18. Optimal Methods of Teaching and Training DCR/RDCR

Ethan A. Miles^{1, 2} and John C. Maitha³

(1)

75th Ranger Regiment, US Army Special Operations Command, Columbus, GA, USA

(2)

Uniformed Services University of the Health Sciences, Bethesda, MD, USA

(3)

75th Ranger Regiment, US Army Special operations Command, Savannah, GA, USA

Ethan A. Miles

Keywords

TrainingTransfusionRemote damage control resuscitationPrehospitalMedical directionValidation

The practitioner of RDCR (remote damage control resuscitation) is tasked with taking a team sport (DCR) which is typically practiced by large well-trained teams in major medical centers and perform the key tasks in a remote and typically dangerous environment often by themselves with nothing but a small aid bag on their back. The prehospital provider may be a military medic, a civilian EMS paramedic, a wilderness search and rescue team, or a rural physician. Regardless of level of formal education, the majority of procedures and knowledge may be taught to most medical providers. If given quality training and medical direction, individuals can be expected to successfully provide the majority of the key components of RDCR in any environment.

The medical director must include four key components to allow the prehospital provider to practice: (1) training and education, (2) certification, (3) licensure, and (4) credentialing. The training and education of RDCR should be done with the ultimate goal in mind of credentialing the individual to perform the key components described in this chapter. Written and hands-on testing of RDCR is a key component in the process of credentialing and requires definitive goals in the performance of RDCR given the unique environment in which the individual provider is expected to perform. By setting specific goal directed steps, the student can clearly identify performance steps required for successful completion of the training. Given the severity of consequences and lack of alternate treatment in the resuscitation of patients with hemorrhagic shock in the remote setting, scope of practice tends to be much wider than typically encountered. Ultimately though, it is up to the medical director to determine the scope of practice given in RDCR to the practitioner.

Utilizing the crawl, walk, and run methodology allows the instructor to ensure the student has a solid understanding at each phase of instruction and allows for simple resets when knowledge gaps are discovered. In training RDCR, the crawl phase consists of developing a core basis of understanding of DCR as well as the development of the required procedural skills in a lab or classroom setting. The walk phase advances to the application of DCR principles into the student’s expected environment and how the skills learned may be utilized in their setting; decision-making should be emphasized at this point. The run phase recreates the student’s expected environment as closely as possible (i.e., in a helicopter at night, under simulated enemy fire, or in the back of an ambulance while moving) with timed scenarios designed to challenge both the knowledge gained as well as the actual skills application (i.e., multiple casualties with limited equipment in CCP-casualty collection point).

There are two goals of RDCR training. The first goal is to develop an adequate understanding of life-threatening hemorrhage (LTH), hemorrhagic shock and its consequences, components of RDCR, when to use the components of RDCR, and how they affect the patient. The second is to master the basics of TCCC and fully integrate RDCR principles into a standardized trauma patient primary assessment. When training RDCR in the initial education phase, great emphasis should be placed on how the physiology applies to practical application vs. an in-depth review of processes which do not directly impact decision-making in the field. The graphic below is an example of how the concepts of LTH, hemorrhagic shock, and oxygen debt [1] are taught at the 75th Ranger Regiment during RDCR training with specific emphasis on how to manage each pathway. See Fig. 18.1.

../images/453814_1_En_18_Chapter/453814_1_En_18_Fig1_HTML.jpg — Fig. 18.1

The RDCR treatment approach to delay the secondary effects of trauma

By gaining a solid understanding of how the principles of DCR apply to the casualty in the field, the student may then conceptualize the importance of each step in the process of RDCR.

Following the completion of the first goal of initial education of the lethal triad effects a focus on the primary trauma assessment should be started. Without mastery of a basic trauma assessment RDCR is futile. The purpose of the trauma assessment is to treat life-threatening injuries and then apply RDCR to treat the secondary effects of trauma.

Models for Training

Multiple models exist for utilization in training RDCR, and best-training practices typically combines the models to take full advantage of each. The main models currently utilized are task trainers, human patient simulators (HPS), live role players (LRP), live tissue training (LTT), and virtual training. While no single model provides a perfect training solution, a solid understanding of the benefits and downsides of each will help the trainer piece together the optimal training path for student success.

Dedicated task trainers such as IV arms and wound-packing simulators are best utilized during initial skills training in order to facilitate the student learning the physical steps of the procedure. During this step, students are often familiarized with a piece of equipment such as an IO device and instructed through the entire procedure. The second portion of training where dedicated task trainers are helpful is during the run phase where the individual skill has been mastered and the student needs a model to complete a particular step in the trauma lane and move on to focus on the RDCR portion. An example of this would be the utilization of a sternal IO trainer when using a live role player, thus allowing the student to perform the task as they would in a live patient without incurring the risk of performing an IO in a live role player.

