REBOA Training For Emergency Medicine Residents
Amanda Studer - Naval Medical Center San Deigo
Background: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a potentially life-saving intervention to treat non-compressible torso hemorrhage (NCTH). Emergency Medicine (EM) physicians are well-trained in obtaining rapid vascular access and may be key players in performing REBOA for initial resuscitation. This is especially true in forward-deployed settings with limited surgical capabilities, but with access to rapid evacuation to surgical care. To fill this gap, we designed and tested a REBOA training curriculum.
Methods: Participants enrolled in an accredited 4-year military EM residency program (N=11) completed a 12-hour REBOA training course. Assessments included a 25-item written knowledge exam, decision-making competence based on case studies, placement success, and time-to-placement (seconds). Data were analyzed using t-tests and non-parametric statistics at the p<0.05 statistical significance threshold.
Results: Knowledge significantly increased from pretest (65%±5%) to posttest (92%±1%), p<0.001. On Day 2, correct recognition for REBOA indications was 100%, and correct placement was 100% in Zone 1 and Zone 3. RATT placement times averaged 267±13 in Zone 1 and 289±29 in Zone 3, while cadaver placements in Zone 1 averaged 381±40. Exit survey data indicated increased participant preparedness, confidence, and support for incorporating this training into residency.
Discussion: This study was limited by the modest sample size but provides evidence that the course effectively teaches the requisite skills for appropriate REBOA placement. This study should be replicated using Special Operations Forces medical providers and testing in operational environments, all of which can have a potentially meaningful impact on reducing preventable deaths on the battlefield.
Pediatric Damage Control Surgery From Iraq And Afghanistan: The Most Common Operating Room Interventions From 2007-2016
Andrew Oh - Children's Hospital Colorado
Objectives: The wars in Afghanistan and Iraq produced thousands of pediatric trauma casualties, utilizing a substantial proportion of deployed military medical resources. We describe the most common United States/Coalition military operative interventions in pediatric trauma patients from Iraq and Afghanistan between 2007-2016.
Methods: This is a secondary analysis of pediatric trauma patients in the Department of Defense Trauma Registry. We report descriptive and inferential statistics comparing nonoperative versus operative casualties and perform multivariable modeling to assess associations and adjust for confounders.
Results: Over the study period, a total of 3,439 children were treated by US/Coalition Forces, among whom 2,540 (73.8%) patients required 13,824 operative procedures. Compared to the nonoperative group (n=989), the operative group were older (10-14 years vs 5-9 years, p<0.001), had a higher proportion of explosives (45% vs 36%, p<0.001) and firearm injuries (24% vs 16%, p<0.001), and had a higher median composite injury severity score (10 vs 9, p<0.001). The most common operative procedures were related to wound management, burn repair, orthopedics interventions, intra-abdominal repair, and specialty care. Multivariable analysis revealed that serious injuries to the extremities (OR 6.59), abdomen (OR 4.50), skin (OR 1.66), tourniquet application (OR 2.48), age-adjusted tachycardia (OR 1.44) were associated with requiring an operative intervention.
Conclusion: Most children required at least one operative intervention during hospitalization at deployed US Military Treatment Facilities. Likelihood of operative intervention was associated with serious abdominal, extremity, and skin injuries. Data on the required surgical care will aid in wartime and humanitarian mission planning.
KSA Maintenance In A Peacetime Environment: Where We Stand And How To Maintain.
Thomas Aubuchon - Naval Medical Center Portsmouth
Background: KSAs are the Knowledge, Skills, and Abilities deemed necessary for Naval medical personnel to ensure mission readiness. In order to ensure Naval medical personnel meet and exceed their operationally-focused KSAs, Navy Medicine is developing standardized enterprise-wide Naval Medical Readiness Criteria (NMRC), in support of readiness performance metrics. KSA fall into one of 3 categories: Category 1 – Core Practice/Clinical Currency – Fundamental training and skills, usually obtained through medical education and maintained through Medical Treatment Facility (MTF) experience and/or partnerships. This category of requirements links to the attainment of core practice, clinical currency, and KSA Threshold for medical personnel. However there is discordance between the skills we train for in peacetime against the requirements in the conflicts of war. Identifying approaches to remain proficient in critical skills is a challenge for Navy Medicine. (BUMED SSG Critical Skills Sustainment) However there is no information IRT current Navy physician comfort levels or current methods of skills sustainment.
Objectives: Determine the perceived confidence and impact of a KSA lab on the confidence in performing key medical procedures and staff perceptions of potential benefits of a KSA lab as a mechanism to enhance teaching and building teamwork.
Methods: Utilizing the KSA requirements established by the BUMED working group, a self-directed, mixed simulation task trainer/ cadaveric skills lab was created. A survey was devised from an iterative process, based on the framework by Schonnop et al, to incorporate current Navy Emergency Medicine KSAs. The survey was distributed in electronic format to EM staff immediately prior to and following participation in the KSA lab. Results are being downloaded and analyzed.
Results: Formal result calculations are pending with estimated completion within the month. However, preliminary results demonstrate significant variability in provider comfort levels and upwards of 80% feeling some level of uncertain in performing one or more emergent procedures. The KSA lab overall appears well received with positive marks in skills retention, value as an educator and in fostering teamwork.
Conclusion: KSA maintenance is absolutely critical for Navy physicians to remain operationally ready. The degradation of mission critical skills is therefore a top priority for Navy medicine. Our data hopes to provide insight into our current state, gaps and potential solutions.