UK-REBOA_11.23

Speaker 1:

Welcome back to behind the knife. This is Patrick George off. And today we're going to discuss a recent landmark publication that studies a very controversial topic and that's Roboa. And I'm joined by a surgical education fellow, Dr. Nina Clark and a very special guest, Dr. Kareem Brohi. So Dr. Brohi is a trauma and vascular surgeon at the Royal London Major Trauma Center and director of the London Major Trauma System, which is the largest integrated urban trauma system in the world and manages over 33, 000.

Speaker 1: injuries a year. He studied at the University of College of London, where he obtained degrees in both computer science and medicine. And Dr. Bro, he went on to train in general surgery, vascular surgery, and anesthesia and critical care in the UK and trauma surgery in Cape Town and San Francisco as well.

Speaker 1: He's a prolific researcher and has led multiple large trials. Dr. Bro. He were pleased to have you on behind the knife today. Thanks for the invite. So before we dive in, I want to encourage listeners to check out

episode 290, which was published in April, 2020. This is a big T trauma episode. And in this one, we reviewed the underpinnings for a boa's use and cover potential indications placement and complications and offered a critical review of the literature, which at that time was up to date.

Speaker 2: Yeah, but Patrick, you've officially been scooped. We've got more fodder for discussion now. This is the first randomized trial studying the use of Roboa in trauma patients. And the trial was published just in October of 2023 in JAMA to much fanfare. And it's titled, Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients with Exsanguinating Hemorrhage, the UK RBOA Randomized Clinical Trial.

Speaker 2: You can find a link to the paper in our show notes, and the lead author is Dr. Jan Jansen, who is writing on behalf of the UK RBOA Study

Speaker 1: Group. Right. So we're going to go through the paper in terms of design and results relatively

expediently. So we can focus on discussion about trial findings, but then really more importantly, is how we may or may not want to use for boa clinically and in the trauma setting.

Speaker 1: So this is really a, it's a spicy topic. It stirs the pot in the trauma community, which we love and is foster some really good and important discussion. So let's start from the beginning. Dr bro. He, why was. This study needed and what questions were you looking to answer?

Speaker 3: Yeah. So I think it's very difficult with devices and any complex intervention as to when do you actually study them?

Speaker 3: Do you study them early on in there? evolution when perhaps the technology hasn't evolved yet, but there be the uptake is happening and patient selection is under consideration? Or do you do it really late in the course of a device when, you know, it's being used everywhere and then it becomes very difficult

to actually Change practice, even with the results of a trial.

Speaker 3: So I think the the stop phrase is there's never a great time to do a device trial, you know, because they're constantly evolving and innovating and credit to Jan Jansson and Marion Campbell and the team. They saw a window of opportunity really as this Was being talked about a lot deployed in multiple different circumstances In the UK to actually say, well, let's actually do the proper study and at least we'll get a pragmatic view of where the technology stands and its utility within the context that people were talking about at the time.

Speaker 1: This is an enormous amount of work and an extraordinarily. Difficult topic. And as you mentioned, let alone device trauma patients, et cetera, multiple institutions. So the entire group should be just commended on what was I'm sure a Herculean amount of effort and work and very important results. So, again,

congratulations to everyone for that before we go any farther to dive into the study design aspects.

Speaker 1: And so Nina, if you will, let's talk about some of the key points of it. And maybe Dr Bro. He can Thank you. Refine what we talk about and or highlight certain things when it comes to study design.

Speaker 2: Yeah, absolutely. And I think it's important to highlight that this was a pragmatic study design, which I think is critical, especially when this is a known device to most trauma surgeons at this point and implementation is really the question at hand is how we actually roll this out and use it.

Speaker 2: So this was a pragmatic randomized control trial with the main Study group and eligible study participants being patients with confirmed or suspected life threatening torso hemorrhage thought to be amenable to adjunctive treatment with a Zone 1 or a Zone 3 Reboa. And the inclusion was really at the discretion of the trauma surgeon treating these patients.

Speaker 2: Their primary outcome was 90 day mortality, but they also studied mortality at 3 hours, 6

hours, 24 hours, and 30 days, as well as time to hemorrhage control as a procedure, and then blood usage and other complications. All eligible centers underwent some training beforehand. So they underwent either the basic endovascular skills for trauma or the best course or the endovascular skills for trauma and resuscitative surgery, the E STARS course, to provide a baseline of training prior to rolling out this, this study procedure.

