E44 Joe Dubose On Integrating Vascular And Trauma Surgery

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Chad Ball  00:00

This week on Cold Steel…

Joe DuBose  00:02

What I have to remind myself is this is my 200th time seeing somebody shot in the chest with a hole in the heart. For the med students for that student nurse, this is their first time. And if you don’t start to help them to conceptualize it now and they internalize this abnormally, that’s what PTSD I think is largely come from.

Chad Ball  00:29

Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your host, Ameer Farooq and Chad Ball. The goal of the CGS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy it.

Ameer Farooq  01:14

True rarity in an era of increasing sub specialization is someone who can successfully merge two different disciplines. Dr. Joe DuBose, is a trauma and vascular surgeon at the University of Maryland Medical Center. In this episode, we talked to Dr. DuBose, about his training pathway, his experience in the military, and about integrating his vascular training with his trauma background, which includes his thoughts about REBOA. Just wanted to remind all our listeners that we’d love feedback and comments. And please feel free to email us at podcast.cjs@gmail.com or on Twitter @CanJSurg. Thank you, and enjoy the episode.

Chad Ball  01:56

Well, Joe, Joe, welcome to cold steel. You know, first I’d like to really thank you as we do with all of our guests. But you know, you in particular are a super busy guy. And I would argue that, you know, you’re probably the most academically prolific trauma surgeon that I know about in the first half of their career. So and you’re always a tremendous guy to listen to and to follow and to watch and you got some really dynamic things. And I hope we can talk about some of those. So thank you and welcome.

Joe DuBose  02:25

Absolutely. Pleasure to be here. Thanks for having me, Chad.

Chad Ball  02:28

Yeah, I guess my first question out of the gate is for those listeners up in Canada who may not know you as well as we do. Where did you grow up? And how’d you end up in surgery and what was sort of your training pathway along the way, so to speak.

Joe DuBose  02:40

Oh boy today, it’s a rapid succession of decisions made with little information that seemed to work out. I grew up in South Texas, let’s stop Texas for a Military College called Virginia Military Institute back in 1996. Because there’s only place that offered me a track scholarship. I knew nothing about the military or that institution in particular, but I did go. It was fantastic for me, I loved the regiment. It it was really what I needed at that stage in my life. And from there transition to the signing. My mother was a nurse and was this still is my hero. So I transitioned interest in medicine with the University of Virginia where I completed and wanted to pursue surgery residency. At this point, the Air Force they pay the United States Air Force they paid for most of almost all of my education. So I certainly owe them time. And they told me Well, you know, we’d love to have you for circuit training. We’re going to send you this whole place in Biloxi, Mississippi, Keesler Air Force Base Medical Center, never heard of it. Sleepy, relatively sleepy little facility. But about almost all the way through that a little summer early fall storm called Hurricane Katrina rolled through and literally destroyed the entire hospital. So now I had to scramble to find a spot to finish my surgery residency and went back to University of Virginia to do that. I met another one of your Canadian cohorts Kenji Inaba during a rotation and at Keesler when he was at the University of Miami as a fellow himself and we were fourth year surgery residents and just really fell in love with trauma when I was down there on that four month rotation, loved Kenji, loved his hunger for research. He and I are just kind of like, you know, kindred spirits in many ways that from across the border. He talks like you and says our “aboot” and things like that, and I talk with redneck southern drawl, but we understand each other. So I followed him to LA County where he was a young faculty, finished my fellowship there went from there to San Antonio for a year at the Wilford Hall Medical Center there went to ultimately shock trauma here at University of Maryland from 2009 to 2013. And then went to do a vascular fellowship at University of Texas, Houston for two years, then went to University of California Davis and Travis Air Force Base for two years and then moved back to Baltimore in 2000, I think 17 or 18, and have been here since. And somewhere along that way, I had spent some time with seven trips out with the United States military base locations. For a while there, I was going for months every year. So it’s been a lot of moving around.

Chad Ball  05:21

Yeah, no, no kidding. You know, it’s interesting, though, you know, obviously, I haven’t been involved in the military. But certainly, I would say that, you know, with each one of the steps that I went through, personally, I moved to a different place. And there was so much benefit in that not only meeting new people and laying that foundational groundwork, but in particular, just seeing different systems, like you say.

Joe DuBose  05:43

Yeah, you know, really does help you become a dogma breaker of sorts, because every institution has their a little bit, we have this in our own fields as well. But there’s just a little bit of dogma and practice patterns that really just because they’ve always done it that way, at a certain place. And they come in and be able to add a little more, you know, a little salt, where there’s pepper, from your background at other institutions. I think it’s good for the environment and good for the trainees and has really been enlightening for me.

