During Trauma Awareness Month: A Program to Stop the Bleeding

May 24th, 2017

Dr. Ronald Stewart answers questions about the Stop the Bleed program, which he presented to a Rotary Club in San Antonio this week.

Dr. Ronald Stewart, Chair of the Department of Surgery at the UT Health Science Center San Antonio, has an audacious goal: to teach 200 million people a simple approach to stop life-threatening bleeding. As Chair of the American College of Surgeons (ACS) Committee on Trauma, Stewart is an ambassador for the Stop the Bleed program, a nationwide campaign sponsored by the ACS and the U.S. Department of Homeland Security.

“We want to turn bystanders into first responders,” he explained, as he began his presentation to a roomful of Rotary Club members in San Antonio this week. By remembering the ABC’s of bleeding, people who witness terrible accidents, car crashes, blasts, or shootings can save lives. Uncontrolled hemorrhage is the leading mechanism of death resulting from a traumatic injury.

The ABC’s of bleeding are:

A-Alert (call 911 immediately)

B-Bleeding (locate the source of the bleeding)

C-Compression (apply direct pressure or a tourniquet to stop the bleeding)

“Often people are worried they might hurt the victim they are trying to help,” he said. “But if the victim dies, that’s a moot point.” Dr. Stewart encouraged the audience to act fast and not be afraid. An effectively placed tourniquet is going to hurt, but it’s better to cause a few bruises and save a life, he noted.

Dr. Stewart demonstrates proper placement of a tourniquet.

The very best option is to have a bleeding control kit on hand, which will include a standard tourniquet and sterile hemostatic dressings to use for compression. “But if you don’t have a tourniquet or hemostatic gauze (such as QuikClot or Celox), stuff any gauze or clean cloth directly into the wound and apply pressure,” Stewart instructed. “It’s better to pack the gauze into the wound than to simply hold it on top of the wound.”

“The only thing more tragic than a death is a death that could have been prevented,” said Stewart in urging the audience to learn the technique, purchase bleeding control kits, and spread the knowledge.

Order your Bleeding Control Kit. Contact the ACS Committee on Trauma at 1-877-305-9440 to become a Stop the Bleed trainer.

Trauma News Interview with Stewart and Winchell Captures Gist of Stakeholder Meeting on Zero Preventable Deaths

May 16th, 2017

Suggesting that the messaging surrounding the development of a national trauma system should shift from the traditional public health realm to the realm of national security, Dr. Ronald Stewart and Dr. Robert Winchell elaborated on the outcomes of the April meeting of stakeholders in the NASEM report on a National Trauma Care System published last year.

The broad consensus at the meeting, held in Bethesda, MD, was that “there needs to be a strong central directive, but the details need to be worked out locally,” said Winchell. Following establishment at a federal level, he said, “The actual nuts and bolts of the system would be developed by a broad coalition of the providers of the trauma community.”

Dr. Stewart also noted that trauma deaths occurring before the victim arrives at a hospital need to be explored if the goal of Zero Preventable Deaths after Injury is to be realized. “People recognize that if we’re going to get to zero preventable deaths, we have to know what those deaths are and when they occur. That would impact, for example, where you might put EMS resources or what you might do to improve access.”

Another gap in understanding is long-term outcomes for those suffering trauma. “We need to try to work towards data linkage to get more information on those prehospital deaths and also on long-term outcomes after somebody leaves the hospital or leaves a rehabilitation center,” explained Stewart.

“While you might argue that the NASEM report argues for some major revolutionary changes in how things are done, the practical implementation will in many ways be more evolutionary,” suggested Winchell. ”This effort is not necessarily creating entirely new systems, but leveraging existing initiatives and existing programs in a way that serves the end goal better.”

Attendees agreed that the call to action should be modified to ZPDD: Zero Preventable Deaths and Disability.

Read the article.

Trauma Surgeon Provides Sober Context for Alcohol Awareness Month

April 18th, 2017

Dr. Terrence Curran is a trauma surgeon in Morristown, NJ.

There is a disease that causes approximately 88,000 deaths each year in the United States, shortening the lives of those who die of it by an average of 30 years. It is responsible for 10% of deaths among adults aged 20-64 years and kills more than 4,000 children each year. The economic costs are estimated at a staggering $250 billion annually. There are strategies to prevent it, and yet it continues at this alarming rate with many misconceptions about its epidemiology and impact.

Alcohol abuse and misuse is not a new phenomenon, and I am not calling for the return of Prohibition. But it is a major public health problem with known interventions that can diminish its impact.

The negative side effects of alcohol abuse ruin many lives each year. Impaired driving leads to motor vehicle crashes, both fatal and nonfatal, that devastate lives, unnecessarily consume healthcare and law enforcement resources, and have major financial impact on society. Decreased inhibition, impaired decision making and coordination lead to interpersonal violence, including homicide, suicide, sexual assault, and domestic violence.

