The Role of REBOA in the ADF
Complex trauma management, especially in patients with severe non-compressible junctional, pelvic, and abdominal trauma, can be particularly challenging with combat casualties in austere environments. Up to 20% of fatalities are consequences of uncontrolled internal haemorrhage and can be potentially preventable.
The traditional approach to management of these types of injuries is surgical (resuscitative thoracotomy or laparotomy), which is not readily available in combat environments. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a minimally invasive technique utilising placement and inflation of an endovascular balloon in the aorta to temporarily control massive haemorrhage in patients with major trauma until definitive surgical treatment is available [1-4]. This would allow stabilisation of the critically injured patient until definitive surgical care can be provided (by obtaining haemorrhage control, and improving perfusion to the coronary arteries and brain), ideally within thirty minutes of the injury.
LTCOL Carl Hughes (US Army) initially described the concept of REBOA in the mid-1950s during Korean War. However, REBOA was not considered seriously in trauma management until about 2010 by COL Todd Rassmusen (US Air Force). REBOA has since been successfully used with London Helicopter Emergency Medical Service (HEMS) in pre-hospital setting. REBOA is being introduced to the UK and US military. The US Joint Trauma System (JTS) has recently updated their Clinical Practice Guidelines (CPG) for REBOA as a haemorrhage control adjunct.
REBOA is not yet available within the Australian Defence Force (ADF). However, the Surgeon General has demonstrated interest in introducing REBOA into the ADF. A decision brief is currently being drafted for the acquisition of REBOA kits. The US JTS CPG will be slightly modified for protocol of its use within the ADF. The final requirement in implementing REBOA within the ADF Services will be development of a strategy for training.
REBOA Training within the ADF
There are several options for REBOA training in the ADF, some of which are currently available, and some which are still in development. The most obvious is the utilisation of Real Environment Simulations, which include mannequins or animal models. However, there are constraints to using Real Environment Simulations including the associated costs, and the inability to replicate a combat environment where utilisation of REBOA will be warranted.
Developing an effective and sustainable training program is critical as:
- Each REBOA balloon is approximately US$3500 and single-use only, making training using conventional methods un-economical; and
- Training for REBOA needs to be team-focussed as well as individual-focussed.
- There are significant contraindications and complications associated with the use of REBOA, and its utility within the ADF needs to be considered on a case-by-case basis.
Our strategy is to develop a training platform based on the Reality-Virtuality Continuum.
We are working with the University of Adelaide Virtual Reality (VR) and Augmented Reality (AR) team to develop an appropriate REBOA training environment for the ADF. Initially, the objective is to develop a VR environment as a training tool for REBOA. Subsequently, we aim to expand the environment to AR and Mixed Reality (MR) platforms, to enable haptics, add environmental combat effects into the “virtual environment” to recreate the challenges found in the combat environment, and facilitate multiple users to allow team training. The use of holographic devices will significantly enhance the training experience of the treating team. Conceptually this can be further expanded to include other complex procedures and scenarios.
Project development is anticipated to have five arbitrary stages, which may evolve serially or in parallel (times are estimates only):
- Stage 1 = Development of a VR concept for REBOA without haptics with a single user [First half of year 1].
- Stage 2 = Development of a VR concept for REBOA without haptics with a single user including environmental combat effects [End of year 1].
- Stage 3 = Development of VR/AR concept for REBOA without
haptics with multiple users including environmental combat effects [First half of year 2].
- Stage 4 = Development of VR/AR/MR concept for REBOA with haptics in
combat environment with multiple users working as together as a team
- Stage 5 = Development of VR/AR/MR concept for other more complex
trauma (and non-trauma) procedures for education to military and
civilian personnel [Year 3 and onwards].
About the authors:
Abhilash is a Consultant Vascular Surgeon at Royal Darwin Hospital and Ashford Hospital in Adelaide, and a Medical Officer in the Royal Australian Army Medical Corps. He has completed his Fellowship in Vascular Surgery in early 2017, and will complete his Fellowship in General Surgery in 2018. He has also completed a MSc in neonatal respiratory distress syndrome, and a PhD in interspecies organ transplantation. He has a strong interest in management of major vascular trauma, and transplantation of solid organs.
Andrew is a Graduate of the Royal Military College, General Service Officer, full-time Army, in the Royal Australian Army Medical Corps. He has worked as a Ski Patroller in Canada and completed an Emergency Medical Responder course (minimum level Ambulance Certificate in Canada). Currently, he is managing the reserve members at the 3rd Health Support Company, Adelaide, as the 2IC. He is studying a Bachelor of Business in Finance at James Cook University (by correspondence) through the Army Tertiary Education Program.
- Pasley J et al. (2017). Resuscitative Endovascular Balloon Occlusion Of The Aorta (REBOA) For Haemorrhagic Shock (US Joint Trauma System Clinical Practice Guideline; published 06 Jul 2017).
- Smith S et al. (2017). The Future Of Resuscitative Endovascular Balloon Occlusion In Combat Operations. JRAMC (published 10 Aug 2017).
- Morrison J et al. (2014). Resuscitative Endovascular Balloon Occlusion Of The Aorta: A Gap Analysis Of Severely Injured UK Combat Casualties. Shock. 41: 388-93.
- Manley J et al. (2017). A Modern Case Series Of Resuscitative Endovascular Balloon Occlusion Of The Aorta (REBOA) In An Out-Of-Hospital, Combat Casualty Care Setting. J Spec Oper Med. 17: 1-8.
- Milgram P et al. (1994). Augmented Reality: A class of displays on the reality-virtuality continuum. Proceedings of Telemanipulator and Telepresence Technologies. 2351–34.