Chad Ball  06:10

Yeah, there’s no doubt what was practicing, or at least training during Katrina like?

Joe DuBose  06:17

You know, I was there. So we, we had five surgery residents, and typically, you know, it’s on the Gulf Coast of Mississippi. So we had hurricanes that came through and I was the single guy at the time in the program, everybody else would take their families and evacuated a little bit further up north. And it was a great deal for me, because I would sit and be the resident of a calm hospital for that week until the storm passed, and nine times out of 10, until Katrina came through, you literally just didn’t do too much. You could read some, pedal around. And then when everybody else got back, you got a week off, and I would go fishing or do something like that. Unfortunately, Katrina, hit Biloxi on the teeth, and then a couple days later shattered the the levees in New Orleans and created havoc there. So that was very different. And it was a little strange in that of those people that I trained with, most of them I never saw again, you know, aside from at meetings for years. There’s still some I still haven’t seen, I’ve talked to on the phone, but it’s just the middle of your training one day you just pick up and have to go and it’s there’s no real transition kind of emotionally or, or or talking with those folks, you know.

Ameer Farooq  07:25

Did you have a very interesting kind of fellowship training? And how did you think about that? And were there any doubters in terms of how you sequence that and in your vision for your career?

Joe DuBose  07:38

Yeah, you know, I, I had been, I got out of my trauma fellowship, and was really just progressing to being an academic trauma surgeon very much enjoyed that that’s still half of my practice. Maybe probably a little bit more honestly, of my practice. But as time progressed, if you ask any trauma surgeon what their best case was, in the last six months, odds are, it’s probably gonna have a vascular injury associated with it. And I was no different. And then I love those kinds of things. And I could see the you know, because it’s dramatic, you stop bleeding, you repair vessel, you restore profusion, you save the day. And the fascinating the marriage of anatomy and skill sets and procedures, it’s just really good. It makes me giddy, you know, I’m a nerd out about that stuff. And I could see more and more. It’s a slow trend. I think it’s picking up pace now. But there’s it was a slow trend towards this implementation of endovascular technologies for some of these trauma skill sets, at least starting with diagnosis and some of the definitive management stuff and more stable patients. So I said, you know, how do I go back about doing this, and I don’t think any civilian trauma surgeon would entertain it after being out six years, because the pay differential between a surgeon who’s been out in the US for six years, and the fellow is probably pretty dramatic, going home and telling the wife that you want to take several hundred thousand pay cut for two years, it’s probably not going to go over super well. But I have always been a military surgeon. So the pay was going to be consistently low for me, relative. And it really lined up with the, my the time I wanted to spend in the military. If I gave him the two years for that basketball fellowship, and I had to give them two years back, it would line up perfectly to get me my 20 years for a time. And it just made a lot of sense to me. And I did talk to a lot of folks. I think there’s a lot of and I really honestly, I got a lot of encouraging support in that regard. Not many people told me I was crazy knowing that I was in the military not going to take this huge pay cut, but no one really tried to talk me out of it. They just did wanted me to be realistic and understand what that process was going to be like and how it was going to feel. Going back from being the quote unquote boss as a trauma surgeon to being back to being one of the you know, the kids as a fellow. And that was a very humbling experience. Because when I showed up at UT Houston, they didn’t care that I had written however many papers and trauma what my expertise was, I was a rookie vascular trainee, and they I was going to be treated accordingly. But it was fantastic. And I really did enjoy it.

Chad Ball  10:07

That’s fantastic. Joe, you know, one of the other, you know, clear things that I think all of us know you on that on the injury side in the world for has been your fusion, you know, predictably of vascular in particular endovascular and percutaneous maneuvers and techniques into trauma and obviously, you know, with specific relevance or target to stopping bleeding. How did you initially frame that sort of in your mind, and try and move some of those techniques along and really propagate that within the trauma community, which I think you know, for me coming from HPV and you coming from vascular a little bit and trying to integrate those things, with trauma as our as our as our really the core of what we’re trying to get to at the end of the day. There is certainly obstacles and speed bumps and doing that in from the outside anyway, it seems like you’ve done that so effortlessly and flawlessly. But I’m sure you haven’t.

