by Rose George
Brohi is a tall, gray-haired man with a calm air and quiet words, some including a London glottal stop (his Twitter biography reads “Londoner”). He is the director of the Centre for Trauma Sciences, known to thousands of medical students and conference attendees as Mr. Trauma and by most measures he is eminent. Brohi is a vascular surgeon by training because when he was a student the specialism of trauma surgery was not available to him. It didn’t exist.
He was a junior emergency medicine SHO (a senior house officer, a junior doctor who is actually quite senior) when he saw a couple of trauma patients who, even with his limited knowledge, he could tell “were badly treated, clinically, and I was pretty sure we could do better.” It wasn’t that clinicians knew what to do and did it badly: they didn’t know what to do. Since then, his career has consisted of trying to rectify this. It is an ongoing task. He set up a website to aid medical professionals here and abroad and called it trauma.org. It is a place where I can spend many hours, running through its moulages, where you play at being a trauma doctor in simulated situations. I fail consistently. For example: a motorcyclist traveling at around seventy miles per hour who went into the back of a stationary vehicle on the side of the motorway and was thrown some fifty to sixty-five feet from the bike. I’m given three options: assess for intra-abdominal bleeding, check the airway, or chat to the fire crew. I pick the most medical-sounding option and check for bleeding.
YOU ARE SO UNBELIEVABLY WRONG. One hundred chimpanzees with one hundred computers wouldn’t have chosen that option in a hundred years. Go back and try again.
I choose next to check the airway.
To the shouts and cheers of the fire crew you run toward the patient. A blur of orange, dashing through the puddles. The fire crew are waving and jumping about. OK, you look good, but you’ve never had this reaction before. Then a thought goes through your head … puddles? It hasn’t rained in a week. Looking down you realize that you are in fact running through a pool of petrol. The next thing that goes through your head is the back wheel of the motorcycle as the car explodes. You would feel stupid, but you can’t feel anything anymore.
I tell Brohi it’s funny. He dismisses this by saying he wrote it “back in the day.” But he also wrote it so it could be used in developing countries. That’s why its layout seems old-fashioned, as analog as digital can get, so it can be useful in places that don’t have hi-tech or Wi-Fi. “There’s a reason it’s shit.” There’s also a reason it’s funny: we remember humor, like smell. It sticks.
In the same simulation, I eventually choose to check for pelvic instability. The patient is bleeding, and I’m given two options: give crystalloid or colloids. Both of these are volume expanders. TV hospital dramas would call them “fluids.” I choose crystalloid.
Despite the number of IV sites you find, and the amount of fluid you keep pouring in, the patient’s pulse and blood pressure keep on falling. Finally you get control of the situation—that is, if a pulse and blood pressure of zero is “control.”
I have killed the patient, again. But this time I can’t really be blamed for my choice. Until the last decade, modern resuscitation relied on crystalloid. The clear stuff in bags, as one trauma surgeon described it to me, was pumped into trauma victims in the hope of boosting a circulation that was being drained by hemorrhaging. Refill the circulation with fluid, even if it’s not blood, and the body’s damaged blood cells will have enough strength to get oxygen to the tissues and organs, as it is supposed to do.
But this was wrong. This is why my moulage patient’s pulse and blood pressure kept falling. “Now we know,” says Brohi, “that if you give lots of fluids when someone is actively bleeding, you dilute down all the good stuff in the blood, which is desperately hard to deliver and restore.” The good stuff is what the blood needs to deliver oxygen to organs and tissues, as well as remove toxins and waste. A person who is bleeding is like a bucket with a hole in it. “All you do is pour fluid into the top, and you’re putting more pressure in the bucket for it then to bleed more.” And hypoperfusion begins. This is the medical term for the body’s failure to deliver oxygen to tissues and organs. You’ll know it better as shock.
