REBOA is being used more frequently as part of the EVTM concept of using minimally invasive methods of resuscitation and bleeding control. With increased use of REBOA, there is increasing debate about “who should be performing REBOA?” (12-16). This study shows that both surgical and non-surgical physicians are successfully performing REBOA, with it being performed mainly by EM physicians followed by trauma and vascular surgeons. However, there were significant differences in patient characteristics between the two groups. Patients treated by non-surgeons were older and more severely injured. The explanation for these differences is not yet clear and could be multifactorial. One reason could be that in some participating centers, surgeons may not be continuously involved in the management of trauma patients in the ER, for example the majority of Japanese ERs do not have trauma surgeons (19). EM physicians may therefore often take the lead in urgent trauma situations with severe injuries. EM physicians usually treat a wide range of patient age groups and diseases. In some countries, trauma surgeons usually treat adult patients, often without associated comorbidities, although this is now changing. In the settings where no surgeons are involved in the ER management and REBOA procedures are performed by surgeons in the OR when needed, patients who arrive to the OR need to survive the ER stage before being treated by surgeons. This might be one reason why patients with REBOA performed by surgeons are less severely injured, younger (see Figure 1) and have a lower mortality. Another probable reason, as confirmed by our results, is that surgeons who are available in the ER may decide quickly to transfer the patient to the OR for surgery. This reduces the time the patient spends in the ER. There is clear evidence that short time to definitive bleeding control reduces mortality (20, 21). The lower mortality in the surgeons group should not be overrated, since this is the unadjusted mortality and, due to the younger age and lower ISS of patients, a higher rate of survival is to be expected. The same apply to the lower rate of overall complications in the surgeons group, which could be caused be the younger age, the lower ISS, less comorbidity or rather by more experiences in invasive measures, early addressing potential complications and their treatment. These data should, therefore, be cautiously interpreted in the discussion concerning “Who should be performing REBOA?”.
Independent of the medical specialties performing REBOA, all centers participating in the ABOTrauma registry were prepared before treating the first patient with REBOA. The preparation phase was almost similar in most centers including:
- Organized workshops prior to initialization of the procedure
- Familiarization with the equipment and developing ultrasound skills specifically to be able to identify the femoral vessels and to perform ultrasound guided insertion of the needle.
- Theoretical presentations on issues regarding REBOA such as when, where, and how to perform the procedure, pitfalls, and complications.
- Several centers attended the REBOA/ EVTM workshop of the University of Örebro (Sweden)
- Some centers use commercially available REBOA simulators (like the RATT Pulsatile Simulator, REBOA Access Task Trainer), to coach the staff and keep a high-performance level.
Regardless of the medical specialty or the trauma center performing REBOA, a key step to successfully save trauma victims is proper training, being prepared with knowledge and continuous education, and being familiar with equipment and setting (22-25). There is no shortcut to success and ”You don´t rise to the occasion, you sink to the level of your training!” (Archilochus - Greek lyric poet) and that’s regardless of the medical specialty.
EM physicians, anesthetists, surgeons (trauma, vascular, general), and interventional radiologists can be involved in the immediate and direct care of trauma patients, depending on the setting and trauma team procedures. EM physicians and/or anesthetists control airways, respiration, and hemodynamics to gain time and allow a definitive procedure to be performed by surgeons or interventional radiologists to stop the bleeding (19). EM physicians, anesthetists, vascular surgeons and interventional radiologists routinely place sheaths, a technique that is necessary in REBOA. It is, therefore, not surprising that REBOA is performed by all these various medical disciplines. In contrast, other than in Japan, the majority of studies have reported that REBOA was performed at level 1 trauma centers by trauma surgeons who were trained in REBOA or who were experienced in vascular surgery (26-28). Surgical exposure of the CFA is an essential skill needed for the successful use of REBOA if percutaneous access fails (4). Early American clinical experience demonstrated that almost half of the patients required surgical cut-down for vascular access. With increased experience over time, subsequent studies have shown more successful percutaneous access (29, 30). Our study, similar to others, has shown that surgical cut down is used less frequently and that use of external anatomic landmarks and palpation alone to puncture the CFA has a high rate of success (3). This could be related to the availability of smaller and guidewire-free REBOA catheters such as the ER-REBOA™ catheter (Boerne, TX, USA), which is compatible with many 7 Fr sheaths. Emergency physicians and anesthetists are familiar with percutaneous ultrasound-guided CFA cannulation, which can avoid the need for surgical cut-down (4). The reduced profile of new devices will likely increase the use of REBOA by non-surgeons. This is because REBOA has a wide range of possible indications besides trauma, such as cardiac arrest, post-partum hemorrhage, non-trauma related intra-abdominal hemorrhage, and trauma in the pre-hospital setting (3, 4, 9, 10, 31-33). In addition, closure after a low profile REBOA device is possible either with percutaneous technique or just pressure bandage, making open surgical techniques for introducer removal optional.
In this study, REBOA was performed in the ER in about 50% of cases, in the OR in about 40% and in the AS in less than 10%. REBOA is considered to provide a bridge to definitive hemorrhage control and patients who have received REBOA in the ER should be quickly transferred to the OR or AS for definitive bleeding control procedures. Furthermore, a hybrid theatre can be an ideal environment to address these complex situations with the need for more than one therapeutic modality (34).
Since trauma care is multidisciplinary, the discussion regarding “Who should be performing REBOA?” is not central. REBOA should be a team approach involving all members of the trauma team. This will vary in different settings depending on training, experience, availability of trained staff, proper equipment and availability of blood products and clotting therapy. Each hospital has a responsibility to define the indications, setting, technique, and process, including “When, Who, Where and How”.