Joe DuBose  11:03

Well, it’s been, there’s been challenges along the way. I think that I certainly didn’t do it alone. I’m not some trailblazer of sorts, it’s been a group of us. And it’s been both trauma and vascular surgeons. And then this core group, there’s about a dozen of us in the country in the US that are dual trained and dual boarded. I think that first wave is kind of people who did the full training on both sides is going to is necessary because we have to be card carrying members of both parties and be able to speak at both, you know, the vascular meetings and the trauma meetings from the consideration standpoints and be, you know, respected as someone? Well, they did our training basket, guys talking about trauma surgeons need to be integrated in vascular injury care. But yeah, did vascular training and he practices vascular training, practices what he preaches. So I think that that’s been helpful, I do think that a time will come where some of these skill sets will REBOA is an example of that, right? I mean, that’s an endovascular balloon that’s being placed in the aorta by trauma and acute care surgeons. Mainly by necessity, because the vascular surgeons aren’t there, when the patient comes in the blood pressure 50 they had to come from home. So those kind of opportunities for partnership between the two specialties are going to only increase I think, with the advent of new technologies. And the funnest part for me is seeing something that’s developed for something entirely different in the vascular world. And then recognizing, oh my gosh, there’s a trauma application. And if you don’t practice and dabble in both worlds, you don’t see those potential needs on either side. So I think that’s the most exciting thing for me. And it really just is it’s a, it’s a, it’s a variable harvest of ideas when you are able to practice in both and see how things can be applied for both subsets of patients bar from both practice, practice.

Ameer Farooq  12:56

One thing that’s always fascinated me is sort of like the mindset and how those might be different between the two practices. Dr. Ball and another surgeon in in Hamilton, Dr. Gmora talked about what it was like to switch between doing their elective practices, which is not trauma and then doing trauma surgery. Do you ever find that you have to kind of change your mindset when you’re switching between your sort of your vascular surgery hat and your trauma surgery hat? Or do you find that those just complement each other and kind of contribute and make you a better surgery surgeon and both?

Joe DuBose  13:28

You know, I think there is a mental gear you have to shift when you’re challenged with a trauma patient. I mean, I’ll use as an example right. So I get referred these things for review all the time. And these common pitfalls of vascular surgeons managing trauma or trauma surgeons managing vascular it’s just the inability to frame shift between the two disciplines and I had to catch myself often quite frequently. You know, example a patient who needs a and a lot of what I end up doing on a day to day basis actually probably fall under the interventional radiology field at most centers with immobilization for a variety of bleeding, bleeding sources, solid organ and pelvis. And I have to remind myself with vascular repairs and some of those other entities when I’m placing sheath. That example, if you got a small subarachnoid hemorrhage, probably not a good idea to systemically heparinize the patient. But if I’m a vascular surgeon kind of coming in cold, I’ve done three aortic cases that day and a trauma partner asked me to help them my reflex is going to be okay that we’re now putting in the therapeutic sheath. Let’s heparinize this patient. So you have to have that and if the trauma surgeons moved on to the next case and the vascular surgeon’s the only one in the room those are where the Swiss cheese can take effect. So you do have to frameshift a bit and, and it’s a skill set and I think it’s in inherent to every trauma and vascular surgeon to be able to do that. But in the heat of the moment, we do rely on the reflexes we have from our backgrounds and our training and that’s where you can get into some problems.

Ameer Farooq  14:57

We would be remiss for our audience if we didn’t ask you about your military training and your experience with the military, because you’ve really had some extensive deployment with the military. What does that experience been like? Being a military surgeon? And how has that informed your civilian trauma practice? And can you tell us a little bit about some of your most memorable deployments?

Joe DuBose  15:24

Well, yeah, I’ve been, I’m approaching this as my final year, I’m going to retire at 20 years. So I’m in the final 10 months or so of my military career and I’ve had a lot of chance to kind of reflect back on the kind of the cool things that I have been able to do. I spent the first half of my military career as a trauma vascular surgeon and I remember deploying like literally three months out from fellowship I was put in Iraq as the trauma chief at our rule three hospital there Bagram. And, and I got there, and I’m surrounded by these grizzled old O-6 or colonels. I am the young major. And I had to manage all these personalities. But in the end that they really taught these were general surgeons, for the most part, who’d been to war multiple times in the height of some of these conflicts. And I learned a tremendous amount about triage priorities, and managing these patients collaboratively across disciplines in a very tight knit group. And it’s really in my mind, kind of the gold standard for I wish the way we did trauma care everywhere. And even in the civilian setting, that really tight knit group that all collaborates very well together. Of course, this folks didn’t have elected practices that they were busy with during the day, that was one thing they had to do. And then several years ago, in 2015, I transitioned to join the Joint Special Operations Command, and that’s really smaller teams, very small teams, actually. And the team lead is not some O-6 colonel, it’s typically a physician assistant, who has special forces background could be SEAL could be Army Ranger could be special Army Special Forces proper. And that’s who you take orders from and that person may be a captain. And you may have 10 years more military experience, they people, when they say jump, you jump, because in that setting with that clientele, you are, for all practical purposes, a weapon system that needs to be moved around aggressively to support the intervention. So it’s a lot of mobility, a lot of making do with kind of limited resources and thinking about how to preserve those resources in the context of trauma care. So that has also been an interesting kind of caveat and a different experience that I really do cherish. And I think both of those experiences to the two halves of the career really have informed what I do every day in the trauma realm. But the biggest thing is just the close-knit team morphic, you can do so much with so little if you have the right team and they play well together.

