EMCrit Guest Post - The good, the bad, and the ugly of the Joint Statement on REBOA by Zaffer Qasim

by Zaffer Qasim

In December, a paper was published in a relatively new, open access journal entitled “Joint statement from the American College of Surgeons Committee on Trauma (ACS-CoT) and the American College of Emergency Physicians (ACEP) regarding the clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA).” This paper set out a number of recommendations for the use of this technique (for a quick refresher, see the discussions on this site and others).

The paper eventually came to the attention of the wider surgical and emergency medicine world. To say it set off a literal firestorm on social media and at medical meetings is an understatement. Rightly so – reading through the text of the publication highlights a multitude of overly prescriptive statements and limitations on an evolving procedure best implemented as a multidisciplinary effort.

Let’s look at this in more detail:

The Good

Is there a need for a statement at all?

The fact is that REBOA remains an evolving procedure. Even as I write this, I’m sure one or two new publications will appear on PubMed. The evidence is primarily observational – no RCT exists to clearly demonstrate survival advantages. There is no national guidance on appropriate utilization or even clear consensus on patient selection (for example some papers cite particular BP thresholds). REBOA is being performed only at a relatively small number of hospitals worldwide. Nevertheless, interest in this procedure is high, as is thus a risk of misuse and poor patient outcomes. Hence a statement is useful to help guide understanding on its safe use.

It’s not just about the procedure

At several points, the statement does highlight rapid access to definitive care, usually in the operating room. This links directly to something I keep emphasizing: REBOA is not just isolated to a procedure, you have to have a game-plan for what happens after the balloon is up. The reality is that the body does not tolerate prolonged ischemic times, especially with Zone 1 occlusion. I’ve seen it – these patients with prolonged occlusion survive their index operation only to die from multisystem organ failure later on the ICU. The risk of limb loss cannot be overemphasized either – there has to be a system in place to monitor for and manage limb ischemia following placement.

It is imperative then that responsible REBOA implementation occurs by appropriately trained practitioners within a system where delivery of the patient to definitive care in an expedient fashion is emphasized, all complications are understood, and appropriate modifications be made to anesthetic and critical care management following the index operation.

This last point is really important for those thinking of bringing REBOA to hospitals feeding into a level 1 center, especially as we move to the concept of partial REBOA – does your trauma system support this rapid transport? Just because we can do a procedure does not always mean we should.

Protocols are key

Protocols are critical to safe implementation at your facility. The joint statement points out that these should be developed in conjunction with vascular surgery…and that’s a good start but not enough. In order to roll this out safely, you need to collaborate with your team, and your team includes EPs, acute care surgeons, vascular surgeons, and nursing. Here’s an example of how we did this successfully at Christiana Hospital.

The Bad

In case you haven’t heard, hemorrhage control is a team sport

Major resuscitations are successful through being team-based endeavors, and this is especially true for REBOA. All team members should understand the proper conduct of the procedure and its limitations and potential pitfalls. This requires collaboration between EM, trauma surgery, and vascular surgery to develop protocols and assess system suitability of REBOA, ensuring the ability to deliver these patients to definitive surgical care in a near-immediate manner. To neglect to provide this instruction and isolate REBOA’s use to particular practitioners is to doom utilization to failure and invite complications.

REBOA is already being done by emergency physicians

The statement emphasized that emergency physicians without critical care training should not be placing REBOA. The fact is that outside the US, REBOA is often being placed by emergency physicians (and other non-surgical specialties) safely within appropriate systems of care. Both the Japanese and the British have clearly demonstrated this. In Japan, REBOA training makes up part of their emergency medicine curriculum.

You can’t train too much (but you don’t need a critical care fellowship!)

As with any procedure, training is required to understand the anatomy, indications and contraindications, procedural steps, and complications. This goes the same for REBOA. To belittle the ability of “regular” EPs to build on their existing skillset through appropriate training is completely inappropriate – it behooves EPs to learn life-saving interventions, even if rarely performed. Additional critical care training is not necessary. Civilian use overseas is by “general” EPs, and military REBOA use in deployed austere environments has been by EPs and general surgeons without critical care training. It is however crucial that quality be ensured and this is the responsibility of individual organizations through ensuring a robust peer review process.