Speaker 2: The study didn't specify which type of catheter specifically had to be used, and I think that was probably part of the pragmatic design, correct me if I'm wrong, but basically they again left the device choice to the treating surgeon. They incorporated data from 16 separate trauma centers. It was an intention to treat analysis and they utilized Bayesian logistical regression to interpret their results.

Speaker 1: Yeah, Dr. Brewer, anything you want to add to that in terms of design?

Speaker 3: No, I think that was well summarized. I think the key probably is though is that

the clinician had to feel that they might benefit from Rubella, and at that point they were randomized to either receive it or not. So it's not just a, you know, blood pressure less than 90 or something.

Speaker 3: There was, this patient may be a Rubella candidate. We should randomize into the study. And very pragmatic, as Nina says,

Speaker 1: excellent. This study enrolled over 5 years. There were 90 patients in the final analysis and enrollment was stopped prematurely. Because the stopping rule for harm was actually met.

Speaker 1: This resulted in 46 patients in the REBOA arm, versus 44 patients in the standard care alone group. The vast number of patients were blunt injuries, so 97%, and 23 percent of these patients had pre hospital CPR. The ISS was 41. Those are extremely sick patients. And furthermore, the groups were evenly matched, but we should say that there was a bit more hypotension and a bit higher AIS score for the head in the Roboa group.

Speaker 1: A few other key points, and we'll Come back to these because these are extremely important when it comes to discussion. The 1st is that the time from scene to arrival, the median time was 90 minutes. So quite long of the 46 for boa patients. Only 41 percent of them had the device inserted and inflated.

Speaker 1: So again, 41 percent of the patients in the rebel group had the balloon actually up 37 percent responded to resuscitation while rebel was being performed or prepared and therefore did not have balloons inflated 17 percent of patients did not have arterial access established. 4% of patients deteriorated before arterial access could be established.

Speaker 1: The rebo was deployed in zone one, up in the chest in 53% versus zone three, aortic bifurcation in 47%. So roughly even there, the median ed time, or excuse me, the median rival to balloon inflation time,

I should say, was 32 minutes. And you want to talk a little bit about our primary and secondary outcomes.

Speaker 2: Sure. So the primary outcome in the study reminder was 90 day death or 90 day mortality. And there were 25 deaths at 90 days, 50 percent of the group versus 18 deaths or 42 percent in the study. This amounted to an odds ratio of 1. 58 for mortality and a posterior probability. This is a Bayesian term that I've recently learned for an odds ratio greater than 1, indicating increased likelihood of death with Riboa and that posterior probability was 86.

Speaker 2: 9%. With regard to the secondary outcomes, all deaths or mortality basically across the board was increased in that robo plus standard of care group and more were pronounced early in the course. So earlier deaths were more common in the robo a group. There were also more deaths. Due to bleeding, specifically in the Riboa Plus

standard of care group, amounting to about 32 percent of that cohort compared to the standard of care alone, where only 17 percent of patients died because of bleeding, most of those bleeding deaths occurred within the first 24 hours of study follow up.

Speaker 2: 14 of the Roboa group patients or 30 percent had a definitive hemorrhage control procedure compared with 19 or 43 percent in the standard of care alone. So again, more of those patients who were undergoing standard care alone actually eventually underwent a hemorrhage control procedure and fewer of them eventually died of bleeding.

Speaker 2: And I think that's a really important point that we should highlight. The median time to hemorrhage control from randomization was 83 minutes in the REBOA group versus 64 minutes in the standard of care group. So there was about a 19 minute lag in definitive hemorrhage control from the time that patients were randomized if they got a REBOA.

Speaker 2: Transfusion requirements were similar across both groups. The standard of care alone group had more in ICU free and hospital free

days, so they tended to get out of the unit faster and get out of the hospital faster. And there were no significant between group differences in the number of complications overall, which I think is also another important point, because I know I've heard a lot about.

Speaker 2: access point complications specifically with regard to roboa use. That was a lot, Patrick. Yeah, it was a lot. And so probably go back and try to take this kind of point by point. Dr. Brohi, one of the things that I was really interested in seeing just off the bat to kick it off was this 97 percent blunt trauma rate.

Speaker 2: And I'm Curious as to whether that standard in the UK and this is just again another point toward the gun violence epidemic that we have in the United States that we frequently see much more penetrating trauma or if there were specific differences in the institutions that you ended up including in this study that they saw just such a high blunt trauma rate.