Ameer Farooq  17:48

What’s your most memorable experience from for being deployed? If that’s something that you can talk about and share with us on the air?

Joe DuBose  17:57

Yeah, you know, some of the Joint Special Operations Command stuff is probably not fit for listening audience. I don’t know what the current clearance status on some of those missions are. But I will tell you, I’ll tell you one of the most memorable experiences I had from the first half of my career. I got I was an Air Force trauma surgeon of severe shock trauma, actually. And I got called on pretty short notice because they had a big operation going off in Afghanistan, and they had the trauma chief down, there was a 70 plus year old Navy captain who really just great surgeon, good surgeon. But that, that age, that pace, I think was wearing on him. So they sent me down to assist. And I remember it took me oh gosh, forever to get there. I think it was three days waiting in various military terminals throughout random places in the world. And I got off the plane, after being up for not much sleep for four days really just wanted a hot shower and a rack for a couple hours. And somebody came running to the airport and said, Are you Dr. DuBose? And I said yes. He said drop your stuff there. We’ll come back and get it come get me. We just had a fuel truck explosions, the Taliban attack. And there we have 36 caches. And I’m like, well, this is a heck of a greeting. So Wow, get to the facility and it was a joint facility. So a lot of the surgeons will Canadian surgeons with Canadian orthopedic two Canadian orthopods. We had the other confounding factor here is we had a German, a British neurosurgeon, a German anesthesiologist, it was a net true NATO facility. And everybody had kind of done a TLS but it was a little bit of chaos. And these burns were profound. What had happened is a enemy combatant, walked up to a fuel truck that was being escorted by a patrol of Afghan soldiers and blew himself up blew the fuel truck up. And you had we had 36 guys who were severely burned and unfortunately, the majority of them were actually burned beyond the capabilities for us to salvage. But it was just the next after being up that long and being the next 36 hours it was simultaneously one of the most terrific and also one of the most rewarding experience. Because having been trained to kind of burn management in that environment and understanding what our clinical practice guidelines were from our joint trauma system, really a lot of those folks didn’t have any idea what that was. So I was able to show them we were able to go around and triage people, unfortunately had to transition a lot of them to comfort care. But because they had inhalational injuries greater than 80% body surface area burns, but that was that I will not forget that one. That’s for sure.

Chad Ball  20:28

Joe, that that’s an amazing story. And I’m sure you have, you know, many more that would that would fascinate everybody. I’m curious, maybe this is a certainly a softer question. But, you know, for those of us that do emergency general surgery being one thing, but certainly horrific injury, whether that’s civilian or military, you know, dealing with that sort of story, and that sort of outcome, I think can be challenging for all of us. And I think we probably all handle it quite differently. Is there any tips or tricks or thoughts that you’ve generated over quite a long career during high intensity stuff that you you’ve sort of you go to or utilize on a regular basis to do that?

Joe DuBose  21:10

I mean, it kind of the psychological element of dealing with.

Chad Ball  21:12

Oh, yeah, yeah, I think so.

Joe DuBose  21:14

I think, honestly, I think communication, don’t internalize things. If something bothers you, just say, you know, you don’t need to have to be able to get words to say, and that really bothered me and start talking to other folks. I also have found, I’ll tell you the memories from my military time that helped me the most that get me a little teared up when they start rolling out the American flag and the national anthem at a baseball game, for example, or not for my second, third, fourth, fifth, sixth, seventh deployment, it’s the first one. And because the experience was new, it was very traumatic, you’re young, you’re idealistic. There are a couple of patients that I wish I had had different tools or been a bit of a better surgeon that maybe I could have saved them, probably not, I don’t know now, but those are the ones that really the toughest, and I’ve, what I’ve translated that to mean is I, especially in our modern teaching environment, we see patients in shock trauma die almost, certainly, several times a week, just turned up with these gunshot wounds. And what I have to remind myself is this is my 200th time seeing somebody shot in the chest with a hole in the heart. For the med students, for that student nurse, this is their first time. And if you don’t start to help them to conceptualize it now and they internalize this abnormally, that’s what PTSD I think is largely come from a lot of the vets I know they get PTSD, either from repetitive kind of traumas. Or a lot of them, if you look through, you know, you talk to vets at our VA system, and I’m sure it’s same since in Canada is one traumatic incident that occurred early in their career, and they didn’t push through it to get multiple experiences to learn how to cope and deal with it. The surgery is the same way, right? The first time you put a scalpel to skin, I would say probably you guys can back me up on this, it’s a little unsettling. I’m cutting a live human being right, I’m making an incision, it’s your hands a little unsteady, you probably make the cut with like one cell layer, you know, because you’re and I always tell the students, you know, I want to see some fat, it’s okay, you’re not hurting. They’re asleep, and we’ve got them pain control, all that good stuff. But over time, now, if I put a scalpel in your hands, and you need to do something quickly, you do it, you don’t think about that first incision piece. It’s the same with dealing with the most severely injured patients in many ways. And combat experience, I think, in many ways. So you put what you have to on the front end, you have to look around and consider who’s experiencing this for the first time. And let’s talk about it. Let’s even wait till the moment the moment clears. But then talk about it. So Wow, that was really, you know, that was crazy. There’s some deep stuff that went on there. How do you feel about it? And I think that’s important.

