INTRODUCTION

Pelvic fractures, commonly resulting from high-energy trauma, are often associated with severe hemorrhage and shock, leading to high mortality rates [1]. The management of bleeding pelvic fractures generally requires a multidisciplinary approach, including external fixation, preperitoneal pelvic packing, and transarterial embolization as definitive treatments [2,3]. However, most hospitals, apart from designated trauma centers, lack the capability to provide such definitive care. In these situations, patient transfer is unavoidable. Interhospital transfer becomes particularly challenging if a patient’s condition deteriorates. This report presents a case in which resuscitative endovascular balloon occlusion of the aorta (REBOA) was used to stabilize a critically deteriorating patient with a bleeding pelvic fracture prior to transfer to the authors’ trauma center via a physician-staffed ground emergency medical service, “doctor car.”

CASE REPORT

A 62-year-old man, injured in a motorcycle accident, was initially managed at a hospital in Incheon, Korea, where he was diagnosed with a bleeding pelvic fracture (Figs. 1, 2). However, the facility was unable to provide definitive treatment. As a result, a surgeon-staffed ground emergency medical service, a doctor car (Fig. 3) was requested from our trauma center.

A trauma surgeon was dispatched via doctor car to the referring hospital. Upon arrival, the patient’s vital signs were as follows: blood pressure, 72/49 mmHg; pulse rate, 113 beats per minute; respiratory rate, 29 breaths per minute; and body temperature, 35.1 °C. Serum lactate was 9.7 mmol/L, indicating severe hypoperfusion. Due to the patient’s hemodynamic instability, immediate interhospital transport was not possible, necessitating REBOA deployment before transfer. The dispatched surgeon inserted a preprepared REBOA catheter (RESCUE 7, Tokai Medical Products) into the left common femoral artery using ultrasonography-guided percutaneous puncture. The catheter tip was confirmed in zone III by portable x-ray, and the balloon was inflated (Fig. 4). Initial full occlusion led to a rapid rise in systolic blood pressure above 100 mmHg, which was excessive, prompting partial deflation to maintain a target systolic pressure of 80 mmHg. The entire procedure from puncture to balloon inflation took 12 minutes, after which patient transport commenced. The patient arrived at the trauma center within 37 minutes. During transport, the surgeon aboard the doctor car maintained real-time communication with the trauma center to facilitate pre-arrival preparation for preperitoneal pelvic packing (PPP) and transarterial embolization (TAE).

Upon arrival, the patient underwent PPP followed by angiography, which revealed contrast extravasation from a branch of the left internal iliac artery, necessitating transarterial embolization. Postoperatively, he was admitted to the intensive care unit, where he gradually stabilized. The packed gauze was removed 48 hours after PPP, revealing a 6-cm longitudinal laceration on the lower anterior bladder wall, which was subsequently repaired. Additionally, an anterior rectal injury was identified during intraoperative rectal examination, requiring transanal rectal repair and a sigmoid loop colostomy.

On hospital day 5, the patient underwent closed reduction and internal fixation of the pelvic fracture. He showed gradual clinical improvement but required conservative management for a persistent bladder leak, which resolved after 3 months. He was subsequently discharged with no further complications.

Ethics statement

This study was approved by the Institutional Review Board of Gachon University Gil Medical Center, with a waiver of informed consent (No. GCIRB2025-051).

DISCUSSION

Transporting trauma patients in shock presents substantial challenges, particularly when definitive care is unavailable at the referring hospital. In these cases, interhospital transfer is necessary, and bridging strategies must be implemented to stabilize the patient beforehand. REBOA serves as an effective method for temporary hemorrhage control during transfer.

Aortic cross-clamping (ACC) is traditionally used for hemorrhage control in exsanguinating trauma patients. However, its use during transport is significantly limited by the risk of device dislodgement or displacement, which may lead to uncontrolled bleeding. Furthermore, because ACC involves proximal aortic occlusion, definitive hemostasis must be achieved quickly to prevent ischemic complications. Given the potential duration of inter-hospital transport, ACC is generally impractical for transferring severely injured patients.

Although the transport time was 37 minutes, the total interval from initial hospital arrival to definitive hemostasis exceeded 1 hour, raising concerns about ischemic complications from prolonged REBOA use. Fortunately, no ischemia-related adverse events such as tissue necrosis, neurological deficits, or lower limb ischemia were observed. Zone III REBOA was deliberately selected for its lower risk of ischemic injury and suitability for longer occlusion durations compared to zone I [4].

