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Methods TABLE 1 Data Collection Methods
To determine specific barriers to REBOA in deployed environ- Objective Evaluation of objective
ments, we conducted a survey of ER-REBOA placement and Provider(s) with capability Investigator deliberation and
monitoring capabilities at four medical treatment locations training? (defined as Basic consensus based on:
• Focused interviews with
Endovascular Skills for Trauma
in Iraq and Kuwait during the spring of 2019. This project course or familiarization medical leadership at each
was initiated as a quality improvement project in the Iraq/ training) location (including available
Syria theater. We completed site surveys, focus group discus- additional medical assets on
sions, and integrated a REBOA simulation curriculum with the post)
ER-REBOA in-theater. Focus was placed on the physician and • Individual discussions with
providers during training
support staff familiarity with placing the device, as well as the • Survey results (Appendix 1)
supply readiness at the deployment locations for REBOA. • Equipment assessment • Direct inspection of
• ER-REBOA device resuscitation bays, intensive
™
The primary objective was to evaluate each medical site’s abil- • Compatible Introducer care unit equipment areas,
ity to deploy REBOA, which hinged on two factors. First, the Catheter Kit operating rooms, and medical
medical site must have a provider capable of placing REBOA, • Arterial Pressure Monitoring storage
Capability (Compass device or • Interviews with on-site
whether through attending the BEST course or familiariza- pressure tubing, arterial line logistics personal and relevant
tion training. Second, there must be the minimum equipment transducer, and a compatible medical staff
necessary to deploy REBOA, namely the ER-REBOA device monitor)
and the introducer catheter kit. The device and kit must be • Femoral arterial lines for early
placement
stored according to the manufacturer’s recommendations,
which was in a cool, dark location away from direct sunlight. Support personnel for formal Survey results (Appendix 1)
training or comfort
Familiarization training was defined as consensus agree-
ment by the investigators KC and KR for a provider to 1)
understand when to place a ER-REBOA and 2) place an ER- hands-on simulation segment with two simulated cases (zone
REBOA either through training other than the BEST course 1 and zone 3). Both cases required the team to correctly select
or having successfully placed it in a patient. Investigators in- a zone, deploy, and monitor an ER-REBOA in a pressured sim-
terviewed medical leadership and providers and conducted ulation mannequin model. A test was administered at the end
surveys of providers to determine those capable of placing for knowledge retention (Appendix 2).
REBOA (Table 1 and Appendix 1). The secondary objectives
included evaluating support personnel for formal training (or The simulation mannequin model used was the Prytime
comfort level) assisting in the management of a patient with Medical STAAR (Simulation Trainer for Arterial Access and
™
an ER-REBOA device in place and arterial pressure monitor- ER-REBOA), which includes a pulsatile flow loop. This model
ing capabilities for the REBOA. Secondary objectives were offered clinically similar conditions for arterial access train-
evaluated by the investigators through interviews and survey ing and simulated ER-REBOA placement. Providers placed the
results of support personnel and visualization of arterial pres- ER-REBOA while nurses or medics assisted in setting up an
sure monitoring equipment. arterial pressure transduction/monitoring system. The arterial
pressure monitoring device was the ZOLL M Series defibril-
®
®
The investigators and advisors for this quality improvement lator (ZOLL Medical Corporation, Chelmsford, MA).
project consisted of two vascular surgeons, one trauma sur-
geon (BEST course instructor), two emergency medicine phy- The protocol was reviewed and granted exemption by the lo-
sicians (one who had completed the BEST course and one cal institutional review board. The manuscript was reviewed
with familiarization training in ER-REBOA placement), and and approved by the Public Affairs Office and the institutional
two registered nurses with formal training in ER-REBOA Operations Security (OPSEC) Representative.
placement.
Results
We completed four site surveys (three in Iraq, one in Kuwait)
during the spring of 2019. These sites were selected based We evaluated four deployed locations: two Role 2 medical
on their critical access and location in theater at that time treatment facilities (MTFs) with Forward Resuscitative Sur-
(within range of readily available transportation/project time gical Team (FRST) augmentation in Iraq: one Role 3 MTF in
constraints). Iraq, and one Role 3 MTF in Kuwait.

Data was collected and stored in Excel 16 (Microsoft, Red- A total of 113 individuals participated in the evaluation and
mond, WA) and reviewed by two investigators after completion. training (Table 2). While all sites had the minimum training
and equipment requirements to complete the procedure (one
While not a primary or secondary objective, the study inves- REBOA-capable provider, an ER-REBOA device, and an intro-
tigators created a training curriculum to educate participants ducer catheter kit in proper storage), one site only had expired
on ER-REBOA placement and monitoring as part of a quality ER-REBOA devices and kits. This site was deemed unable
improvement initiative. After completing the site survey, the to deploy a REBOA. Overall, 6 of 32 (18.7%) of physicians
investigators gave a didactic-simulation session for physicians were capable of placing an ER-REBOA, whether attending the
and support staff. The curriculum consisted of 1.5 hours of BEST course or with familiarization. Of 81 medical support
lecture describing pathophysiology, indications, contraindica- staff (nurses and medics), 1 (1.3%) reported ER-REBOA sup-
tions, complications, management, transport considerations, port proficiency, and 17 (20.9%) reported proficiency with
and discontinuation of ER-REBOA. It was followed by a arterial pressure transducer set-up and management.

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