Two areas where intervention can have a pronounced impact are on preventing drunk driving and preventing underage drinking.

The days of “one for the road” should be over but, unfortunately, statistics prove otherwise. In 2014, 9,967 people were killed in motor vehicle crashes related to alcohol impairment. In 2015 that number rose to 10,265. The number of victims of alcohol-impaired crashes is multiplied as family and friends are left to grieve.

Visiting the MADD website, one can experience a glimpse of the heartbreak endured by families devastated by drunk driving. Heartbreak that was avoidable. Effective interventions to reduce drunk driving include enforcement of impaired driving laws with sobriety checkpoints, ignition interlocks for all persons convicted of drunk driving, and mass media campaigns to highlight the dangers and legal repercussions of drunk driving.

Underage alcohol consumption is costly: 4,300 lives lost annually, and many times more lives affected.  Although the large majority of persons under 21 do not engage in alcohol consumption, the majority of underage drinking is done in a very risky fashion by a small proportion of youth starting at very early ages, even as young as 12. Underage drinking is strongly linked with death from alcohol poisoning, unintentional injuries, such as car crashes, falls, burns, and drowning, suicide and violence, such as fighting and sexual assault.

Other risky behaviors such as smoking, drug use, and unprotected sex are also more likely when children engage in alcohol use. Schools, families and communities can work together to foster an alcohol-free environment through education, a proper legal environment and offering age appropriate alternative activities.

April is alcohol awareness month. The Centers for Disease Control, the National Council on Alcoholism and Drug Dependence, and Mothers Against Drunk Driving are several of the organizations promoting April 21st as Powertalk21, a day for conversation about the dangers of underage alcohol use. It can also be used to discuss alcohol issues with those over the age of 21, focusing on injury prevention to help prevent deaths, injuries, and despair that are a result of avoidable, alcohol related trauma.

Please visit MADD.org, NCAAD.org or the CDC.gov to learn more.

Advocacy Should Be Part of Every Surgeon’s Job

April 10th, 2017

In a letter published in Trauma Surgery & Acute Care Open April 3rd, surgeons Lewis Kaplan, Erik Barquist, Donald Jenkins and Orlando Kirton argue that more surgeons should be advocating for the trauma profession and for the benefit of trauma patients. Members of national organizations. “…need to embrace advocacy with the same vigor and dedication as they do patient care, education, and scientific inquiry,” they say.

Decrying the limited participation in advocacy among the trauma society memberships, these surgeons believe that “advocacy efforts targeted at clearly defined aspects of care should be considered a professional activity, and given equal footing with administration, academic productivity and teaching.” They appeal to surgeons’ ethical imperative to do so, encourage surgical organizations to bring advocacy into the mainstream at national meetings and to provide training in advocacy, encourage professional journals to publish on advocacy efforts, and encourage academic medical centers to allocate time for this activity.

More surgeons will have to speak to their elected officials if the recent effort to build a national trauma care system and to achieve Zero Preventable Deaths (#TraumaZPD), per NASEM’s 2016 report, is to be successful, they argue.

Mangled Extremity Score Not a Reliable Predictor of Amputation

March 2nd, 2017

In a study with results published in the Journal of Trauma and Acute Care Surgery (Vol. 82, No. 3), the PROspective Observational Vascular Injury Treatment (PROOVIT) group found that “Blunt injuries, vessel transection, popliteal injuries, and concomitant nerve and orthopedic injuries were associated with the need for amputation, and were more predictive than an isolated [Mangled Extremity Severity Score] MESS.”

The group employed the PROOVIT database to re-evaluate the MESS after other tests of the scoring system, originally developed in 1990, questioned its validity. Since the introduction of the MESS, researchers have developed alternative scoring systems including the Limb Salvage Index; the Predictive Salvage Index; the Nerve, Injury, Ischemia, Soft-tissue Injury, Skeletal Injury, Shock and Age of Patient Score (NISSA); and the Hannover Fracture Scale. And military surgeons have concluded that the MESS is not useful in battlefield-related injury classification.

“Prehospital use of a tourniquet, damage control, balanced resuscitation, use of vascular shunts to reduce ischemia time, early fasciotomy, aggressive wound care, mircrosurgical abilities, and advanced tissue coverage techniques have all contributed to our increased ability to care for patients with mangled extremities,” they concluded. “We advocate for the use of a team approach to decision making regarding limb salvage rather than the use of a score.”

PROOVIT investigators, funded by the Department of Defense through the National Trauma Institute, continue to evaluate a growing pool of data in order to inform practice decisions and assure the best outcomes for patients with limb-threatening mangled extremities.