To further reduce the risk of ischemia, partial REBOA was used to allow limited distal perfusion [5], and a permissive hypotension strategy was applied during resuscitation. These measures maintained adequate proximal perfusion while minimizing complications during transfer.

Successful REBOA use requires specialized physician training for both deployment and ongoing management. Its effectiveness depends not only on proper application but also on timely execution of definitive hemostasis [6]. In this context, the doctor car system at our trauma center provides an integrated trauma care model, enabling REBOA deployment and prompt hemostatic intervention in a coordinated fashion for hemodynamically unstable patients.

Physician-staffed ground emergency systems operate in several European countries and Japan, with studies suggesting a positive impact on patient outcomes by allowing trained physicians to provide direct advanced emergency care. Despite ongoing debate regarding cost-effectiveness, existing literature supports their role in improving prehospital trauma care [7,8].

Unlike other physician-staffed models, the doctor car system at our trauma center is exclusively dedicated to trauma patients. While its deployment to accident scenes is infrequent, it is primarily used for interhospital transfers of severely injured patients. When a patient requires transfer for definitive treatment unavailable at the referring hospital, a doctor car deployment request is sent to the trauma center. The on-duty trauma team leader evaluates the necessity of dispatching the doctor car, which consists of a driver, an on-duty trauma surgeon, and a nurse.

The doctor car is dispatched in three primary scenarios. First, it is deployed directly to accident scenes when rescue efforts are prolonged or in disaster situations. For instance, in one case, a patient sustained a crushing injury after their arm was trapped in a large structure at a construction site. To address an extended rescue process, the doctor car surgeon performed a field amputation to extricate the patient [9].

Second, it is used for interhospital transfers when patients need to be transported to a trauma center for specialized care. While the doctor car system may seem to introduce delays due to its round-trip deployment, this is consistent with standard interhospital transfer procedures in Korea. Transfers are typically coordinated via the national emergency medical transport service (“129 Ambulance”), which sends an ambulance to the referring hospital upon request. Thus, doctor car arrival times are often comparable to those of the 129 Ambulance.

Importantly, unlike the 129 Ambulance system, the doctor car is staffed by a trauma surgeon and nurse, permitting advanced resuscitative interventions at the referring facility. This capability is a major advantage, particularly in time-critical situations where definitive care is delayed, as shown in this case.

In recent practice, the doctor car may also be equipped with packed red blood cells for emergency transfusion, enabling life-saving resuscitation at hospitals lacking an in-house blood bank. This significantly improves the quality of pretransfer care, especially for patients in hemorrhagic shock.

Lastly, the doctor car is dispatched when a trauma incident occurs at a significant distance from the trauma center. In these cases, the patient is first taken to the nearest emergency department, where paramedics notify the doctor car team. While the local hospital begins basic resuscitation, the doctor car retrieves the patient and continues transport to the trauma center for definitive treatment.

In this case, both REBOA and the doctor car system were used effectively for the interhospital transfer of a patient with a bleeding pelvic fracture. Beyond this individual case, such an approach has broader implications and may benefit other major trauma patients requiring transfer to facilities with definitive treatment capabilities.

Transporting critically injured trauma patients is especially challenging when hemodynamic instability complicates transfer. In these circumstances, REBOA and surgeon-staffed ground emergency transport systems can serve as effective bridging strategies, providing temporary hemorrhage control and enabling safe transfer to trauma centers for definitive treatment.

ARTICLE INFORMATION

Author contributions

Conceptualization: HS, SHL, KKC; Investigation: HS, SHL, MJJ; Methodology: GJL, BY, MAL, JHK, KKC; Project administration: GJL, BY, SHL, MJJ, KKC; Visualization: JHK; Resources: JHK; Writing–original draft: HS; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

Gil Jae Lee is the co-editor-in-chief, Min A Lee is the associate editor, and Seung Hwan Lee and Kang Kook Choi are editorial board members of this journal, but were not involved in the peer reviewer selection, evaluation, or decision process of this article. The authors have no other conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Pelvic radiograph demonstrating diastasis of the pubic symphysis (arrows) and sacral fracture (arrowheads).

Fig. 2.

Computed tomography shows diastasis of the pubic symphysis with contrast extravasation (arrowheads).

Fig. 3.

The "doctor car," a surgeon-staffed ground emergency medical service for trauma, dispatched from the trauma center.

Fig. 4.

Pelvic radiography following resuscitative endovascular balloon occlusion of the aorta (REBOA)-catheter insertion.

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Figure & Data

References

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