Researchers at Hahnemann University Hospital and Temple Lewis Katz School of Medicine are collaborating on a new study called the Philadelphia Immediate Transport in Penetrating Trial (PIPT) with the goal of increasing the survival rates of victims suffering from penetrating traumas. Temple University’s Dr. Zoe Maher and Hahnemann’s Dr. Brendan McCracken hope this study will lead to a change in the way victims of gunshot, shotgun or stab wounds, who are likely to bleed to death are transported in emergencies.
PIPT will study a highly specific segment of Philadelphia’s population—patients who suffer from penetrating traumas being transported in advanced life support ambulances who are subject to advanced pre-hospital interventions. These interventions include fluid resuscitation, where a patient is given an intravenous salt-water solution to prevent dehydration and the placement of a breathing tube. The findings of this study suggest that it might be better for patients suffering these traumas to receive basic pre-hospital care as opposed to the two aforementioned methods.
To put the study in perspective, there are almost 300,000 emergency medical calls a year in Philadelphia, and PIPT will be examining a population of 250 people a year. Advanced transport is one of three accepted methods to transport patients. 40 percent of patients come in with police, 40 percent come in through advanced life supports and 15 percent come in through basic life support.This study will compare the latter two.
The study will be conducted over the course of five years, collaborating with all trauma centers around Philadelphia and including Philadelphia EMS. During the period of the study, whenever an advanced life-support care transport is assigned to answer a call, they will randomly commit to either of the two intervention methods: basic or advanced. The randomization will be facilitated through the study. Once on the scene, EMS will do what they always do: assess the patient by determining what type of trauma they have and whether or not they are bleeding to death. If patients are bleeding to death due to having been shot or stabbed, they will be considered enrolled in the study. Though this convention, every patient in the study will undergo an accepted method of care. Once a patient is sent to the hospital and treated by trauma surgeons, they will be formally asked to consent to further tracking of their recovery progress.
“This is the kind of patient population that we think will potentially benefit most from, first, more rapid and, second, less intervention based pre-hospital care,” Maher said in an interview. “The first part of this is something people can easily understand. If you’re bleeding to death, faster intervention to get you to stop bleeding to death is common sense,” she continued.
“It’s the intervention thing where I think not just lay people, but medical people kind of have a moment of pause,” Maher explained. According to Maher, past data has suggested that salt water resuscitation and breathing tubes may be unhelpful or even harmful, but that data is low quality.
So we can’t say for sure that we’re right, but there’s a very strong suggestion that we may be right,” Maher continued.
According to Maher, in the case of fluid resuscitations the elegant system in human bodies that controls blood flow can be altered by the influx of fluid provided by IVs. When losing large quantities of blood, the body will normally reduce blood flow to the injured area and increase flow to vital organs such as the brain. However, the influx of salt water from an IV affects this process in several ways: it decreases the oxygen carrying capacity of the blood because salt water cannot carry oxygen, decreases the body’s ability to coagulate or create blood clots to plug up holes and lastly allows for the potential reopening of previously created blood clots.
“There are two more factors to add on to this,” Dr. McCracken added during the interview, “The salt water we end up giving to these patients is actually colder than the body’s blood temperature. Dropping body temperature also affects the body’s ability to form clots. In addition to that, all of the salt solutions that we give are very acidic. Even the less acidic ones have a pH in the five range. This also hinders our body’s ability to clot.”
When discussing the breathing tube placement, there is a different set of factors that may come into play for a patient’s survival. “When someone’s bleeding to death, they may or may not be able to breathe on their own, so classic teaching has included assistance breathing,” Maher said.
“When you put a breathing tube and a bag [on a patient], you actually increase the chest pressure and expand the lungs. The expanded lungs can put pressure on the inferior vena cava and the superior vena cava, the largest vessels that go to and from the heart. So now you take a heart pump that’s mostly empty and you can actually make it a completely empty heart pump,” Maher said. This conclusion was based on retrospective data on animal models. Maher also claimed that there have been studies published as recently as February 2016 that support the idea that breathing tubes can worsen survival chances.
The PIPT study hopes to strengthen this conclusion by conducting a blinded prospective study and taking away confounding factors by solely focusing on advanced life support transports.
“The challenge of this study is that when someone is in a life threatening situation where you can’t really delay care to get standard informed consent, you have to do research in what’s called an Exceptions From Informed Consent fashion,” Maher said.
Using this highly regulated research method, the PIPT study will be going into the community to notify them that this study will be occurring, why it’s occurring, and providing the community with an opportunity to provide feedback about the study itself. People will have the opportunity to read about and become familiar with the study prior to its initiation. After this process, the study hopes to launch this coming summer. More information on this study can be found at piptrauma.com.