“The optimal management of peripheral vascular injury remains a complex issue,” said Joe DuBose, MD, the study primary investigator. “Our effort was designed to re-examine the validity of standardized grading systems in predicting outcome for these injuries. I think the work proved useful in determining that we need additional research on the topic. It is our hope that the further maturation of the PROOVIT registry will provide some much needed answers in this important area of trauma care.”

Read the article in JOT.

Novel Markers of Mortality Identified in Combat Trauma

February 24th, 2017

This month, NTI board member, Deputy Chair of Surgery and Division Head of Critical Care and Acute Care Surgery at the University of Minnesota, Greg J. Beilman, MD, and colleagues published a study evaluating plasma metabolomics in combat trauma in the Journal of Trauma and Acute Care Surgery (Vol 82, No 2). The researchers hypothesized that succinate was a marker of mortality and sought to identify other biomarkers of mortality and injury severity.

Extracting and evaluating demographics and outcome data from the Joint Trauma Systems database, Beilman et al. determined that succinate and lactate are major markers of mortality and injury severity, as is hypoxanthine. “In short,” report the researchers, “VIP-identified metabolites associated with trauma are positively correlated with clinical markers known to increase with severe bleeding and are negatively correlated with clinical markers known to decrease with traumatic hemorrhage.”

The work confirms previous findings in porcine models and may lead to testable treatments for the outcomes of trauma in both civilian and military patients.

Read the article: Assessment of key plasma metabolites in combat casualities

USAISR Receives FDA Approval for Compensatory Reserve Indicator

February 6th, 2017

Collaborating with other scientists and engineers, the U.S. Army Institute of Surgical Research developed an algorithm that measures the body’s ability to compensate for blood loss, or the compensatory reserve. The compensatory reserve index (CRI) can predict when a patient is about to go into hemorrhagic shock. The device, which takes readings from a standard pulse oximeter, received FDA clearance in December 2016.

USAISR researchers believe that combat medics attending to battlefield wounded, as well as civilian EMTs, can employ the device to save lives, as it can continuously monitor patients and provide a guide for fluid resuscitation and other interventions.

Read the full story.

CDC Reports on Higher Death Rates in Non-Metro Areas

January 17th, 2017

The January 13th edition of the CDC’s Morbidity and Mortality Weekly Report (MMWR) provides an assessment of the leading causes of death in non-metro and metro areas between 1999 and 2014, concluding that higher rates of death occur in non-metro areas of the U.S.

After calculating age-adjusted death rates and potentially excess death in metro and non-metro areas for the five leading causes of death–heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke–the CDC concluded that more than half of all deaths (57.5%) from unintentional injury, specifically, that occur outside metro areas were potentially excess (potentially preventable). In metro areas, that rate is 39.2%.

The report suggests the higher rate of excess death in more rural areas of the country may be related to a variety of factors including less access to health care services, further distance to trauma care centers, and reduced EMS services as well as behavioral factors like physical inactivity during leisure and lower use of seat belts.

“Routine tracking of potentially excess deaths in nonmetropolitan areas might help public health departments identify emerging health problems, monitor known problems, and focus interventions to reduce preventable deaths in these areas,” the report concludes.

NTI Board Member Gibran Earns Distinguished Alumna Award

January 9th, 2017

Dr. Nicole Gibran, professor and Director of the UW Medicine Regional Burn Center at Harborview Medical Center, has been honored by colleagues in the Alumni Association of Boston University School of Medicine (BUSM) with its Distinguished Alumna Award. This annual award will be presented to Dr. Gibran in recognition of the significant impact she has had in the medical field on a national and global scale. The award will be presented to Dr. Gibran at BUSM in May 2017.

Dr. Gibran is a member of the NTI Board of Directors, one of many positions of prominence she holds within the medical field.

Op-ed in JAMA Surgery Decries Limited Funding for Trauma Research

January 5th, 2017

Despite significant advances made in U.S. trauma care and systems over the past 50 years, traumatic injury continues to be an unacceptable and increasing societal burden, argues Kimberly Davis, MD, in an opinion piece published in JAMA Surgery in December. Davis is a professor in the Dept. of Surgery at Yale University and a member of the executive committee of CNTR, the Coalition for National Trauma Research. The National Trauma Institute is a member of CNTR.

Davis and co-authors Timothy Fabian, MD, and William Cioffi, MD, point to the lack of a centralized national home and stable funding stream for trauma research to explain how this public health problem has reached epidemic proportions. “…[S]ince 1966 the mortality rate has increased 0.66% per year,” they say. And the annual costs are astronomical: $214 billion for fatal traumatic injury and $457 billion for non-fatal injuries, including healthcare and lost productivity.

Davis et al. consider the billions of dollars in research funding directed toward Ebola and Zika–both serious public health issues in recent years, yet neither impacting the United States to any degree–and wonder about the lack of attention paid to trauma. “It is shocking that nearly 150,000 deaths every year do not warrant a similar response.”

Read the article. (doi:10.1001/jamasurg.2016.4625)