Ameer Farooq  23:57

This is some really moving and…

Joe DuBose  24:01

This got really deep. I thought this was going to be like yeah.

Ameer Farooq  24:08

But we can’t couldn’t not have you speak of something that’s so important. I think that advice is is, is really profound.

Joe DuBose  24:16

It is very important. I think when they come to you around a patient, and just try to look around the room and see who’s in there, whose eyes are a little misty, who is shaking a little bit. And those are the people as we do this more we’ve learned to cope with it. Be the next generation help the next group cope with it too.

Ameer Farooq  24:31

That’s fantastic advice. Dr. DuBose, I did want to talk to you a little bit about obviously what we’ve sort of alluded to and what is clearly an area of expertise for you which is the merging of your vascular surgery background as well as trauma surgery. You actually have a fantastic talk about this on YouTube, where you give grand rounds talking about the evolving paradigms in vascular injury management. For those of us who haven’t seen that talk, could you sort of summarize the concepts in that talk?

Joe DuBose  25:08

Yeah, I think the enthusiasm I have for this talk in this area is that we have a lot of emerging technologies, which are very exciting and have the potential to do a lot of good for a lot of patients. And I think it’s a marriage of devices developed for vascular indications that have trauma implications, so and the ability to recognize that and apply them appropriately is really a cool thing. And I think we’re going to help a lot of patients, but the, the challenge is, just because you have a shiny new toy doesn’t mean it’s always the right thing to use. And so even when you think about endovascular stents, for example. It’s changed the way we do business for blood thoracic aortic injury. Open aortic repair the old clamp, and so is essentially nonexistent anymore, right? Axillary subclavian injuries are moving that way. If you look at data from five years ago, about 11% of those were managed with endovascular stent technologies. And now presently, about 40% are from our most recent review of our AAST vascular injury registry. Other sites may not make as much sense. We have some pretty durable solutions for extremity stuff for example, I don’t think you need to be putting stents in the superficial femoral artery when you can do a reverse saphenous vein graft repair. Just simply from the standpoint that we know those inner position repairs are going to behave themselves and do well for patients for decades, because we have that experience. Where as in endovascular stents likely to need multiple intervention, serial follow up, anticoagulation. The carotid artery is another one where boundless enthusiasm in atherosclerotic world creeped over into the trauma world for stent grafts about you know, eight to 10 years ago. And then we finally figured out that the majority of those just need antiplatelet therapy and a chance to heal before we make that hard decision to put up some a piece of metal. And so I think it’s exciting. There needs to be a caution there needs to needs to be data driven. But it’s really a cool time to be interested in vascular injury for more asset.

Ameer Farooq  27:18

And there’s a lot to kind of unpack in what you just said. I think one thing to bring up right out from the outset is sort of, you know, who is in your opinion going to be at the forefront of actually managing vascular trauma as we go forward? You know, especially as there’s more options available to surgeons. Do you see trauma surgeons continuing to be the primary operators when vascular trauma comes in? Or do you think that there’s going to be eventually a shift and, you know, if you ever want to have some fun, you can go on Twitter and look up, You know, whenever some of the trauma surgeon vascular surgeons start talking about vascular trauma, you’ll see some fireworks. But like, where do you see that the evolution in practice going down the road?

