All posts by TheTraumaPro

REBOA At An Academic Trauma Center

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is the big thing these days. I’ve written about this topic in the past, and a number of centers continue to refine our understanding of this new(er) tool.  A recent paper from the University of Florida – Gainesville outlines their experience in implementing this procedure at an academic Level I trauma center.

This trauma program is staffed by a group of surgeons who have considerable experience in guidewire-based skills, fellowship or military exposure, and/or completion of a vascular fellowship. One surgeon attended a trauma endovascular skills course (6 hrs).  An internal education program with a 1.5 hour slide presentation and some hands-on simulation training was developed. All surgeons and residents completed this program.

A retrospective review of their experience from June 2015 to March 2017 was carried out on unstable trauma patients due to hemorrhage. All cases were performed in a hybrid OR with imaging capabilities. A 12Fr REBOA catheter was initially used, but was changed to 7Fr once that catheter became commercially available.

Here are the factoids:

  • 16 patients underwent REBOA in this 22 month period; mean SBP was 97 torr and mean ISS was 39
  • Hemodynamic status improved in 10 of 16 patients to a mean SBP 132
  • 14 survived the initial operative procedure, but only 6 survived to hospital day 30. It appears that all of these patients were neurologically normal (GCS 15+0).
  • 1 survivor developed a common femoral artery pseudoaneurysm
  • The authors made the interesting comment that they also performed 8 ED thoracotomies (EDT) during this period and that there were no survivors
  • The authors concluded that the procedure was beneficial, that extensive training was not needed, and that it should be available trauma centers

Bottom line: But not so fast! This was a very select academic Level I center. The surgeons had extensive wire skills and vascular experience. All procedures were performed in a hybrid room, which is a very controlled OR setting. And they only performed REBOA every 6 weeks or so. 

REBOA is still an advanced procedure, and the average trauma surgeon would probably benefit from some more intensive training to ensure adequate initial skills. But if the surgeon can’t then maintain their skills via somewhat regular practice, errors may creep in. In a group of 6-8 surgeons, each may only get to perform the procedure once a year! Add in some interested emergency physicians, and no one can keep in practice.

The bit about ED thoracotomy is a bit of a red herring. Typically, this procedure is performed once the patient has lost their vital signs. Comparing mortality from REBOA with EDT here is not valid, because it appears that most of the REBOA patients in this study still had vital signs when it was inserted. It would be interesting if the authors shared the outcomes in the REBOA patients who had the device inserted after arrest to level the playing field with EDT.

So what to do? Be cautious and thorough if you are planning to try out REBOA at your center. Do the math. On how many patients per year can I expect to perform this? How many physicians want credentialing to do it? How many procedures can the typical physician expect per year? What is the baseline level of physician training and what additional training is needed? Will I report my experience to a national registry or write it up for sharing?

These are important questions! Everyone wants to play with the newest shiny toy in the toybox. But make sure that when you do play with it, you are able to provide the maximum benefit to your patients with the least amount of harm!

Help Your PI Meetings Run Smoothly

Multidisciplinary Trauma PI Committee is an essential part of all trauma centers verified by the American College of Surgeons. A lot happens in that one hour (or so) meeting. But efficiency hinges on being prepared, and we’ve all experienced meetings where the case presentations just weren’t crisp.  Unfortunately, some of the committee members may not have even glanced at the record in advance, and try to catch up during the actual meeting!

What to do? Here’s a set of guidelines to help your presenters do the best job possible. They rely on advance preparation and good communication with your trauma program.

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Download a pdf copy of the guidelines here

And please comment with your own twists and turns on making trauma PI an efficient and meaningful process!

Trauma Coverage By Locum Tenens Surgeons

Trauma call coverage is not always easy to come by, especially at Level III and IV trauma centers and in rural areas. Many centers come to rely on locum tenens surgeons to fill gaps in their call schedules. Unfortunately, this can create quite a few headaches.

