A recent joint statement by the American College of Surgeons Committee on Trauma and the American College of Emergency Physicians has raised questions about which physicians are best suited to implement resuscitative endovascular balloon occlusion of the aorta (REBOA), pitting emergency physicians against their own college and against the panel of surgeons and emergency physicians that wrote the statement. (Trauma Surg Acute Care Open 2018;3:1; http://bit.ly/2GLIY3H.)
Even after ACEP's president released a statement intended to smooth over EPs' objections, the controversy remained largely unresolved when the ACS COT/ACEP panel stood by its initial recommendation that REBOA not be performed by emergency physicians without critical care training.
REBOA requires at least two people to implement in patients bleeding to death from noncompressible injuries to the chest, abdomen, or pelvis. It involves placing a flexible catheter into the femoral artery, moving it into the aorta, and inflating the balloon at its tip, halting blood beyond. It is a bridge to keep the patient alive until he can receive surgery or interventional therapy in a suite designed for it.
The technique has the advantage of being less invasive than a resuscitative thoracotomy, and skilled hands may apply it more rapidly, the panel noted, adding that “acute care surgeons can learn and safely perform REBOA after a formal training course.” The statement also said REBOA is standard of care for certain patients at a small number of trauma centers where surgeons are immediately available.
The panel wrote that an acute care surgeon must be immediately available to address complications such as arterial disruption, dissection, pseudoaneurysms, hematoma, thromboemboli, and extremity ischemia. These problems have to be repaired, requiring patches, complex arterial reconstruction, bypasses, limb ischemia, and amputation. It is also possible, they said, that the balloon could burst when it is inflated larger than the aortic diameter, and inflating it accidentally in the iliac vessels may lead to rupture or clot formation. If the aorta is blocked for a long period, fatal complications or injury to the spinal cord is possible because of prolonged ischemia to an organ, they wrote.
The group acknowledged that recent improvements that resulted in smaller femoral access sheaths could reduce adverse events associated with accessing the femoral artery, but they warned that limited high-quality evidence guides the use of REBOA. That, combined with the substantial risk of complications, required a statement that took these issues into account, and appeared to lead to the panel's recommendation limiting who should perform REBOA. The group advised:
- REBOA should be performed by an acute care surgeon or interventionalist (vascular surgeon or interventional radiologist) trained in REBOA. An acute care surgeon must be available to treat the immediate cause of the hemorrhage to prevent ischemia associated with blocking the aorta.
- Emergency physicians with added certification in critical care and trained in REBOA may train and perform the technique in conjunction with an acute care or vascular surgeon who is also trained. The surgeons must be immediately available to control the bleeding at its source.
- Emergency physicians who were trained in REBOA and used it during military deployment may perform REBOA along with an appropriate surgeon trained in the technique and who is immediately available to control the bleeding.
- Emergency physicians without critical care training should not perform REBOA.
- REBOA should not occur in emergency departments where patients cannot receive definitive surgical care, meaning that the writing team does not think that transport can be life-saving.
Response to the statement was swift and heated. Steve Carroll, DO, MEd, an assistant professor of medicine at Emory University and Grady Memorial Hospital, said he immediately had a negative response when he saw the statement. He criticized “ACEP agreeing with ACS” that EPs couldn't perform REBOA without training in critical care in several tweets: “Way to sell out your members who are perfectly capable of being trained in this, ACEP,” he wrote on Twitter, later adding that emergency physicians “need to stop thinking we always need to play nice in the sandbox with other specialties on clinical guidelines. It's incredibly harmful to us in chest pain. This isn't helpful with trauma.”
“I don't know the origins of the statement at all,” he told EMN. “I am a relative bystander, but I was minding my own business at home one evening when I saw it and had a visceral reaction. I'm not a REBOA expert, but to say you cannot perform it unless you have critical care training rubs me the wrong way.”
The stringent training criteria for emergency physicians was the sticking point for Dr. Carroll, who blogs at http://embasic.org/. “I agree that this is not something a community emergency physician should do, but to say blanketly that emergency physicians should not do it is absurd,” he said. “I want to get further training, but this statement cuts me off at the knees.”
He said he agreed that the technique should not be done at community hospitals at this time, but that he could see that further research might define ways to reduce the time for transfer.
Justin Hensley, MD, an emergency physician at Baylor College of Medicine who blogs and tweets as @ebmgonewild also tweeted, “Like thoracotomy, cricothyrotomy, and any other procedure, anyone trained to do [it] should be able to. REBOA isn't just for critical care docs.”