Joe DuBose  28:09

You know, I think it’s going to be far more individualized by center and experience than anybody is arguing. We can have these debates about Oh, it should always be vascular surgeons that own vascular injury should always be trauma surgeons that are capable. The reality is that it takes a it takes a champion or ideally, champions, at whatever institution and whatever configuration of skill sets that bring open and endovascular to the mix. Is that dual trained people? Sure, that’ll work. Interventional radiologists and trauma surgeon that sure works. A vascular young vascular partner, and trauma provider that also works. Whatever the configuration, however you build your team, if you want to win the championship, you got to build an effective team. And, and I think that’s the key to success. Now, where we get into these real battles, these turf wars I see classically on the American east coast where you have kind of congested centers, big bulky centers where people have you’ve got IR, interventional radiology, vascular and trauma, all with big personalities, well established large, successful divisions, then you get into these turf battles that are a little bit unhealthy. Now that’s I’m caring. I’m not trying to characterize every senator that way. But I certainly know some that are. And yet you go to the American west, where there’s a lack of those kinds of strong, big, bulky programs and people they figured out, you know, they have whoever’s interested, acquires the skill set to do it safely. And partners in effective fashion with all the other disciplines and they figure it out, and they do great.

Chad Ball  29:40

I think that’s so true, Joe, you know, clearly, we both written a lot about timeliness to stop doing bleeding and it’s not like you and I have come up with that technique. It’s been around for almost 100 years. But you know, the reality and I think the line really is, a lot of these practice techniques are that they’re their techniques, their tools in a tool belt, and it’s about delivering you know, rapid and timely care to the right person in the right place, and whoever is the skilled individual in that system to do that should probably be supported, you know, to the best of everyone else’s abilities to be able to deliver that care.

Joe DuBose  30:14

Well, and the other thing, you have its not just interest, right. It’s not just the skill set, it’s also about availability. Yeah, that’s why I don’t think trauma surgeons will ever be completely out of mix. Because we have somebody has to get the process started, whether it’s just getting femoral access, putting a REBOA in, take him to the operating room to get things started, while the vascular surgeons come in from home. You it’s like a, I don’t know the hockey equivalent for you guys. But it’s, it’s like a baseball team. I mean, you need a starter, you need a middle reliever, and you need a closer. And I think that if you build out your team effectively, that’s how you win ballgames.  Yeah, there’s no doubt I completely agree. Joe, let me revisit the REBOA, in particular, with you just, you know, because it’s, it’s sort of been sexy now for, I don’t know, what do you think, like probably close to 10 years. And there’s certainly been some heavyweight debates or personalities on both sides of that, both sides of that, and, you know, a lot of discussion of, of the pendulum swinging too far one way in some centers versus others. With all that said, how do you frame REBOA in the real world, and in particular, you and I think we both agree it’s an essential tool on the right patient, but how does a program then go about obtaining expertise in REBOA and being able to safely not only introduce that technology and utilize it, but also the importance of monitoring their outcomes and, and improving over time? Yeah, I think you hit the two big points is acquire the expertise that can be done through the American College of Surgeons basic endovascular skills for trauma course teaches, primarily, REBOA but you can learn it from a master of your own facilities. Be familiar with a device familiar with the pitfalls. Most importantly, if you know where the cutting can go wrong, you can avoid it. And I think it’s not going to be for every patient. The hard part about REBOA and the challenging thing to study is who’s the perfect patient for REBOA and I don’t know if we’re ever going to define the perfect patient. Because so much of that also, you have to get the perfect outcome, you need the ideal patient, and you need the expertise. And the follow on. I think you do need to be have a appropriate process improvement, review these things when they happen. Was this the right patient? Was it not the right patient? How did it go? Where can we improve? Educate everyone on what REBOA is and what it can and cannot do. And most importantly, I think sometimes we, you know, it’s a challenging thing to study because so much of the information that we need to determine if a patient is correctly selected for REBOA or not, occurs in the first minutes, first 10 15 minutes of arrival, did they respond to resuscitation or not? And unfortunately, there’s no registry out there that has the response to resuscitation. I have their mission blood pressure, right, for 90 db, or any of the TQIP study, which is the TQIP data has been used by multiple folks to look at and it’s not particularly flattering for a bow when you use it. But I would contend that is you don’t know how much blood was given over what time frame and what physiological response was. If the patient responded to blood, they didn’t need REBOA. If they don’t respond, then you need to do something different. And if you can get to the OR in five minutes, like the old guys really can’t which is a can which is a myth, then great, but you can’t let the patient expire in front of you for want of a tool that might assist them. I also think we need to avoid the conversation. We got into this discussion about Swan-Ganz catheter is like 15, right. It’s a tool. REBOA and the Swan-Ganz are both tools. And it’s not the tool that’s to blame. It’s how you use the tool. Right? Swan-Ganz is a classic. I mean, there’s all kinds of studies you can find. Swan-Ganz killed people, Swan-Ganz don’t kill people. They’re useless or they’re not. It’s not what the Swan-Ganz in particular was a device endovascular device which was used for advanced monitoring information. And what you did with that information was what is important, and I think REBOA particularly now as a monitoring device with some of the modern devices, we can get A-line monitoring above or below the balloon and a therapeutic device, we fall into some of the same trap. It’s not REBOA, it’s the training and the expertise and patient selection and the patient selection of all the things is the most challenging to try to get at but we’re chewing away at it and trying to figure out.