There’s more than one way to skin a cat

While on the subject of training, the joint statement firmly stated that basic training consisted of completion of the ACS-COT Basic Endovascular Skills for Trauma (BEST^®) course. Citing only one proprietary training course that does not currently accept civilian EPs as the standard negates the role of other appropriately designed, inclusive military or civilian courses. I have been fortunate to observe and teach on several of these, and those that are 1-2 days in length provide the fundamental skills and knowledge required to build on a practitioner’s existing skill set to safely deploy REBOA.

I also highly advocate that attendance at a national course needs to be supplemented by local training incorporating interprofessional simulation. This is crucial to understand how this procedure fits safely into a center’s existing trauma or major hemorrhage response. This local training can also serve to maintain skills over time.

A fast way to a person’s aorta is through their common femoral artery!

The statement rightly says that the critical step to this procedure is accessing the common femoral artery (CFA). The interim analysis of the AORTA trial highlighted that 50% of the time this was achieved by cutdown – this has been cited as why this procedure should be done by surgeons, since groin cutdown is not thought to be in the remit of the EP.

The reality is that outside the US, EPs are primarily using ultrasound and direct percutaneous techniques to access the CFA. Ultrasound training has only recently started being incorporated into surgical training curriculums and has certainly not kept pace with the EM world. EPs also see critically ill and moribund medical patients, in whom skills can be maintained by placing CFA arterial lines when the need dictates. By no means are these lines easy, but they are within the skillset of the EP.

As for cutdown – I thought this was an important skill to learn when I trained to place REBOA because the truth is, sometimes that’s the only way to get to the CFA. This is a skill that can be taught to EPs also through appropriate training. In fact, when I went out to Paris last year to train their SAMU prehospital EPs on REBOA, we incorporated the modified cutdown technique they were already using for ECMO cannulation.

Brothers (and sisters) in arms

Military lessons learnt often inform and advance civilian trauma care. The joint statement did not adequately take into account the US military’s significant experience with REBOA, its comprehensive, evidence-based clinical practice guideline, or its pragmatic approach to skills development. Lessons learnt, such as the United States Air Force’s (USAF) Special Operations Surgical Team’s recent multidisciplinary team experience with REBOA as a viable option in mass casualty incidents, are relevant and timely to civilian practice. Any guidance proposed in civilian health systems should not inadvertently restrict the practice of military EPs and surgeons utilizing REBOA to save lives in austere environments or to continue to maintain their skills and train civilian counterparts within appropriate systems when they rotate back to the US.

“I don’t care how you get here, just get here (if you can)”

The section on “Transfer of Patients” minimizes the capability of some prehospital systems already involved in advanced inter-facility transfers such as extracorporeal membrane oxygenation (ECMO). There exists a significant burden of preventable prehospital death from torso hemorrhage. These cases do show up at smaller centers within a trauma network, where their management is challenging. Ultimately, as with other forms of hemorrhage control, REBOA will have a place here.

In the right system along with the anticipated evolution of REBOA procedural technique (e.g. partial REBOA), this topic requires further discussion between ACS CoT, ACEP, and the National Association of EMS Physicians (NAEMSP). Optimum use in transfer and primary scene response situations should be reviewed, with particular attention on assuring adequate system support to do so responsibly. As seen in the London HEMS system, this will ideally involve development within the hospital prior to taking this prehospital.

Words set in stone

The ultimate problem with papers like the joint statement are their downstream effect on hospital systems. Such statements run the risk of becoming standard of care at individual institutions, limiting utilization within systems where REBOA can be appropriately placed by a multidisciplinary team, and stunting growth in those wishing to progress.

The Ugly

As if the silo mentality between specialties wasn’t enough, and in particular the unnecessarily broad restrictions placed on EM, this paper came out. I personally think that my very skilled non-physician prehospital colleagues have a role in all forms of hemorrhage control, including REBOA. However, you’ll note that some of the authors on this paper promoting training and use by non-physicians are the same as have written the joint statement, in particular comments such as EPs without critical care fellowship should not place REBOA and that prehospital provides are unable to appropriately manage and troubleshoot the devices during transport.

That sounds conflicting to me…and if nothing else underpins the need to revisit and revise this joint statement. This revision needs to include input from multidisciplinary specialists who are very familiar with and have done the procedure and have a clear understanding of the current literature. To exclude input from and limit training and use of a rapidly evolving technique to only a subset of resuscitation practitioners is extremely short-sighted.

At the end of the day we’re all in this together.