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Rachel Leah Blumenthal

Unpublished article for a science journalism graduate course (11/16/08)

Saving Bleeding Trauma Patients: Too Much Tradition, Too

Little Evidence
A fifty-five-year-old man with an accidental gunshot wound
to his thigh arrived at the Dartmouth-Hitchcock Medical Center
(DHMC) emergency room with massive pelvic bleeding, low blood
pressure, and other indicators that his blood was not clotting.
Like many other critically injured patients, he was suffering from
coagulopathy, an injury-induced inability to clot blood. Doctors
were able to tie off a damaged vein in the pelvic area, but he had
already lost several liters of blood and was quickly losing more.
Following massive transfusion guidelines, doctors supplied him
with 24 units of red blood cells, 20 units of fresh frozen plasma,
and four units of platelets. He spent the next six hours in the
intensive care unit, still bleeding, with an abnormally low body
temperature. He was given more blood, and his temperature
stabilized. The bleeding finally stopped. “He really continued to
bleed profusely from the pelvis, despite no further large vessel
injury, because of his coagulopathy,” explained Dr. David Hughes,
the trauma chief resident at DHMC.
Coagulopathy affects about one in four trauma patients.
When blood cannot clot, the patient cannot stop bleeding. About
40% of trauma deaths are caused by uncontrolled bleeding, often
due to coagulopathy, so better understanding of the condition
may drastically decrease that death rate.
According to a survey published in October’s issue of Journal
of Trauma by the Educational Initiative on Critical Bleeding in
Trauma (EICBT), a panel of trauma experts, there are vast
regional differences in how hospitals recognize and manage
coagulopathy in the early stages after injury. The survey
indicates a need for standardized protocols.
As recently as ten years ago, many doctors didn’t even
realize that coagulopathy was a significant problem within the
first hour after injury. Patients would come to the emergency
room “potentially bleeding to death,” and there would be an hour-
long lag between arrival at the ER and blood tests coming back
from the laboratory, according to Dr. Rajan Gupta, director of the
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Rachel Leah Blumenthal
Unpublished article for a science journalism graduate course (11/16/08)

trauma program at DHMC, who was not involved with the EICBT
survey. When the test results finally showed that a patient was
suffering from coagulopathy, doctors treated the patient with
blood products. “That’s too slow…you’re often too late,” said
Gupta. The recent wars in Iraq and Afghanistan have taught
doctors that they must act more quickly, making treatment
decisions based on “clinical suspicion” before the lab results
come back. This new paradigm has become more widespread
over the last several years, although understanding and
management of post-traumatic coagulopathy is still inconsistent
throughout the medical community, according to Gupta.
In an effort to increase understanding of coagulopathy,
especially with regard to that critical first hour, a group of trauma
experts formed the EICBT in 2006. The interdisciplinary panel
spans the globe. Novo Nordisk, a Danish foundation that supports
“scientific, humanitarian, and social purposes,” provides the panel
with grant money. In late 2006, the EICBT began to put together
the survey that was published last month. It aimed to assess
worldwide variations in the medical community’s recognition and
management of coagulopathy. Members of the EICBT sent the
survey to colleagues around the world, and 80 people from 25
countries responded.
According to the survey, hospitals in different regions varied
in how they assess whether a patient is suffering from
coagulopathy. Measurements of blood loss, temperature, and pH
are widely used diagnostic factors, but there were significant
variations in the use of rotational thromboelastometry, a special
test that assesses the physical properties of clotting blood.
The early management of injured patients falls under
different people depending on the region. In the Americas, a
surgeon is almost always in charge in the beginning. In Europe
and the Middle East, however, it’s either an anesthesiologist or a
multidisciplinary team. Asian countries also tend to have
multidisciplinary teams in charge at the beginning.
Although these are significant variations in diagnostic tools
and who’s in charge of the patient, they may not be dangerous
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Rachel Leah Blumenthal
Unpublished article for a science journalism graduate course (11/16/08)

problems. More alarming is the varied usage of protocols for

performing massive blood transfusions. While nearly half of the
respondents did report using protocols, another one-fifth admitted
inconsistent use, and about a third do not use them at all.
Additionally, protocols that do exist are different from each other.
While two-thirds of protocols instruct physicians to use specific
ratios of the different types of blood - red blood cells, platelets,
and fresh frozen plasma - other information varies widely. This
leaves doctors without consistent guidelines to follow when trying
to save patients who are bleeding to death.
The absence of consistent protocols has a potentially
dangerous effect on critical care: tradition takes hold. In the
discussion of their survey, the EICBT wrote, “Many aspects of
clinical practice seem to be based on tradition and dogma rather
than scientific evidence.” Many physicians mentioned problems
with the system in place at their own institutions, and about two-
thirds acknowledged that barriers exist at their institutions that
negatively affect patients.
“We strive to create evidence-based medicine but what we
frequently do is create guidelines based on little or low-level
evidence,” explained Dr. Zbigniew Szczepiorkowski, the director
of the transfusion medicine service at DHMC. “Evidence can be
divided and stratified based on the source.”
Lack of timely lab results, poor team training and
communication, and lack of equipment are also problems at many
hospitals, the survey found. Over 60% of respondents thought
that international guidelines on how to manage coagulopathic
trauma patients would help their institutions improve. However,
some expressed doubts that their institutions would readily
change. “The review of "scientific" data by different individuals
and groups will not always result in acceptance of new concepts,”
said Dr. Kenneth Burchard, a professor of surgery at DHMC. “A
new paradigm will require not only a mindset shift in the first
responder, but a similar institutional shift that would result in
more rapid diagnosis and treatment.”
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Rachel Leah Blumenthal
Unpublished article for a science journalism graduate course (11/16/08)

Unfortunately, improvements in the understanding of

coagulopathy happen slowly; it is a difficult condition to study,
especially because there are no reliable animal models for blood
clotting, according to Dr. Ernest Moore, the chief of surgery and
trauma services at Denver Health. However, he is currently
involved in research to improve upon a technology called
thromboelastography that will aid in coagulopathy research.
It is also tricky to design human studies well. “There are
obvious difficulties in designing and performing randomized
controlled trials in trauma, especially when the patient may not
have a chance or opportunity to give an informed consent to
participation in the study,” explained Szczepiorkowski. “For this
reason in some of those trials a community consent is used which
is not only expensive but also cumbersome.”
In a commentary accompanying the survey, the EICBT wrote
that “the evidence base that can explain the mechanisms behind
early traumatic coagulopathy and the corresponding animal
models with which to study this phenomenon is thin, and …
further research is warranted.” Further research is indeed
occurring; coagulopathy is the most frequently explored topic in
the current trauma literature.
“Concepts of trauma-related coagulopathy are rapidly
evolving, especially as information about military trauma care in
Iraq becomes more disseminated,” according to Burchard. “At
present, the most useful concept is that trauma can cause
coagulopathy early and that anticipation from a diagnostic and
therapeutic perspective may prove beneficial.”