By Suzanne Ovel, Regional Health Command PacificJuly 2, 2019
MADIGAN ARMY MEDICAL CENTER, Joint Base Lewis-McChord, Wash. -- Surgical research at Madigan Army Medical Center directly contributed to new trauma medical procedures to address the top cause of battlefield deaths -- abdominal bleeding due to blast injuries.
The study on how to more effectively use a balloon inserted into the aorta (called a resuscitative endovascular balloon occlusion of the aorta device or REBOA) to stop hemorrhaging from the abdomen first published in May 2018 and its results were translated into the Department of Defense's Joint Trauma System's clinical practice guidelines just five months later.
"The best evidence available, albeit pre-clinical, is being used to guide current human studies as well as recommended battlefield practices, (and it) comes directly from the research team's project studying intermittent REBOA aortic occlusion. Our lab's results are now the basis for recommended battlefield practice," said Lt. Col. (Dr.) Matt Eckert, Madigan's trauma medical director and co-director of Madigan's Surgical Research Program, and one of the study's researchers.
While hemorrhaging has always been the No. 1 killer in conflicts, battlefield medicine evolved to become much better at controlling bleeding from extremities, according to Capt. (Dr.) John Kuckelman, who led the REBOA study.
"We're good at stopping bleeding from the appendages but anything that is bleeding in the abdomen is still very difficult for us to control, so it remains the number one killer of our Soldiers," said Kuckelman, a Madigan surgery resident. "The REBOA is probably the best answer to that question right now."
The military's forward surgical team began using the device five years ago, with at least 20 patients since then receiving the device in pre-hospital settings.
"It's really kind of changed our management of trauma," said Lt. Col. (Dr.) Daniel Cuadrado, Madigan's deputy chief of surgery and chief of cardiothoracic surgery; he also teaches providers how to use the REBOA device and studies it as well. "The old-fashioned way to get control of someone who's bleeding or is arrested, is to open up their chest and put a cross clamp on their aorta. It's very effective, but especially when we're in a forward or austere environment, if it's very cold outside or if you're in the back of a helicopter transporting a patient, that hyperthermia kills. It's giving us a different way of managing and looking at these patients. You can potentially do a catheter in their leg and have the ability to cross clamp their aorta without opening up a body cavity."
A potential pitfall to the previous protocol for the REBOA device -- to keep it inflated until surgery can be performed -- is that after 40 to 60 minutes, the same lack of blood flow to the abdomen that keeps the patient from bleeding out also builds toxins in the tissues that are now blood-deprived; once the device is removed, the toxins are then released into the bloodstream as well. With transport to the next level of medical care downrange averaging two to four hours, the risk of serious damage to vital organs is a real concern.
"Our problem that we faced, or the question that we wanted to answer was, what are some ways that we can use this that are simple in a battlefield setting that will help mitigate the issue of tissue death?" said Kuckelman.
That's exactly what his study examined, using an intermittent approach to inflating the balloon in the device to allow limited blood flow to keep tissues alive; the regiment of 10 minutes up and 3 minutes down resulted in extending the safe use of REBOA for up to two hours. The research team purposely sought to set up a method that works with the limited medical supplies that might be on hand in a combat setting away from a medical facility to help ensure greater success of this practice.
Although the goal of most medical research is to eventually make a direct impact on the care patients receive, the quick timeline of this study's influence on downrange medical practices is quite unique.
"We're really very proud of this; this is probably one of the biggest accomplishments that have come out of our research lab that directly affects the way that we care for Soldiers," said Kuckelman, who said Madigan studies on REBOA are the most innovative when it comes to a point-of-injury field focus. "This is why we do the research to make things better for our Soldiers downrange, and for it to be used in that way is the best possible outcome for this research."