Chad Ball  34:33

Yeah, I think that’s you know, it’s so well said, your summary is you know, dead on and I’ll tell the listeners that you know you’re a humble guy but you’ve worked and trained in two places that are really on the leading edge of the of the use of knowing quickies tricks and techniques but but REBOA in particular and you know it’s it’s easy to say well institution extra institutional, why uses that and everybody in too much, but whenever you speak on it, the way that you frame it is superb. And I think your your voice has really risen above the rest as reliable and, and helpful. So thank you for that.

Joe DuBose  35:10

Yeah, I, you know, I just I think about it a lot and I think about the smart way to do it. There’s a lot of divisive voices out there people who are super proponents for REBOA or super opponents from REBOA.

Chad Ball  35:21

For sure. Yeah.

Joe DuBose  35:22

And I think it’s okay, on the, it’s okay to be critical of any new technology. But you can’t be dismissive. You know, just outright dismissive on the basis of data that it’s not answering the question. So be critical of any new technology gets introduced, but avoid being dismissive, because otherwise somebody else is going to pick it up and use it. And then you’re not going to be left without that tool to save your patients.

Ameer Farooq  35:47

You sort of already touched on this, as you said, were, you really need to review your outcomes and have a robust way of tracking quality. But how do you see us going forward in terms of evaluating new tools like REBOA? Like what do you how do you how do you see that going about what what things do you think we can do better? To ensure that these things get rolled out safely that like, you know, I can tell you, in the colorectal world, there’s a big debate going on about TATME? Like there’s many, many different areas of surgery that are running into this problem? How do you see, you know, us going forward, embracing new technologies, while at the same time recognizing that, you know, many things that we thought were were useful, are maybe not as useful as we thought or only useful in in very specific situations?

Joe DuBose  36:37

Yeah, you know, you have to build a foundation of data. And you can do that through different ways. Everybody would love to do a prospective randomized control trial that has 20,000 patients in it, but it’s just not a reality, particularly here in the US. The way that we have skin some of that cat and trying to provide at least some foundational information, and the US has been through these blur, or I have at least is that my goal has been to build these larger multicenter registries that help get at some of these vascular injury questions. We have the AAST prospective observational vascular injury treatment, or PROOVIT registry, you got to have an acronym for study. It’s not gonna stick right. So it’s the PROOVIT registry. And then the REBOA registry is the AORTA, Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery, or AORTA registry. Those are not perfect. I don’t have in those all the variables I would love to have, but it’s most in the US at least trauma is one of the least funded disease processes that inflict effects, you know, more people than I mean, there’s more research going on in hangnails. Maybe I’m extrapolating a little bit or exaggerating, then trauma in the United States, but we need to do a better job of getting funding for some of these things. But in the absence of that, you have to rely on well-intentioned people who can provide reasonable quality data to try to get at some of these things. I think, and continue the debates. I think all of all conversation, I’m not talking about screaming matches, not talking about digging your heels in because my dog was better than mine, your dog mark. But real open ended thoughtful conversations between smart people, we’ll figure out the where the applications fit to a 90% solution, we’re never gonna get to 100%. But you got to have data and an open minded people to get to that 90% solution.

Chad Ball  38:24

That’s a that’s a really interesting point that you bring up, Joe, which is the, you know, the the funding of the research and the quality improvement side of what we do in injury and how traditionally and chronically underfunded that element is compared to, you know, a lot of the things I do on my HPV oncology side, which are much, much, much better funded, and it’s an interesting thing to think about, I always sort of have taken the viewpoint that a lot of it’s our, our fault. You know, there there’s enough TV shows on injury and pre hospital care and physician shows that we really shouldn’t be, I think, sort of in this position, you know, nationally and internationally. But we seem to be and I don’t know why that is probably is everyone’s busy and hasn’t really put the infrastructure together to deal with it. But do you have any thoughts on on funding and the chronic challenges of that, especially on the research and the quality side?

Joe DuBose  39:21

I don’t have a great solution. We’ve struggled there, I will tip my hat to the American College of Surgeons committee on trauma, which and other trauma organizations in the US which have tried to change the thought process of law makers with regards to funding for trauma, but it’s, you know, our National Institutes of Health doesn’t even really think about trauma as a disease process. The other organizations, all these other disease process cancers, a variety of the breast cancer, colon cancer, prostate cancer, they all have on some level, everybody’s been touched by those things. And the most, a lot of people been touched by trauma too, but they’ve been touched by these in these organizations have fun runs, they have very effective fundraising mechanisms. They have commercials. They have breast cancer week. We don’t have a trauma week, you know, in the United States.