REBOA can be life- or limb-saving when a nontrauma emergency center is part of a robust trauma system that can move patients to an operating or interventional suite quickly, said eight emergency physicians led by Bryant K. Allen, MD, of Carolinas Medical Center in Charlotte in a letter to the editor to the same journal. (Trauma Surg Acute Care Open 2018; http://bit.ly/2DI1R4q.) They also objected to the requirement that emergency physicians be trained in critical care to use the technique. “REBOA requires rigorous ‘specialized’ training, not fellowship training. It is ACEP's responsibility to defend this position,” they wrote.
They also said the college should support recommendations for a full-fledged and rigorous training program, adding that even many military EPs are struggling for ongoing trauma experience and may not have the training to which the writing group refers in its statement. A complete program from ACEP will be “how the house of medicine builds a robust trauma care system that saves lives,” they wrote.
A second letter noted that the writing group did not include representatives from the U.S. military's Joint Trauma System, and did not cite that system's studies of how to prevent hemorrhagic deaths in the field or how to develop the smaller endovascular sheaths that make REBOA easier. (Trauma Surg Acute Care Open 2018; http://bit.ly/2FQlj57.) “The working group asserts that military general and trauma surgeons ‘should’ and military emergency physicians ‘must’ take a proprietary ACS course before they can attempt REBOA,” wrote Joseph J. DuBose, MD, of the University of Maryland Medical Center; Todd Rassmussen, MD, of the Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center; and Michael Davis, MD, of the Defense Combat Casualty Care Research Program at Fort Detrick.
“Furthermore, military emergency physicians must have an acute care surgeon present prior to attempting the procedure,” they continued. “Both statements are unduly prescriptive and fail to address the fact that the initial effectiveness of REBOA in deployed settings was not achieved by fellowship-trained trauma or vascular surgeons, but by general surgeons, emergency physicians, and anesthesiologists without critical care certificates.”
The letter also said the U.S. military has consistently found that “an inclusive, team approach, guided by standard operating procedures and practice guidelines, is more useful in deployed settings than arbitrary rules based on specialty interests,” and it cautioned that “overemphasis of needed certificates could limit the use of REBOA and other endovascular procedures to only fellowship-trained endovascular surgeons and interventional radiologists, a move that would be antithetical to the premise to save lives in the ‘pre-operating room’ setting.”
ACEP Clarifies Position
Two letters to the editor that appeared in the journal and comments made on Twitter alerted ACEP President Paul Kivela, MD, MBA, to concerns among his colleagues. Dr. Kivela told EMN, after discussion with and input from at least 100 others in ACEP, ACS COT, the National Association of EMS Physicians, the U.S. Uniformed Health Services, researchers, and current users of REBOA, that ACEP leadership reevaluated the statement and the issue, and “will continue to advocate to clarify that [emergency] physicians with sufficient training who work in coordinated trauma systems are capable of and should be eligible to perform the REBOA procedure.”
He said a letter from ACEP and the ACS COT was accepted by Trauma Surgery & Acute Care that includes a statement that the two colleges “support a team approach including emergency physicians and surgeons who have sufficient training for REBOA placement.”
That letter has not been published or appeared on the journal's website at press time. Debra G. Perina, MD, and Christopher Kang, MD, the two emergency physicians on the panel that wrote the statement, did not respond to repeated requests to discuss it.
The statement panel also responded that they had aimed “to keep focus on the patient safety in the use of this device. We believe there is insufficient evidence to support the widespread adopting of REBOA in both civilian trauma centers and non-trauma centers where there is no immediate access to definitive hemorrhage control.” (Trauma Surg Acute Care Open 2018; http://bit.ly/2HRTNR7.)
They noted that they do not know how long the aorta can be occluded or how long is reasonable for transport from one emergency center to a hospital with an appropriate operating or interventional suite. While emergency physicians can be trained to introduce the catheter, “more appropriate questions are, even if taught to place it, under what clinical, ethical, and system-based circumstances should it be placed at all?” They called current REBOA literature “equivocal,” with some studies showing survival benefit and others that it may worsen mortality. “We recognize that these recommendations are inconvenient and demanding for surgeons and require some professional self-restraint by emergency physicians.”
The panel, in responding to the letter from the team led by Dr. DuBose, twice said they stood by the original statement, taking care to praise military advances and personnel who brought REBOA to civilian practice. “We stand by the recommendations and fundamental message of this document which seeks to ensure patient safety with implementation of this new tool in injury care.” But they ended their response to the criticism with this: “We support an inclusive team approach including emergency physicians and surgeons who have sufficient training for REBOA placement in patients cared for in well-developed, coordinated trauma systems.”