Mentoring significantly increased nonsurgeon procedural confidence when asked if damage-control laparotomy was a realistic task for them to perform (p = 0.030), if they felt confident in their current abilities to perform a damage-control laparotomy (p = 0.004), and if damage-control laparotomy would be less dangerous for the patient than beneficial in their hands (p = 0.004) for the RTM MedTechs compared with the UTM MedTechs. Surgeons were significantly more confident in their current ability to perform a damage-control laparotomy when compared with either RMT (p = 0.002) or UTM (p = 0.004) groups. The telementored group also felt strongly that telementoring was beneficial. When asked if they would want to be telementored again if they were asked to perform another laparotomy or if telementoring would increase their confidence when performing another laparotomy, subjects strongly agreed, answering a median of 5 of 5 on a Likert scale. When asked if telementoring would decrease their stress when performing another laparotomy, mentored subjects felt it would help, answering a median of 4 of 5 on the same scale (Table 2).
The Cut Suit is an anatomically accurate simulator that can be safely worn by humans and allows for the performance of a variety of complex, realistic surgeries and procedures as encountered in real casualties.24 After a relatively brief period of instruction, all nonsurgically trained military MedTechs were able to understand the basic principles and steps of a damage-control laparotomy and were able to perform one using a Cut Suit with simulated massive hemorrhage. Furthermore, after the completion of a surgical packing task, there was no significant difference in postpacking fluid loss between any group, implying that if a novice responder can access the site of hemorrhage, then an effective but radical prehospital intervention might be provided.
Thus, theoretically otherwise unsurvivable casualties with no other treatment options might be offered such as a lifesaving intervention (LSI), considering that the most recent review of Canadian Forces deaths in Afghanistan automatically deemed all cases of torso exsanguination “nonpreventable.”25 The Trauma Hemostasis and Oxygenation Research (THOR) Network has defined an LSI as a medical procedure that if not performed conveys a high probability of morbidity or death,11,26 with the terms far-forward and austere denoting environments in which professional health care providers do not normally operate.11 Delayed evacuations refer to situations in which evacuation times exceed 60 minutes and prolonged for more than 6 hours from point of wounding until arrival at a medical treatment facility capable of providing damage-control surgery.11 The current reality is that the wounded warriors of the future will increasingly be seriously injured in far-forward locations, facing prolonged or nonevacuations, being cared for by motivated but nonsurgically trained providers, yet requiring LSIs (most commonly for hemorrhage control) if they have a hope of survival.
Great strides have been made through the introduction of RDCR techniques and philosophies in recent years,11 with major advances in resuscitative techniques that a far-forward damage-control laparotomy might not be unthinkable. Chaudery et al.29 recently reviewed the current technologies potentially available in the prehospital setting to enable abdominal hemorrhage control in catastrophic hemorrhage, noting that most studies were preclinical in vivo trials. Of the potential techniques, specifically intra-abdominal foam injection30–32 and resuscitative endovascular aortic balloon occlusion,33,34 were considered as attractive candidates.29 Chaudery et al. notably did not consider prehospital open surgical interventions as a potential option despite noting that “manual force is one of the most effective means of controlling bleeding.” However, as early as 1983, NASA think-tanks identified the ability to perform laparotomy as the minimum desirable surgical capability to save lives before transfer to earth, arguably one of the most dramatic prehospital settings.35,36
In the present study, there was no difference in fluid loss between nonmentored MedTechs and surgeons; however, there was greater fluid loss in those being mentored. This was likely related to the technical settings of the Cut Suit, which has a versatile fluid loss capability. Thus, the selection of a 12 psi (82.74 kPa) hemorrhage rate, while accurately replicating conditions of exsanguination, was conducted at supraphysiologic pressures, greatly exaggerating any effect of delay, even appropriate delay, on fluid loss parameters in any group. We thus speculate that the mentored group had greater fluid loss because of the brief but inherent nature of a two-way communication between the mentor and the mentee. So while this delay likely explains increased fluid loss, the increased confidence that the mentored MedTechs reported was notable. Preliminary data still being fully analyzed noted that the while the RTM MedTechs demonstrated stress levels similar to those of the surgeons, the UTM MedTechs had significantly higher stress levels as indexed by the low frequency–to–high frequency ratio of heart rate variability (Jocelyn Keillor, personal communication, February 1, 2014). Therefore, one of the greatest benefits of the telepresence of an experienced and presumably emotionally distanced expert may be to bring reassurance and confidence to a far-forward responder, who will often unfortunately be extremely emotionally close to the victim.
The information technologies used were simple “off-the-shelf” software with two-way audio and one-way video display as this was a proof-of-concept study. The Skype proprietary “closed source” software is protected by multiple systems to address security and privacy.37 All information is sent over secured socket layer that uses 256-bit Advanced Encryption Standard (AES) for all the information, leaving a transmitting computer that can only be decrypted by the Skype server. Nonetheless, greater encryption will typically be required for special operations. It is only logical that ever greater information and encryption capabilities will continue to expand in the future. The same can be expected of the degree of communication richness between the mentor and the mentee. The mentored MedTechs could only hear the remote mentor. There are rapidly evolving technologies in which the mentor may in the future by able to telestrate38 on displayed images such as anatomy demonstration on a heads-up video display39 worn by the MedTech for instance.
There are limitations to this study. We were not able to measure iatrogenic injuries as a result of improper laparotomy techniques. Therefore, this may have biased the study against telementored medics. More “simulated blood loss” was observed in the telementored group, as these medics took longer to open the abdomen and pack the solid organs. While the Cut Suit currently will demonstrate gross inadvertent bowel injuries and advances in the materials and construction of the model is constantly progressing, mammalian tissues are still perceived to be more susceptible to inadvertent injury. Thus, future complementary studies may be considered in animal models, where the outcome of interest is not only time to task completion and successful solid organ packing but also iatrogenic injuries to the bowel or other visceral structures.
In conclusion, perihepatic packing of an exsanguinating liver hemorrhage simulation was readily performed by military MedTechs after a focused briefing without obvious performance differences compared with trained surgeons. While real-time RTM did not improve study outcomes, it significantly increased nonsurgeon procedural confidence, which may increase the feasibility of the concept in actual operational application.
We thank Major Barbaraanne Besenyodi, Major Douglas Kromrey, Master Warrant Officer Danyal Beale, Warrant Officer Paul Trudel, Warrant Officer (Retired) Patrick Papineau, Dr. Brett Mador, Dr. Michael Kim, Dr. Jacinthe Lampron, and Dr. Paul Cantle for supporting the study.
This research was primarily funded by the Canadian Forces Health Services with support from the Royal College of Physicians and Surgeons on Canada. A.W.K. was the principal investigator of a randomized trial on open abdomen management funded by the Kinetic Concepts Corporation. A.W.K. has received travel reimbursement to attend laboratories from the Innovative Trauma Care, Synthes, and Life Cell Corporations and the donation of a NannoMax portable ultrasound machine for unrestricted research purposes from the Sonosite Corporation. J.L.M. is the research director of Innovative Trauma Care, Edmonton, Alberta, Canada. K.L. is the executive vice-president of Strategic Operations, San Diego, California.
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