Chad Ball  40:13

Yeah. Exactly.

Joe DuBose  40:14

And the trauma processes are frequently abrupt. They’re sad. They’re the ones that really claim lives are sad and abrupt. It’s not, you know, I watched my mother suffer through breast cancer, and that now I’m going to champion this cause. I had time to really get that whole cause burned into my very soul to move forward and champion for funding. And those are the people that marched on Capitol Hill and get the funding. And it it’s touched so many people, cancer diseases in particular, that it needs funding. But I just I agree with you, I’m kind of a marvel a bit of how trauma has not it’s, you think about you think about any cancer, you can think of a movie star that’s had that, right? Or even aortic aneurisms, you can think of a movie star that’s died as a complication of that. But trauma, James Dean crashed his car into a pole, you know, all those decades ago, didn’t seem to result in any additional trauma cheques. Right? Trauma fund. So it’s.

Ameer Farooq  41:09

It’s really been a pleasure to have you on the podcast. And I wanted to just put in a plug for a podcast that you recently started, called Tiger Country. And we’ll put the links in the description in the show notes. But I just wanted to also note that you’ve been on a lot of other podcasts. And one of the ones I really enjoyed that you were recently on was the podcast with Scott Weingart on the EMcrit podcast, we were talking about this before we started the show. And you did a really interesting episode with him talking about something that we don’t discuss very often but is underlying reality, to our interactions with emergency medicine, you talked about with Scott, Scott Weingart about why emergency medicine and trauma surgery just can’t get along. Can you tell us a little bit about what that discussion was like? And what motivated you to do an episode like that?

Joe DuBose  42:02

Yeah, and you know, I don’t want to ruin the whole podcast, because it was an exceedingly interesting conversation. And I would encourage, I’m not trying to self promote here. But Scott’s a really thoughtful guy. We didn’t agree on everything. But that whole thing came about, essentially, you know, we all notice it, right? We’re all taught. A lot of the people listening here on this podcast, you’re going to be surgeons, and we’re all taught don’t trust the ER doctors, they don’t know what they’re doing. They don’t know surgical diseases, right? So and the ER doc’s if you ask them and call them, what they’re told by their senior mentors, about surgeons is Oh, those guys just want to come down and cut up people and want to actually make people but you know, whatever the stereotypes or stereotypes across every specialty. And I think that the fun thing about stereotypes, and I’m not talking get into the deep weeds, and the dark waters of racial stereotypes are those things, although those need to be talked about openly as well, especially in the modern era. But when it comes to specially stereotypes, the best way to confirm is just head on and ask people what it what’s that what’s your stereotype of me? Of my field? And how do I fit into that? What do I how do I reinforce that? And what are the factors that contribute to that, and if you understand those factors, and I think more than anything, if you understand the stressors, and the thought processes of the people that you’re working with, that you have stereotypes about with regards to their specialty, you better become better partners. So Scott, and I had a great conversation. Like I said, I didn’t agree with everything. I think at one point there, he said that surgeons just have no business going to resuscitation, they should just stay out of the way and you know, and he talked a little bit about the fact that we often depending on every facility is different here. Shock trauma, we don’t really have an ER we have our trauma resuscitation area where we work with kind of collaboratively with anesthesiology ourselves and our EM heavy burden to the EM residents not a part of the heavy opportunity for EM residents to get involved. But, you know, your traditional some of your traditional trauma centers, you’re stepping down as a trauma surgeon into the ER doc’s realm and you’re often as surgical type A personalities which that’s their stereotype of us, you’re stomping, you’re stomping in there with your cowboy boots and your spurs. And you’re bossing folks around and you’re not and you’re not being respectful of dragging the mud in on their carpet, you know, so it’s, it’s, I find the stereotypes fascinating. We did one with our my wife just finished nurse practitioner training. And we did one with her before she finished on nurses, trauma nurses and doctors. And there’s a couple other ideas that I have along those lines. But I think it’s those stereotypes kind of confronting them head on and talking about them. One, it’s amusing because we all kind of know what the other folks say about us in terms of the stereotypes, but if you talk if you can mention it, you can manage it. And I think leaving those kinds of things on spoken about what the stereotypes are and why they exist because really criminal, you know, you got to get them out.

Ameer Farooq  45:04

You’ve been listening to Cold steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So feel free to email us at podcast.cjs@gmail.com or connect with us on Twitter @CanJSurg. Thanks again.