Speaker 2: So,

Speaker 3: I mean, no, it's not typical of UK major trauma centres at all, actually. So, if you look at the Cryostat 2 trial, which was published in the same

issue, a penetrating rate in Cryostat 2 was like 50 percent nearly. So, I think this is about who clinicians felt Roboa was appropriate for. And again, this is conjecture rather than we haven't studied this in the gunshot abdomen who just needs to get to theater and have his belly open versus the complex blunt trauma patient with occult hemorrhage from somewhere and maybe a head injury as well, possibly pelvic issues, and you don't know where you're going necessarily.

Speaker 3: And then they seem to be the ones where Reboa was considered by the clinicians. They're obviously the ones with significantly worse outcomes than the simple penetrative.

Speaker 1: Yeah, and that's seen also in the relatively high rate of death. These are blunt trauma patients with extraordinarily high injury burden.

Speaker 1: And so it was 54 percent in the robo group versus 42 percent rate of mortality in the non robo group. And Nina, I'm glad you brought that up because it's extremely important when analyzing this study and thinking about your

own practice to recognize that 97 percent blunt injury rate. These are very different types of patients than some of our Penetrating patients and the prior literature in Roboa should be contextualized in that sense in terms of having more patients that were suffering from penetrating injury.

Speaker 1: So we worked on a list of different questions and how we can suss this out when looking at those results. And so the next one I have for you is in the Roboa arm, only 41 percent had the device actually inserted. and inflated. That's a lot of different ways to think about why that may have occurred. What are your thoughts on it?

Speaker 3: Yeah. So if you look at the breakdown and which you actually went through before, so about 40 percent had the balloon. So 19 patients essentially of the 46 also randomized to Roboa had the device inserted the balloon up about the same number of cases, slightly less. It was decided at some point not to proceed with the Reboa because

they'd actually got better, so their hemodynamics dynamics had improved.

Speaker 3: And only, I think, in eight patients did they actually either deteriorate or Reboa couldn't be instituted. So, I think that reflects the heterogeneous group of patients that these people are and how difficult it is to understand what their trajectory is going to be and therefore to decide who actually has that exsanguinating non compressible hemorrhage that will benefit from Rubella, who's behind and will respond to resuscitation, who has got bleeding that will stop.

Speaker 3: by other means or that can be managed sufficiently by ongoing resuscitation that they can get to the operating room and undergo definitive control. So, so yes, this isn't really a, this is not a study of in a patient, patient with active non compressible, Bleeding does rebella improve outcomes. This is a study of

in somebody who looks like they've got non compressive bleeding Who may benefit from rebella does rebella improve outcomes and those are quite significant differences, I think Yeah, let's

Speaker 1: expand on that just a little bit because again We talked about the significance of this being a pragmatic study design and I think that's critical Based on what you just described to us because a lot of folks will look at this study and say well only 41 percent of Patients in the Roboa group actually got Roboa.

Speaker 1: Can you explain a little bit more about the significance of the real world applicability of Roboa when it comes to discussing that statistic and applicability to different trauma centers moving forward?

Speaker 3: Yeah, I think this speaks to things that were touched on earlier about, well, here's a patient in front of you who's hypotensive, obviously severely injured.

Speaker 3: looks like they might be bleeding. In that context, does that patient need or would they benefit from aortic balloon control prior

to anything else? And as we know, it's actually very difficult to determine the, both what's actually going on with those patients and on the subsequent trajectory of those patients and their response to resuscitation.

Speaker 3: So the Rabova trial essentially says at that decision point. If you choose to do a Rubella on all comma patients in the context of all the major trauma centres in the UK who are part of the study, it doesn't work. Now that doesn't necessarily mean to say, well, if you could identify the specific patient who had, I don't know, active liver bleeding that wasn't going to respond to standard resuscitation events, that in that patient, temporary Zone 1 occlusion would benefit.

Speaker 3: But in the context of the clinical entry criteria, that wasn't the case in these patients. Now, there are a few patients, of course, where arterial access and rubella was attempted and it just couldn't be done and there have been a lot of

comments around the place about, well, you know, it's really easy to do Reboa and everyone should know how to do access.

Speaker 3: I don't know who these people are. They're obviously much better than I am, but patients in UK Reboa, they'd arrested, they were properly hypotensive. I've found that I've struggled to get arterial access. And to do Riboa in exactly that patient, that's how I do it. And you're

Speaker 1: a trained vascular surgeon, to be

Speaker 3: clear.

Speaker 3: And I'm a trained vascular and endovascular surgeon, you know, and I, it's the sort of thing I do all the time. It's very, very different doing it on somebody with a blood pressure of 90 or 70 than doing it on somebody who's got no palpable pulse at all and you can't see any flow on an ultrasound, you know.

