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Philadelphia conducting experiment to save gunshot victims

PHILADELPHIA (AP) — In all of last year, there were only 22 days when someone wasn’t shot in Philadelphia. Nearly 1 in 5 victims died.

Now, in a bold effort to stem the bloodshed, several Philadelphia hospitals are about to conduct a citywide experiment that will ask: When gunshot or stabbing victims are being rushed to the emergency room by ambulance, could paramedics do more to save them by doing less?

It’s a counterintuitive approach that could test long-held beliefs and change practices at trauma centers across the country.

Maybe all across the country, but I think that’s an exaggeration. It’s been known since the height of the Iraq and Afghanistan wars that early intubation decreases survival. For almost 10 years military surgeons have stopped intubating patients until just seconds before surgery starts. Why this news didn’t make it to Philadelphia, I don’t know. I know that the trauma centers I’m familiar with started doing this a few years ago. The more severe the injury, the more early intubation increased mortality.

Normally, paramedics intubate patients to keep their airway open, and give IV fluids to counteract a drop in blood pressure. But supporters of the study say that for victims who are bleeding through an open wound, these procedures may cause an increase in blood pressure that can accelerate blood loss and death.

Way, way, way, behind the treatment curve and current recommendations. I’d have to say that we stopped aggressive fluid resuscitation in trauma patients over a decade ago. Rapid fluid resuscitation increases hemorrhage and death. Our protocol was to keep the blood pressure around 90 systolic, no more. We didn’t make that up, it came from the surgeons who did the studies. Again, it’s surprising, or maybe shocking that they are just studying this in Philadelphia.

It is being headed by Temple University Hospital’s chief of surgery, Dr. Amy Goldberg, who has treated thousands of shooting victims in the three decades she has worked in Philadelphia.

“If this is not a public health crisis, I don’t know what is,” she said.

I wonder what her survival rate is if she is that far behind the rest of the trauma treating world? Oh, and she obviously doesn’t know what a public health crisis is. This might be a crisis, but it’s not a public health crisis.

The Temple surgeon patiently laid out her case, even as she acknowledged the selection process is “like the flip of a coin.” Retrospective studies, she said, have shown that gunshot and stabbing victims given basic life support – such as an oxygen mask, CPR or immobilization – had an 18 percentage-point survival advantage over those given advanced procedures, such as intubation, in an ambulance.

As the saying goes, “Nothing heals like cold steel.” The cure for trauma is surgery, the sooner the better. When you are doing something that is proven to not only not help, but harm the patient, you are violating one of the basic tenets of medicine. Trauma care is simple. Stop the bleeding, maintain an open airway, ensure sufficient air exchange, go to the hospital. This is why I laugh when I see systems that put cardiac monitors on patients, do blood glucose checks, and ask people who are bleeding to death what their favorite vegetable is.

Okay, I’m kidding on the last one, but not by a whole lot. Do the basics, minimize on scene time, transport to a trauma center (if there is one), and stop farting around. Feel free to insert a stronger word that starts with F into that sentence.

I also laugh that the hospitals are going to take five years to “study” this.

Keep in mind that the only drug that is likely to change the long standing paradigm of prehospital trauma care is Tranexamic Acid. It might be the long sought after “Holy Grail” of pre hospital trauma care, but that’s a topic for another day.

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.

2 COMMENTS

  1. We have just been informed that we are gearing TXA in our system. I know you said that’s a topic for another day, but dammit, you brought it up.

    We’re a rural system that doesn’t see a great deal of massive trauma hemorrhage. I’m dubious.

    • I have no direct experience with it, but people who do tell me it works well. I think my former agency is going to start using it soon. I’ll ask around and see what I can find out about it. Stay tuned.

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