Page 72 - JSOM Winter 2024

Discussion Limitations
Our study has several limitations. There are ethical issues with
Surgical Teams Can Rapidly Learn How to performing training and validation testing on humans, so we
Cannulate and Manage VV ECMO used an animal model as a substitute. There are similarities in
We developed a VV ECMO training course that combined anatomy between human and swine anatomy; however, the
didactic, skills station, and model training to teach SOSTs to femoral anatomy is more tortuous in swine. Given the ana-
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cannulate and manage VV ECMO. Our course was unique tomical differences in the femoral anatomy in swine, bifemo-
in that SOST personnel may not have access to perfusionists ral VV ECMO cannulation is likely more challenging than in
or ECMO specialists and may be required to independently humans. Second, validation testing occurred immediately after
manage both the patient and the VV ECMO equipment. didactic training, so sustainment and retention of training was
In addition, SOSTs operate in austere conditions and may not studied. Follow-on studies will examine length of time of
need to perform advanced procedures in low light condi- skills retention and adjuncts that can be used to refresh knowl-
tions. Though no participants had formal ECMO training edge. Third, we did train participants to manage and perform
prior to this course, surgical teams consist of personnel with procedural interventions on VV ECMO; however, only 2
extensive medical expertise and experience. Course partic- hours per scenario was allocated. PCC tuations may require
ipants were able to understand the physiology and man- longer holding of patients on VV ECMO prior to transfer to
agement of VV ECMO in addition to the technical aspects experienced ECMO management teams. Use of operational
of the procedure. They were then able to independently set VV ECMO SMEs and further prolonged management train-
up and prime the VV ECMO circuit and cannulate models ing through didactics and exercises will be important in im-
for VV ECMO. Prior to the course, no participants met the plementation of VV ECMO in forward locations. Fourth,
80% standard of knowledge to perform VV ECMO. After given operational and training requirements, obtaining two
completing training, 75% met this standard. In addition, 6-person teams with each AFSC represented was not feasible
participants were able to perform ECMO circuit set-up and so substitutions to the usual team composition was necessary
cannulation at or below previously established times. Finally, for this study. This could limit broader applicability to SOST
participants successfully managed all alarms and emergency implementation of VV ECMO. Fifth, 6 participants had spe-
scenarios. Our study demonstrates similar findings to a pre- cialized training in advanced vascular access courses which
vious ECMO training study demonstrating that military may skew our results. However, attendance at these courses
medical personnel can be trained to perform ECMO. Our offered to SOST personnel may also be representative of the
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study expands on the literature by demonstrating that surgi- skillsets of these medical providers. Sixth, given that the same
cal teams can meet validation metrics and perform procedures knowledge assessment was used before and after the course,
on models on VV ECMO. Through knowledge assessments, this learning effect and targeted retention of material could
self- assessments, and validation testing of skills learned, this be observed in the improvement in scores. Finally, we trained
course demonstrates that SOSTs can be trained to safely and 12 SOST-qualified personnel; however, our training platform
effectively cannulate for and manage VV ECMO. This study may not be applicable to other surgical teams or non-surgical
is a first step toward demonstrating that forward surgical medical personnel. Validation of our course in other military
teams possess the expertise to successfully accomplish initial medical personnel is needed.
training.

Special Operations Forces (SOF) Conclusions
Application of VV ECMO In a cohort of United States Air Force SOST personnel, using a
VV ECMO is increasingly used to stabilize patients with se- modified training curriculum and a 2-hour, hands-on validation
vere thoracic injury with good results. There is benefit to early testing improved self-assessment and knowledge assessment
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initiation of VV ECMO in trauma as part of a resuscitation scores in performing VV ECMO. Given the rise of extracor-
strategy to improve hypoxemia and hypercarbia and forward poreal support use in the care of medical and trauma patients
surgical teams can rapidly learn to employ VV ECMO in aus- and possibility of PCC in the military population, forward VV
tere environments. Thoracic injuries are common in both ECMO training and sustainment should be studied further.
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blunt and penetrating trauma with survival rates as low as
4.6%. 31,32 Blast injuries and penetrating thoracic trauma put Author Contributions
patients at particular risk of requiring operative intervention. EKP performed literature review, study design, data collection
33
Severe pulmonary injury and hemorrhage may require pneu- and analysis, data interpretation, and writing. TR, JKW, SJ,
monectomy or removal of the lung for hemorrhage control as AEM, and DA performed study design and critical revision,
part of a damage control strategy. 34,35 VV ECMO can provide BST, RK, MK, and TMS performed data interpretation, writ-
stabilization of these patients, allowing for transportation out ing, and critical revision, SMG performed study design, data
of theater. Future conflicts requiring PCC and multidomain analysis, data interpretation, and critical revision.
transports could use expanded extracorporeal support to im-
prove patient survival. SOF are at particular risk for severe Disclosures
injury and delayed transport given austere operational envi- The authors have no potential competing interests to disclose.
ronments. Medical personnel that support these personnel can This work was presented at the 34th Extracorporeal Life Sup-
improve outcomes through research and clinical innovation. port Organization Conference Seattle, WA Sept 28–Oct 1,
In addition to device innovation and study of novel clinical ap- 2023.
plications, clinician training is an important part of expanded
VV ECMO implementation. Our study is the first step in this Disclaimer
development and demonstrates that SOSTs that support SOF The views expressed in this material are the views of the au-
can be trained in VV ECMO.
thors, and do not reflect the official policy or position of the

70 | JSOM Volume 24, Edition 4 / Winter 2024