Speaker 3: It's a very different kettle of fish. And clearly, That induces some sort of delay, which leads to more bleeding. At least, that would be the The assumption, the reading, or my, that's my reading our reading of U. K. Rivera's for

Speaker 1: adults.

Speaker 2: And I think that really speaks

to both the pragmatic nature of this trial, as well as the intention to treat analysis, right?

Speaker 2: In my master's of epidemiology now, and we're learning all about how to design a trial appropriately. And I think that's really important and hard to. Interpret if you're not kind of familiar with that type of trial design and analysis that it doesn't matter if you got the intervention of choice, right?

Speaker 2: It doesn't matter if the balloon was up and you got hemorrhage control via Robo. It matters that you were randomized to that. arm of the study. I'm curious, there, there was one comment on learning curve effects analysis and specifically with regard to balloon success or a successful insertion of the device.

Speaker 2: I wondered, it says that it didn't change overall findings, but did you see an increase in once folks were getting familiar with the device and getting arterial access early? Did you see any effects of that or impact of that over time of the study?

Speaker 1: And I want to just add on again, then we, we threw out a lot of numbers earlier.

Speaker 1: So the median balloon inflation time as reported

was 32 minutes.

Speaker 3: Yeah, so that the team did some analyses excluding the first patient and things to see whether there was a learning curve effect. And obviously some trauma centers were already using Raboa before they went into the trial. Others came on board as the trial was going on.

Speaker 3: But of course, in each of these centers, you've got, you know, multiple people taking a call on different days. So you can't guarantee who's going to be doing it or when. And again, it reflects. The fact that Roboa is just not straightforward to do, and I think one of the results of UK Roboa is that it really points to where we need to go in terms of, if the balloon technology is right, then we need new and better ways to gain that access.

Speaker 3: Yes, you can put arterial lines in earlier, but it's actually very difficult to know, again, who these people are who are going to benefit from it subsequently. And every intervention delays. Everything essentially, if we're

talking about a 20 minute delay overall, in terms of getting to hemorrhage control for Rubella, that's essentially the same as putting someone through the CT scan, we're talking about a similar sort of delay incurred by from the decision to do it, to actually getting to definitive hemorrhage control somewhere along the way, 20 minutes is lost.

Speaker 3: By the decision to do Rebecca and we know that time is is life in these patients.

Speaker 2: We've talked to folks who do video review of trauma resuscitations and the main takeaway that I got from talking with them is that everyone is slower than they think they are, right? You think it's just simple, throw it in an art stick and get the balloon up, but it really does suck up some time.

Speaker 2: I think everything does, as you mentioned. Yeah,

Speaker 3: once you've got access, the actual idea of passing the balloon and blowing the balloon up takes two minutes. There's a big difference between that and actually deciding to do Reboa and getting that balloon up.

Speaker 1: And so you're clinically

active, you see a lot of patients, and again, You have been trained as a vascular surgeon.

Speaker 1: What are some of the problems you see in the trauma bay on the ground when it comes to getting that initial a line? How do you talk to your trainees about that? And what things are happening simultaneously? Etcetera.

Speaker 3: Yeah, I think in the context of remote, obviously, there's. The sooner that you can get that early access with when the patient has a palpable pulse, the better an ultrasound is usually used as it's there from the beginning to be used to guide that access.

Speaker 3: Although we've also had patients where we couldn't see anything on ultrasound and we've had to go blind using landmarks. I think it's very different though. If you think, well, actually rubella is not the way to go, then femoral arterial access may also not be the way to go. in these patients. It's not innocuous.

Speaker 3: It does cause problems later on down the line, which may be

large or just a niggle. And compared to standard radial access for arterial lines, I think if you're not doing it for a boa, then I'm, I'm not sure you, it would be your first point of call to do a femoral arterial stag. Groin access is a skill and a technique that you may need to do as a trauma surgeon for all sorts of reasons.

Speaker 3: So, you know, it's something you need in your armamentarium.

Speaker 1: Okay, let's talk about hemorrhage control 30 percent of patients in the rebel group and 43 percent in the non rebel group at any point went on to have a hemorrhage control procedure, which is interesting and at first glance, you might think that's not very many.

Speaker 1: And so I'd love to hear more about your thoughts on that.

Speaker 3: Yeah, I mean, I think again, if you look at, let's say the rebel group, so a third of them, more than a third of them got better without rebel. Bye. Bye. And so a number of

them had stopped bleeding one way or the other. Before we also know that a couple of people deteriorated and probably died before they could get.