The HPS provides a training model, which can be fairly appropriate for most tasks in RDCR training. In training RDCR, the advantages of an HPS include full size and weight (which pushes the student to use proper movement and hypothermia prevention techniques), realism of injury with newer models, and vital sign feedback without instructor coaching and allow the majority of the individual tasks to be performed on a single model. The downsides of the HPS tend to be technical reliability, time involved in setup/refitting, lack of variability in wound patterns, HPS operator proficiency, and a rapidly fading realism effect. The HPS is best used during the “walk” phase where the student is starting to bring together multiple steps of the assessment and intervention phase in RDCR. This allows the student to get multiple trauma lane runs in, which facilitates committing the key steps of the process in the right order.

Live role players (LRPs) provide an optimal model for a realistic training model in several areas. Distinct advantages include live patient feedback, accurate model for measuring vital signs, and obtaining vascular access with autologous blood transfusion If using a properly trained LRP , the student often pays much more attention to hypothermia prevention, safe realistic patient movement techniques, and pain control. Disadvantages of LRPs include a limited number of procedures you can perform; limited vital sign variability and injury patterns generally rely on moulage which has limited ability to replicate massive hemorrhage. LRPs are generally utilized best during the run phase and can significantly contribute to the chaos of MASCAL event training.

Live Tissue Training (LTT) , using animal models to recreate trauma models, provides several distinct advantages to include; absolute realism with hemorrhage control, live real-time physiologic feedback, ability to perform WB transfusions, and variability of real wounding patterns. Disadvantages include restriction of use, smaller patient size, anatomic differences, difficulty with integration into large unit level exercises, backside veterinary support and cost. While this training is often restricted, its value when combined with a comprehensive training program is significant. This type of training should not be utilized as a one size fits all, rather it should be utilized only after careful consideration of the goals of training and in conjunction with the models outlined above.

Human cadavers provide the highest accuracy for an anatomically correct training model. The cadaver provides an ideal model to learn anatomy and perform many key procedures such as IO placement, airway adjuncts, surgical airway, needle decompression, and chest tube insertion. The cost and sensitivity have a potential to significantly impact availability of use. Cadavers are typically best utilized during the crawl phase when the student is gaining a detailed anatomic understanding of injury patterns and lifesaving interventions.

When selecting models to use in training RDCR, care should be taken to match the models for the objectives. In the majority of training, a combination of models will be needed to train (and retrain) students as they refine their ability to run a trauma lane. By objectively grading at each phase, the instructor can utilize the best model to facilitate optimal training in area identified as a weak spot for the student. The chart below shows a simple diagram identifying individual model strengths and weaknesses to facilitate a proper combination for training based on what is available. See Fig. 18.2.

../images/453814_1_En_18_Chapter/453814_1_En_18_Fig2_HTML.png — Fig. 18.2

Training model strengths and weaknesses to maximize individual RDCR skill training effectiveness

Goals in RDCR Training

The first goal of training is the early recognition and intervention in LTH, which is the first step in the MARCH (Massive Hemorrhage, Airway, Respiration, Circulation and Hypothermia/Head Injury) process. Students should be taught to recognize injury patterns that pose a high risk for massive hemorrhage loss or continued noncompressible hemorrhage. Additionally, the provider should train on the management of the designated medical team as well as the management of nonmedically trained responders during this time.

The Crawl Phase

During the crawl phase students should complete multiple MARCH assessments while communicating to the instructor common injury patterns on casualties to engrain the algorithmic approach. The crawl phase can include verbal prodding from the instructor to facilitate emphasis and focus on injury patterns during each step of the casualty assessment.

