CSSALT conducts simulator-based study of virtual coaching for REBOA insertion and placement

In some medical emergencies, the time it could take to transport a bleeding patient to an operating room could mean life or death.

A technique called REBOA, or resuscitative endovascular balloon occlusion of the aorta, is used to manage internal hemorrhage mainly in the abdomen and pelvic region. In patients who are non-responsive to adequate resuscitation measures and at risk of imminent cardiac arrest, the flexible REBOA catheter can be inserted into the femoral artery, a major artery in the thigh. The catheter is maneuvered into the aorta and a balloon at the tip is inflated to stop bleeding.

Doctor Acar showing a resident a R-E-B-O-A catheter

But teaching the REBOA technique can be time consuming and challenging, particularly because an experienced trainer is needed, and existing simulators are not always easily accessible.

Now, using their own open architecture development platform called SMMARTS (System of Modular Mixed and Augmented Reality Tracking Simulators), UF mechanical engineering students in a design course and engineers with the Center for Safety, Simulation & Advanced Learning Technologies (CSSALT) have built a new simulator-based REBOA training featuring a virtual coach. It was built under the supervision of Sean Niemi, Ph.D., an assistant professor in the Department of Mechanical & Aerospace Engineering; David Lizdas, Travis Johnson, and Anthony DeStephens, CSSALT simulation engineers; and Yahya A. Acar, M.D., a CSSALT simulation fellow.

As part of the ongoing study comparing the efficacy of the virtual coach with a human instructor, UF Health surgery residents had the opportunity to participate in simulator-based REBOA training in early September under the direction of Robert S. Smith, M.D., RDMS, FACS, professor and trauma medical director in the Department of Surgery, and Acar, who is the principal investigator on the project. After the UF phase of the study is completed, the study will continue at Madigan Army Medical Center in Washington.   

The mixed-reality simulator allows trainees to practice REBOA catheter insertion and placement with the help of realistic anatomical models and virtual ultrasound guidance.

A key advantage of a virtual coach is that once the system is fully validated, trainees can independently learn the technique on the simulator without a trainer, saving time and resources.

Surgery resident practicing on the R-E-B-O-A simulator

“One of the hardest challenges in teaching REBOA is finding an experienced trainer and finding time to make it a regular hospital-wide training,” Acar said. “A regular user can set up our turnkey simulator in seven minutes. Its padded transport case meets airline checked luggage restrictions and it can be shipped anywhere, including to the frontline.”

The virtual coach not only trains the learner, but also assesses their learning. “We are not just making a simple assessment but training to mastery learning,” Acar said. Mastery in REBOA insertion is defined as two consecutive successful REBOA catheter insertions in four minutes without any complications.

In many situations, patients have to wait to reach an interventional radiologist, making it important to expand the availability of the training. The simulator is in the prototype phase, but after the system is fully validated, it is expected to be a cost-effective training method that allows for teaching nurses, interns, and other medical professionals.

Acar had been interested in REBOA before coming to UF in fall 2020 and built the simulator with other CSSALT engineers over the past year. They were able to create the system so rapidly in part thanks to the SMMARTS platform created at CSSALT. SMMARTS facilitates simulation learning by providing open architecture and a modular design, helping clinicians and engineers focus on specific content tailored to learning objectives rather than back-end tasks.

As a military emergency medicine physician who trained in Turkey, Acar knows firsthand how important the REBOA technique is, especially for limited-resource settings and in situations when patients are unable to reach interventional radiology or a designated operating room.

“I saw many patients die in emergency services with pelvic hemorrhage,” Acar said. “You can provide REBOA catheters, but if there is no adequate training for all associated staff, it has reduced value. Recently, there are data that REBOA can be applied as an advanced cardiac life support (ACLS) adjunct for non-traumatic cases. In traumatic or non-traumatic emergency situations or military settings, I believe the REBOA technique and a widely accepted cost-effective training have a great potential to save lives.”