Speaker 3: to hemorrhage control. And then there's another group who we know receive Riboa and then appear to stop bleeding. They can have the balloon taken down and then they seem to stabilize and then they go to scan and there's nothing actively bleeding. And again, if somebody's not bleeding, then they might spend more time in the emergency bay.

Speaker 3: They don't need to crash into the operating room. So again, this is about, well, this patient looks like they might be bleeding and benefit from roboa, but actually a good proportion of them either weren't bleeding, had bled. And it stopped all the amount of bleeding reduced during the course. So you'd guess maybe about, I don't know, 30 percent of the

patients were actively bleeding to the point where they needed that definitive hemorrhage control, or they died before they got there, which was a relatively small, I think, two patients or something.

Speaker 3: I can't remember exactly. A small number of the group who actually exsanguinated before. Yeah,

Speaker 2: and I think that brings up a good point. I mean, both about the time in the trauma bay. These are undifferentiated bluntly injured patients, right? I wonder if that a little bit of that was just kind of puzzling through them.

Speaker 2: And then to your point again, about the large proportion of these patients who did get better without any intervention, really. whatsoever in the Roboa group in particular. I'm curious about that time to definitive hemorrhage control procedure, because not only was the proportion higher in the non Roboa group, but also the time to definitive hemorrhage control was longer, 19 minutes longer to be exact in the Roboa randomized group.

Speaker 2: And I'm curious, I hear a lot from my institution about. Box ticking the

2nd, you get that balloon up and you need to move somewhere else and get definitive hemorrhage control. Do you think that played a role in that time being longer? Does it kind of lull people into into feeling like things are safe and controlled at that point?

Speaker 2: I think Patrick, yeah,

Speaker 1: just to follow up with that. I want to add the minutes to it. Just again, just because we went through everything so quickly earlier. The median time to hemorrhage control from the point of randomization was 83 minutes in the Roboa group and 64 minutes in the Standard group. And I'm very curious to hear what you think about that too, because this has prompted a lot of discussion amongst

Speaker 3: folks as well.

Speaker 3: So I think to the first point about blood pressure gets better, people take their foot off the gas. I think that may well have been. an issue in, you know, in one or two cases. And we've, you know, we've certainly had patients early on in REBOA out with the REBOA trial where, you know, the balloon has gone up, they seem to stabilize, and then somebody has decided to take them to the CT scanner, you know, because to see what's going on.

Speaker 3: And so, again, I think this is about

understanding. The use of Reboa and where it's used and also understanding the difference between how Reboa is used between as a exsanguination control device versus a adjunct to hemorrhage management, as it seems to be in many studies. In terms of the timeline, time to definitive hemorrhage control, the goal across the UK as a standard is an hour from arrival.

Speaker 3: I think time to randomization itself was relatively short. So, and again, given that these are the blunt polytrauma patients, I don't think it's far off what you would expect across the broad spectrum of trauma care. So again, I think it reflects. Real world practice again, you know, it's only 40 patients in each in each arm So you can't draw huge numbers of conclusions from them But the actual signals about you know Deaths due to bleeding and delayed time

to bleeding come through loud and clear even within that small group of patients Yeah

Speaker 1: And I have to say that time to hemorrhage control is certainly longer than we would hope to see especially in patients This sick who required significant pre hospital transport times on one hand You have to remember that these are complex patients with blunt, not penetrating injuries, and they're often more complex.

Speaker 1: However, 83 minutes in the robo group and 64 minutes in the non robo group is hard to reconcile, especially when these patients are so hypotensive. Now, we'd like to think that we are faster than we are. That's for sure. And there are some data to suggest that these times are in fact consistent with real world practice.

Speaker 1: But I'd like to know if you think this contributed to the relatively high mortality rate in these, again, very sick patients.

Speaker 3: I mean, if you look at studies like the Harbin study on formal laparotomy mortality and things, which, you know, is well described on both sides of the Atlantic and military and civilian as remaining very high for this group of

patients.

Speaker 3: This is, these results are right on the money, essentially, in terms of what the mortality would be expected from people with an ISS40 blood pressure less than 90 and who are going for a laparotomy and requiring significant transfusions. It's the same. And some centers are clearly using it as, you know, adjuncts to a bloodless field during trauma laparotomy or something where they're just going in in the operating room just prior to procedure or very late in the ED course.