There is currently no trauma literature on this topic. Other disciplines, most recently pediatric surgery, have some published suggestions (I hesitate to call them guidelines) for requirements and expectations based on the ACGME core competencies.

Here are some of the nuances that any trauma program needs to recognize if the use of locum tenens surgeons is being considered:

  • Board certification – This is a basic tenet of trauma center verification and is absolutely required
  • Trauma CME – Recent changes in CME requirements by the American College of Surgeons have nearly eliminated this need. However, do you want a surgeon who does not keep up with trauma education on your call panel? If you allow this, prepare yourself for some interesting performance improvement issues. Make sure that all locums meet some basic requirement for CME or internal education program (IEP) before they start
  • Dissemination of committee proceedings – Make sure that this is well-documented. These surgeons must attend at least 50% of your required committee meetings. If they can’t make it, they must be aware of all items discussed, particularly if it involves their care. Use teleconferencing, or at least send them a (confidential) copy of the minutes.
  • Responsibility for quality issues – This is the most troubling aspect of using locums. It’s tough to hold one of these surgeons responsible for issues arising from their care if they have left and are never coming back. Make sure there is a mechanism to send feedback about their care even after they are gone for good. And document it well!

Bottom line: In my opinion, the use of locum tenens to cover trauma call gaps is a necessary evil for some centers. They should only be used until a more stable coverage pool is available. The management of quality issues in particular is much more difficult when using roving surgeons. And with the adoption of the new Resource Document (Orange Book), it’s even harder to use them. If you must, use them wisely and only briefly.

Reference: Proposed standards for use of locum tenens coverage in pediatric surgery practices. J Pediatric Surg 48:700-703, 2013 (letter).

How Safe Is ED Thoracotomy?

A few weeks ago, I opened a survey to find out common practices regarding performing emergency thoracotomy (EDT) in the emergency department. This procedure is performed at one time or another in most higher level trauma centers. It’s very invasive and is performed in an area that is not really set up for major operative cases. Furthermore, the atmosphere can be chaotic, and stress levels run high.

How safe is this situation? How does personal safety balance out with saving your patient? There are many, many opportunities for injury during this procedure, with significant exposure to blood and other bodily fluids.

A recently published multi-center study examined the potential for exposure during EDT at 16 US trauma centers over a 1.5 year period (14 Level I, 2 Level II). The study was prospective and observational, and was based on questionnaires filled out by all personnel involved in each procedure. A total of 1360 providers submitted information on 305 EDTs.

Here are the factoids:

  • Mechanism was penetrating in 77% of patients, who were predominantly young and male (91%)
  • 15 patients survived (5%), and 4 had residual neurologic impairment
  • Only 56% of respondents wore full personal protective equipment (PPE)
  • There was a 7% exposure rate per EDT(22 incidents), and 1.6% rate per participant in the case
  • The majority of those exposed were trainees (68%) who were injured by something sharp (scalpel 39%, fracture 28%, needle 17%, scissors 3%)
  • There was a strong correlation with PPE use and no exposure during the procedure
  • Only 92% followed their hospital’s occupational exposure protocol if injured (!!!)

Bottom line: Emergency thoracotomy will always be a dangerous procedure. Things happen quickly, there is little time to properly prepare and sharp, pointy things are everywhere. But according to this paper, the actual exposure rate is low. Factoring in the risk of disease transmission, the risk to an individual provider of contracting HIV is 1 in a million, and for hepatitis C is 3 in 100,000

The most distressing part of this study, to me, was the sense of invulnerability of a few of the participants. How can anyone justify not wearing full PPE during an emergency thoracotomy? I believe this represents a very casual attitude toward wearing PPE in any resuscitation. But this study clearly shows a large decrease in exposure rate when full PPEs are worn. Even more disturbing? The fact that 8% chose not to protect themselves by following their own institution’s occupational exposure protocol. Unforgivable!

The main takeaway messages are: always wear your PPE to a trauma resuscitation because you never know when you’ll need to get invasive (and won’t have time to dress up then), and be careful!!