Counterintuitive emergency trauma practices may save more lives

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Charles Lanier had heard enough. Now, he needed some answers.

For a half-hour on Saturday morning, he and about a dozen fellow members of Hunting Park United sat quietly through a presentation about a new, counterintuitive study aimed at saving more adult gunshot and stab wound victims in Philadelphia.

The Philadelphia Immediate Transport in Penetrating Trauma Trial posits that, for patients who are potentially bleeding to death, less care is better before they reach the hospital.

The citywide study is randomized, meaning enrolled patients will get different medical attention based on the dispatch number city paramedics receive.

One group will get so-called advanced care, which includes common procedures such as inserting a breathing tube or supplying intravenous fluids.

Another would get what’s known as basic care and effectively go straight to the hospital without any of those medical interventions.

“It’s like the flip of a coin if patients are getting advanced or basic,” said Dr. Zoe Maher, a trauma surgeon at Temple University Hospital, which is leading the study.

That didn’t sit quite right with Lanier.

Mixed reaction

“In the interim, you’re still sacrificing people, somebody,” said Lanier on the second floor of the Hunting Park Recreation Center.

Yanitza Gonzalez, special projects liaison with City Councilwoman Maria Quinonez-Sanchez, nodded from across the room.

“It almost seems like we’ll be gambling with people’s lives,” said Gonzalez.

Board member Joanne Taylor also had some trepidation, but like nearly everyone in the group, has first-hand experience with gun violence.

She’s mourning a husband, son, grandson, and cousin, and said she’s willing to support anything that may save more lives. And she wasn’t alone.

“It shakes me up a little bit, but I know something has to be done somewhere,” said a teary-eyed Taylor afterwards.

Community buy-in is key for Maher. She needs it before patients are enrolled, potentially in September. It’s why she has run through the study with civic groups dozens of gunshot victims recovering in the hospital.

Television and print advertisements are also part of this months-long community outreach process.

The study will only look at IV fluids and breathing tubes.

Why less care is better

If someone is shot or stabbed and bleeding to death, the body instinctively tries save itself by constricting blood vessels and forming clots.

For those clots to stick, the body needs to keep your blood pressure a bit low. IV fluid can raise a patient’s blood pressure and upend all of this and, potentially, cause more internal bleeding.

Maher said a breathing tube could also be problematic. She said cardiopulmonary resuscitation — CPR — is a better option because it keeps more blood moving from the heart to the rest of the body.

“In animal models, we have shown that you can precipitate cardiac arrest, meaning make the heart stop faster,” said Maher.

The study’s sample size is big. Every resident in Philadelphia — all 1.5 million people — is automatically a potential enrollee.

Residents can opt out. They’ll get a wristband, which they’ll have to wear for the duration of the study, which is expected to last five years, maybe more.

Anyone who is under 18, pregnant, or a prisoner will also be excluded.

The study is expected to enroll roughly 1,000 patients. Half who get advanced care. Half who get basic care.

The goal is to change protocol in Philadelphia, but also nationally and internationally.

Minimizing risk

Maher said the study would end early if it’s clear that basic care is better for these patients or if that data are showing that it’s doing more harm than good.

“All of the evidence points to us being right, but if we are wrong, we will not complete the study,” she said. “We surely don’t want to hurt anyone.”

On average, about 30 percent of patients who would qualify for this study, die. If basic care becomes the norm for paramedics in Philadelphia, Maher said the rate could get down to roughly 20 percent.

In a city that routinely records 250-plus murders each year, that could potentially mean a lot of lives being saved.

Right now, the majority of patients who would be part of this study get advanced care if city paramedics transport them to the hospital. Up to half of them get to the emergency room by other means, including via police car, what’s known as “scoop and run.”

Every trauma center in the city is participating in the study. That includes: Temple University Hospital, Hospital of the University of Pennsylvania, Hahnemann University Hospital, Thomas Jefferson University Hospital, Albert Einstein Medical Center, Aria Health Torresdale, and City of Philadelphia Fire Rescue.

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