Speaker 3: Medium systolic of 90 millimeters mercury in some studies. These are, these are not those patients. And again, those patients will have had a palpable pulse. Access would have been easier. So this is very much more the, you know, what Reboa was originally designed for by, you know, Todd Rasmussen and people, a solution to exsanguinating non compressible hemorrhage.

Speaker 2: With that in mind, how do we interpret this study and move it into the next phase? I mean, we've talked a little bit

about implementation and how we should be using these devices and how a lot of this has already happened. prior to having randomized data to guide us. So now that we do have some randomized data, how do you think this, these results of the study should be interpreted and moved into actual practice?

Speaker 2: Yeah, I think

Speaker 3: everyone has to look at it within the context of their own setting, their own geography, their own practice, and see how they apply to what they do. I don't think. I don't think I can speak for rural America or Norway or anything like that. I think from the UK context, what's clear is that Riboa, as it is currently designed and delivered, probably does not have a routine place within the major trauma center.

Speaker 3: I think having said that, there are patients where it has proved. Of utility you know, growing blowouts, part of hemorrhage type patients, non trauma type patients. So I don't think it's a,

there's any kind of blanket ban on it, but I think people need to be more specific about when they use it and also understand the time consequence of deploying it.

Speaker 3: And I think if you are going to carry on using Reboa, then you absolutely need to understand your timelines with and without it and to study each case and exactly those timelines and how it's deployed and when it's deployed. I think the other point is that we still need a solution for non compressible torso hemorrhage.

Speaker 3: And it was designed for not for within trauma center care, but for far forward and pre hospital care and. UK Repower does not preclude its use in those settings where transport times may be well in excess of that 20 minute window, and so you may be losing little. Obviously then, with longer transport times, you

need To have a solution for prolonged ischemic times and so partial rubella, intermittent rubella, those sort of things come into play and more study is needed, but, but I think it may well push rubella back to the place where it was originally intended, which is in those deployed settings.

Speaker 1: Yeah. And that's interesting. Pushing rubella back to where it was originally intended, which as this study shows is not in major UK trauma centers for use on sick. Blunt trauma patients. And to me, really one of the paradoxes of robo is that the trauma centers that are best equipped to use it in terms of volume and skill and careful evaluation of outcomes with subsequent iteration as needed.

Speaker 1: These are the same centers who are also best equipped for and have the most practice in rapid hemorrhage control without roboa. So the question is which centers, if any, should roboa be used in? And to your second point, really the intensive area of research should

probably be focused on adjunctive hemorrhage control.

Speaker 1: In this far forward environment, I definitely agree with that. And you know, I want to thank you and really commend you and the rest of the team on phenomenal work. This data was sorely needed and allowed us to have this conversation. And so with that, do you have any additional take home

Speaker 3: points? I think the thing for me that the UK Rubella trial does above everything else is really bring home the fact that time is critical for bleeding trauma patients.

Speaker 3: I don't think there's any better expression of it than the UK Ribeiro trial, actually. You can do all the propensity matching and time series analysis of observational data that you want, but there is a critical difference here of 20 minutes only. in these group of patients that has led to substantially higher bleeding death rates of death from bleeding.

Speaker 3: And I think that applies not just to Roboa, but to everything we do, decisions to go to CT or not, decisions to do it in investigations,

decisions to add in an extra line before you go to the operating room, you know, how quickly you can get coagulation products into patients or get answers back. I think this really In my view is much bigger than rubella and refocuses the mind for these patients on how critical time is and how much faster we really need to move, even when we think we're moving fast in these patients.

Speaker 2: That being said, this is obviously generated a bunch of questions even just. Among the two of us, Patrick and I, but I'm curious what your next questions are for REBOA and for this incredible group of facilities and researchers that you've been a part of.

Speaker 3: Yeah, so we're having some discussions at multiple levels.

Speaker 3: We've got a big dissemination program in track that will involve all the UK major trauma centers. And again, a discussion about what is the place for REBOA and for us and where we go next. We have a

Big pre hospital program using partial pre hospital lead by Robbie Lendrum. We hope we'll be able to report on that very shortly for the first case series.

Speaker 3: And then looking at ischemic adjuncts that may support ischemia to allow those long transport times. So, you know, there's still a lot to do in this place. It's not a, it's not a yes, no question. And maybe there are alternatives for non compressible hemorrhage as well that we need to explore further.

Speaker 1: Well, again, we appreciate your time and for sharing your expertise with us.

Speaker 1: Thanks for coming on behind the knife and to all the listeners dominate today.

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