The start of the crawl phase should emphasize the primary trauma assessment.
The Tactical Combat Casualty Care Guidelines and many military medics use the MARCH pneumonic to identify initial life-threatening injuries. The MARCH pneumonic is effective in the RDCR arena because it is designed to treat and identify the initial and secondary effects of trauma.
This phase should not be stressful to the student promoting a learning environment of question and answers between student and instructor.
The crawl phase should emphasize perfecting the algorithmic approach using the MARCH pneumonic, or equivalent, with numerous trauma assessments on other classmates absent injury or combat equipment. Multiple repetitions of the student touching or verbally implying where an appropriate intervention should be applied in the primary trauma assessment will build a strong foundation for DCR. Technical application of interventions for minor and complex wounding should be added during the walk and run phases. Perfecting the basic algorithmic approach without distractions will greatly increase the effectiveness of run phase as the instructor can focus on decision-making verses technique and sequence correction.
Skill stations or round robin style training should be utilized to cover in detail the capabilities of the equipment used to stop immediate life threats and provide instruction on implementing DCR interventions following treatments of initial life threats. See Table 18.1 for round-robin example.
An effective method to maintain proficiency and updated information on the latest medical developments for the MARCH primary survey is to review the Tactical Combat Casualty Care Guidelines. The guidelines are updated periodically with the latest medical literature and recommendations from deployed military medics. A free website to access updated guidelines, skill sheets, and videos can be found at www.naemt.org or you can download the free “Deployed Medicine” application for Android or iPhone devices.
If the DCR training course includes live tissue training (LTT), a tabletop block of instruction is required. The table top or wet lab block of instruction should cover indication, contraindications, and alternative methods for each procedure performed. Proctor standardization on a training model is highly recommended prior to the start of the tabletop instruction so every student performs individual procedures to the same standard. See Table 18.2 for example of a tabletop block of instruction.
An example training schedule for training initial trauma assessments and DCR can be found in Table 18.3.

Table 18.1

Example of an individual RDCR technical skill rotation

Time	Skill station – round robin
25 minutes	Intermediate airways
25 minutes	Buddy transfusion – blood
25 minutes	Junctional tourniquets
25 minutes	Hypothermia management
25 minutes	IV fluid warmer
25 minutes	Extremity tourniquets
25 minutes	Evacuation packaging
25 minutes	Peripheral saline lock
25 minutes	IO device insertion (sternal)
25 minutes	Monitoring devices – SP02, ETC02

Table 18.2

Example of a minor surgical skill training rotation utilizing LTT

Time	Table top task list
25 minutes	Surgical airway
25 minutes	Tourniquet application
25 minutes	Hemostatic application
25 minutes	Tourniquet conversion
25 minutes	Needle thoracentesis
25 minutes	Chest tube insertion
25 minutes	Intravenous access
25 minutes	Intraosseous infusion (nonsternal)
25 minutes	Lateral canthotomy
25 minutes	Blood transfusion

Table 18.3

Comprehensive training schedule to teach RDCR in 1 week

Day 1	Time	Event	Location	Instructor	Uniform
Crawl phase	0900–1000	TCCC updates			Field
	1000–1100	Deployment casualty AARs			Field
	1100–1200	Skill stations			Field
	1200–1300	Lunch			Field
	1300–1600	Skill stations			Field
	1600–1700	Pain management class			Field
	1700–UTC	Aid bag/equipment preparation			Field
Day 2	Time	Event	Location	Instructor	Uniform
Crawl phase	0800–0900	Trauma airway class			Field
	0900–1000	Thoracic trauma class			Field
	1000–1100	RDCR class			Field
	1100–1200	Blast/burns/crush management			Field
	1200–1400	Day trauma lanes – moulage			Body armor
	1400–1500	Lunch			Field
	1500–1700	Day trauma lanes – moulage			Body armor
	1700–UTC	LTT/equipment preparation			Field
Day 3	Time	Event	Location	Instructor	Uniform
Crawl phase	0800–0900	Animal care brief			Field
	0900–1000	Head trauma/hypothermia class			Field
	1000–1100	Orthopedic trauma			Field
	1100–1200	Spinal trauma			Field
	1100–1200	Proctor standardization			Field
	1200–1300	Lunch			Field
	1300–1400	LTT patient preparation			Field
	1400–1700	LTT tabletop instruction			Field
	1700–UTC	AAR			Field
Day 4	Time	Event	Location	Instructor	Uniform
Walk phase	0800–0900	K9 trauma management			Field
	0900–1000	MASCAL/CCP operations			Field
	1000–1100	Mission brief/planning/rehearsals			Field
	1100–1200	Lunch			Field
	1300–1400	LTT patient preparation			Field
	1400–1700	Day time trauma lanes			Body armor
	1700–1800	Range recovery/chow			Field
	1800–1900	LTT patient preparation			Field
	1900–2000	Mission brief/planning/rehearsals			Field
	2000–UTC	Nighttime trauma lanes			Body armor
		AAR following training completion			Field
Day 5	Time	Event	Location	Instructor	Uniform
Run phase	1200–1300	LTT patient preparation			Field
	1300–1400	Mission brief/planning/rehearsals			Field
	1400–1800	Daytime MASCAL exercise			Body armor
	1800–1900	Ranger recovery/chow			Field
	1900–2000	LTT patient preparation			Field
	2000–2100	Mission brief/planning/rehearsals			Field
	2100–UTC	Nighttime MASCAL exercise			Field
		AAR following training completion			Field