In a cohort of United States Air Force SOST personnel, medical teams already positioned to receive patients and pro-
using a modified training curriculum with 2-hour, hands-on vide PCC could help bridge a care gap in extracorporeal sup-
validation testing improved self-assessment and knowledge port for warfighters.
assessment scores in performing VV ECMO. Given the rise of
extracorporeal support use in the care of medical and trauma United States Air Force Special Operations Teams (SOSTs) are
patients and the possibility of PCC in the military population, forward, unregulated, multidomain medical assets that are
forward VV ECMO training and sustainment should be stud- composed of an emergency physician, general surgeon, anes-
ied further. thesiologist or certified registered nurse anesthetist (CRNA),
critical care nurse (RN), surgical technician (ST), and respira-
tory therapist (RT). These teams provide a high level of clinical
Keywords: SOST; VV ECMO; PCC; battlefield surgery
expertise in Role 2 environments. Previous military studies have
examined the rapid training of medical personnel to cannulate
*Correspondence to elizabeth.powell@som.umaryland.edu
1 Maj Elizabeth K. Powell and Lt. Col Meaghan Keville are affiliated with the Department of Emergency Medicine, University of Maryland School
5
4
5
7
of Medicine, Baltimore, MD. Maj Elizabeth K. Powell, Dr. Rishi Kundi, Lt Col Meaghan Keville, Ann E. Matta, and Dr. Thomas M. Scalea
11
1
are affiliated with the Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD.
1 Maj Elizabeth K. Powell and Lt. Col Tyler S. Reynolds are affiliated with the 720 Operational Support Squadron, Hurlburt Field, FL. Lt. Col
2
2
3
Tyler S. Reynolds is affiliated with the Department of Surgery, Emory University School of Medicine, Atlanta, GA. Col James K. Webb is affili-
5
ated with Malcolm Grow Medical Clinics & Surgery Center, Joint Base Andrews, MD. Lt Col Meaghan Keville and Maj Douglas H. Anderson
6
are affiliated with the Center for the Sustainment of Trauma and Readiness Skills, Baltimore, MD. Maj Douglas H. Anderson and Dr. Bradley
9
6
S. Taylor are affiliated with the Department of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD.
8 Capt Sarah Juhasz is affiliated with the 59th Medical Wing, Joint Base San Antonio-Lackland, TX. Col Samuel M. Galvagno Jr. is affiliated
10
with the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
65