Trauma care faces a significant divide between urban and rural settings in the United States. This division is nowhere more evident than in treating noncompressible torso hemorrhage (NCTH). This life-threatening condition, often resulting from severe trauma, has a staggering mortality rate of up to 45% [1].
Urban centers often find themselves at the forefront of embracing cutting-edge techniques like Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). While this progress is undoubtedly positive, it raises some troubling questions. What does this urban-centric advancement mean for patients in rural areas? Are we inadvertently creating a two-tiered system of care? And perhaps most crucially, how can we ensure all life-saving interventions reach trauma victims, regardless of whether they’re injured on a busy city street or a remote country road?
REBOA and Its Potential
REBOA represents a paradigm shift in managing NCTH. Temporarily occluding the aorta buys precious time for patients who might otherwise bleed out before reaching definitive care. A study by Brenner et al. in the Journal of the American College of Surgeons found that REBOA use was associated with a significant reduction in mortality for NCTH patients, from 54.0% to 35.9% [2]. Although these numbers are compelling, they only tell part of the story.
The Urban Advantage
Urban trauma centers, particularly Level I facilities, are often well-equipped to handle REBOA procedures. These hospitals typically have a multitude of specialists – trauma surgeons, interventional radiologists, and others – who are not only trained in REBOA but use it regularly. This combination of expertise and experience means that when a critical case comes through the door, there’s usually someone on hand who can confidently perform the procedure. Additionally, the availability of advanced imaging equipment and hybrid operating rooms can facilitate the fundamentals of EVTM (Endovascular Hybrid Trauma and Bleeding Management), which includes REBOA. Some urban centers are even exploring prehospital REBOA deployment, with studies showing the feasibility of REBOA placement in the field, potentially paving the way for its use by specially trained EMS teams [3].
Rural Realities
The picture in rural areas is vastly different. Longer transport times to trauma centers are a significant hurdle. The study titled “Disparities in Access to Trauma Care in the United States” by Brendan Carr et al. highlights that rural populations face substantial challenges in accessing trauma care. It found that 29.7 million U.S. residents, particularly in rural areas, lack timely access to trauma centers [4]. The odds of rural residents having access to trauma care within 60 minutes were much lower compared to urban areas. For NCTH patients, these extra minutes can be the difference between life and death.
Furthermore, rural hospitals often lack immediate access to providers trained in REBOA techniques. The cost of equipment and training can be prohibitive for smaller facilities, especially given the potentially lower volume of cases. This creates a catch-22 situation: low case volumes make it hard to justify the investment, but without the investment, rural patients miss out on potentially life-saving care.
The Ethics of Innovation
The urban-rural divide in REBOA implementation raises important ethical questions.
- How do we balance resource allocation to ensure equitable access to life-saving interventions across various geographic settings?
- In resource-limited settings, how do we weigh the potential benefits of REBOA against the risks of complications that may be more challenging to manage?
These aren’t just academic questions. They have real-world implications for patients and providers alike.
Expanding Access to Life-Saving REBOA in Rural Areas
A systematic review by Borger van der Burg et al. explored the use of REBOA in various settings, highlighting the need for adaptable implementation strategies [5]. While this research does not explicitly focus on rural settings, it highlights the potential for REBOA to be widely applied as long as appropriate training and resources are provided. Some regions are implementing targeted training programs to equip providers with REBOA skills, acknowledging that while case volumes may be lower in some areas, the impact of each successful intervention is potentially greater.
The idea of equipping advanced EMS teams with REBOA capabilities is also gaining traction, although it remains controversial. A pilot study by Sadek et al. demonstrated the feasibility of paramedic-placed REBOA in simulated environments [6]. This innovative approach could be a game-changer for rural areas where patients often face long transport times to reach specialized trauma centers. By bringing REBOA capabilities directly to the patient, we might be able to stabilize critical cases right where they are, buying precious time during those crucial first moments after injury. This shift in thinking could save lives in remote areas where every minute counts.
Another promising avenue is the use of telemedicine to bridge the urban-rural divide. By equipping rural hospitals with telemedicine support and REBOA kits while also training staff on how to deploy the device, we can help narrow the gap in care. This way, rural providers can tap into the expertise of trauma specialists at larger centers and receive real-time guidance during critical procedures. With this remote support, rural healthcare teams can more effectively stabilize patients before transfer, potentially improving outcomes in areas where specialized trauma care isn’t immediately available.
Working Together to Advance Trauma Care
As we refine REBOA techniques, we need to think beyond just expanding access—our focus should be on how best to integrate these tools into the unique challenges of different environments. Urban areas benefit from immediate resources, while rural regions face obstacles like distance and fewer specialists.
Real-time collaboration networks between rural and urban trauma teams could close that gap, while mobile training units could ensure remote providers are fully prepared. Adapting to these specific needs can improve trauma care and ultimately save more lives, no matter the location.
The Road Ahead
As we look ahead, we need to think deeply about how we use these life-saving technologies. Are we using them effectively? How can we adapt urban solutions to fit the needs of rural areas? And what new approaches can we discover if we think outside the box?
The use of REBOA in various settings shows just how important it is to get these tools where they’re needed most. Addressing these issues thoughtfully can improve trauma care and make a real difference in saving lives.
References:
- Kisat M, Morrison JJ, Hashmi ZG, Efron DT, Rasmussen TE, Haider AH. Epidemiology and outcomes of non-compressible torso hemorrhage. J Surg Res. 2013;184(1):414-421. doi:10.1016/j.jss.2013.05.099 https://pubmed.ncbi.nlm.nih.gov/23831230/
- Brenner M, Inaba K, Aiolfi A, et al. Resuscitative Endovascular Balloon Occlusion of the Aorta and Resuscitative Thoracotomy in Select Patients with Hemorrhagic Shock: Early Results from the American Association for the Surgery of Trauma’s Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery Registry. J Am Coll Surg. 2018;226(5):730-740. https://pubmed.ncbi.nlm.nih.gov/29421694/
- Brenner M, Teeter W, Hoehn M, et al. Use of Resuscitative Endovascular Balloon Occlusion of the Aorta for Proximal Aortic Control in Patients With Severe Hemorrhage and Arrest. JAMA Surg. 2018;153(2):130-135. doi:10.1001/jamasurg.2017.3549 https://pubmed.ncbi.nlm.nih.gov/28973104/
- Carr BG, Bowman AJ, Wolff CS, et al. Disparities in access to trauma care in the United States: A population-based analysis. Injury. 2017;48(2):332-338. doi:10.1016/j.injury.2017.01.008 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5292279/
- Borger van der Burg BLS, van Dongen TTCF, Morrison JJ, et al. A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination. Eur J Trauma Emerg Surg. 2018;44(4):535-550. doi:10.1007/s00068-018-0959-y https://pubmed.ncbi.nlm.nih.gov/29785654/
