Page 37 - JSOM Fall 2025

noninvasive blood pressure monitoring and checking for loss From this review, it appears REBOA is a relatively uncommon
of contralateral distal pulse. While all sites did not have fem- procedure with specific and circumstantial applications. Thus,
oral arterial line kits, they are not a necessary component for REBOA and its support should not be included in training for
REBOA placement. Instead, they allow early common femoral all military medical personnel, but rather taught to those most
arterial access in anticipation of a possible REBOA. likely to use it—personnel working in resource-constrained en-
vironments where there may be delays in damage control sur-
We discovered several promising areas for improvement. These gery. 8,11,14 For example, the U.S. Army’s Forward Resuscitative
include device-specific training for support personnel (medics Surgical Detachments (FRSDS; formerly FRSTs) are suitable
and nurses), a codified REBOA equipment list and tracking teams that may encounter a need for REBOA placement given
system, and stocking of femoral arterial line kits, Compass their finite surgical capacity and potential austere deployments
transducer kits, pressure tubing, and transducer cables. We also with limited resupply. 15–17 FRSDs have predeployment training
recommend ad hoc in-theater training, especially in regional platforms as the Army Trauma Training Center (ATTC) and
Role 3 facilities in order to maximize operator familiarization Strategic Trauma Readiness Center (STaRC), which are ripe
and success for advanced trauma care for noncompressible avenues for formal courses as BEST or REBOA familiariza-
torso hemorrhage. tion with arterial line set-up. 18,19 Additionally, there needs to
be the ability to sustain this perishable skillset through didac-
Our training curriculum was implemented to briefly introduce tic “refresher” training and/or obtaining a STAAR or similar
the ER-REBOA device and its placement to partners in our area trainer available at predeployment locations for austere units.
of responsibility. The intent was in-service training for physician Successful REBOA capabilities in deployment settings require
and nursing staff, while reviewing clinical practice guidelines. predeployment and sustainment training for select individuals
and teams.
A major challenge identified in this quality improvement proj-
ect was the number of trained staff—physicians, nurses, and Medical equipment sets for deploying units can be standard-
medics—with little to no REBOA and arterial line monitoring ized to include femoral arterial line kits, along with arterial
competency. With 6 out of 32 physicians capable of placing line monitoring cables through the Defense Medical Materiel
REBOA across four different locations, there is little personnel Standardization Program (DMMSP).
redundancy. Similarly, support staff with knowledge of inva-
sive arterial monitoring was as low as 2 out of 28 personnel, Limitations
but, as mentioned previously, this is not an absolute prerequi- There were limitations to this study, most notably that all data
site to REBOA placement. were obtained from individuals who sought out the training
and on a volunteer basis. Volunteer bias may confound results
While our survey demonstrated there was at least one REBOA- to a population less likely to have REBOA familiarization.
capable provider at each site, it is doubtful that every candi- The number of sites and teams was low, they were only in one
date that could benefit from REBOA at these sites would re- area of operation, and all were conducted during a 3-month
ceive it. REBOA training is not standardized or required across period. We did try to account for inaccurate personnel turn-
military medical personnel, and thus medical personnel may out through discussions with on-site leadership teams, but we
not be trained to place or support a REBOA. There are for- may have missed additional providers/support staff who may
mal courses to teach REBOA placement and arterial line man- have had formal training. A major limitation is the fact that
agement, such as the BEST and the American Association of having a “REBOA-capable” provider does not ensure profi-
Critical Care Nurses’ Essentials of Critical Care Orientation, ciency of placement of REBOA. The latitude of definition of
respectively. The BEST Course has both didactic and practical “REBOA-capable” could mean a provider took a BEST course
sessions involving a perfused cadaver, which allows partici- many years prior without sustainment training. Furthermore,
pants to have direct hands-on training in accessing and placing “familiarization training” was based on expert assessment,
ER-REBOA via the common femoral artery, with additional which has marked subjectivity and is not necessarily equiv-
emphasis on ultrasound-guided and open exposure tech- alent to the BEST course. While there is evidence that differ-
niques. The Essentials of Critical Care Orientation is a nurs- ent modalities of didactics and simulation other than BEST
ing-specific course covering arterial access set-up, arterial wave can provide REBOA-improving skills, they have not been
form identification, and arterial line management. However, compared head-to-head. A better assessment of providers
13
tradeoffs of appropriateness of REBOA, time commitment, lo- would be testing REBOA proficiency on a perfused cadaver,
gistical feasibility, and monetary costs of these courses must but this was not possible within the confines of this project.
be considered. Another option given logistical and monetary In addition, the levels of support staff familiarization with ER-
constraints are less formalized avenues of training to obtain REBOA and arterial line set-up varied and was determined by
the technical and cognitive skills involved in REBOA. Techni- self-report. The findings of this study are not necessarily gener-
cal aspects of REBOA are achievable, even without the BEST alizable to all deployed environments given the ever-changing
course. In a prospective trial involving novices, anesthesiolo- personnel, missions, and medical capabilities. Specifically, this
gists, and endovascular experts, novices performed just as well quality improvement project occurred in 2019, after which
as experienced anesthesiologists 8–12 weeks after a 2.5-hour significant changes to medical and operational environments
simulation training on REBOA Seldinger technique. In ad- have occurred.
12
dition, a systematic review of REBOA training revealed that
conceived didactics with simulation was effective in increasing Conclusion
procedural competence for REBOA deployment. 13
This deployed site survey demonstrates that the minimal re-
A review by Thrailkill and colleagues found there were around quirements and personnel for ER-REBOA placement were met
600 cases of REBOA per year, with decreasing use since 2019. at most studied locations in 2019. However, improvements in
2
In-Theater Assessment of REBOA Capabilities and Training | 35