In 1870, the German doctor Hermann Fischer described a patient he had encountered. The young man had been hit by a runaway team of wagon and horses. The wagon’s shaft had struck him in the pelvis. There were no outward signs of bleeding; the shaft had not penetrated his flesh. But soon,
he lies perfectly quiet, and pays no attention whatever to events about him. The pupils are dilated and react slowly to light. He stares purposelessly and apathetically straight before him. His skin and such parts of the mucous membranes as are visible are as pale as marble, and his hands and lips have a bluish tinge. Large drops of sweat hang on his forehead and eyebrows, his whole body feels cold to the hand.… Sensibility is much blunted over the whole body.… If the limbs are lifted and then let go, they immediately fall as if dead.… The pulse is almost imperceptible and very rapid.… The patient is conscious, but replies slowly and only when repeatedly and importunely questioned.7
His temperature is taken: he is cold. His arteries are contracted and of “exceedingly low tension.” Cold, low pulse, rapid breathing: all these things are now known to signal a person in shock. Shock, which has its own society (the Shock Society) and dozens of journals and 130 years of scientific expertise devoted to its study. But shock is still imperfectly understood despite our best efforts. And despite medical advances—clever blood clotting bandages, new tourniquet techniques, better drugs—also imperfectly understood are why trauma can make people bleed so catastrophically and why sometimes we can’t stop it.
* * *
On the road, under the bus, she had stopped talking. It’s not always easy to guess at internal bleeding, but good clinicians can read clues, on the patient and elsewhere. In the trauma moulage, my first step should have been to talk to the fire crew, for example, before doing anything medical: they would have told me about leaking petrol and when it was safe to minister to the casualty. Good emergency doctors will ask bystanders and first responders about the mechanism of injury: if eyewitnesses describe a head hitting a windshield, that is a clue. Head injury, but probably not bleeding. They will read the body. Someone who has been screaming in pain, then becomes drowsy? Probably bleeding. Is the heart rate fast? Probably bleeding. Does the pelvis feel broken? Probably bleeding. Cold, unresponsive? Bleeding.
Bleeding is caused by what clinicians call “derangement” of the body’s physiology. It happens fast. A quarter of all bleeding deaths occur within three hours of injury, says Brohi, and most severely bleeding patients are dead within six.8 Nearly half of patients with severe truncal injury—a penetrating wound to the chest or abdomen, for example—die within thirty minutes.9 There is a concept, now, of the “golden hour,” when trauma intervention must be done. Brohi thinks this is a marketing concept, and in a way not useful: some people bleed fast, others bleed, then stop. Bigger wounds, more holes, more blood loss. But definitely the first minutes and hours are a critical window. What happens to the body after massive injury? Brohi truncates or translates an explanation for me. It is “really really really complicated.”
There is an insect bite on my leg and I scratch it. It’s a bad habit, but I like to see the blood flow. Rich, and red. And then I like to count. Usually within five seconds, depending on what I have scratched and where, the flow stops, the blood clots. It looks like something ordinary, but it is complex and amazing. It probably takes up to one hundred proteins to form a blood clot.10 All that complexity, and the body does it selectively. Cut yourself shaving, and you will clot only at the cut, not everywhere. Break a bone and a clot will form around the break, but only there. “Clotting happens in the right place,” says Brohi, “but it has to be turned off everywhere else. If you were a wildebeest on the plains of Africa and some saber-toothed tiger took a chunk out of you but you survived, you’ve lost some blood so you’ve got less blood flowing more slow
ly around your body.” In consequence, blood becomes less coagulated—less likely to clot—so that you don’t get clots where they shouldn’t be.
A removed chunk: that can usually be dealt with, by either the body or medicine. Those injuries are the survivable kind. But the people who come to the Royal London and other major trauma centers have complex, severe trauma that turns their blood “rampantly anticoagulant.” Nothing is clotting; nothing is stopping blood from bleeding. Patients with such severe trauma, by the time medical professionals reach them, already have this severely disordered clotting. For reasons that are still opaque, their platelets—which should help clotting—also stop working properly. It is a complex derangement of biology known as acute traumatic coagulopathy.
The woman’s blood vessels, so badly crushed, were leaking blood into the body, out of the circulatory system in which it should have been contained. Her blood volume and her blood pressure were dropping. Her heart, which should have been pumping ten pints of blood a minute, was slowing and emptying. Her organs and tissues were being starved of oxygen that the blood could no longer deliver. She was shutting down. Internal hemorrhage sounds like a quiet thing: the body bleeding inside itself, politely. But the violence caused by it is massive. Blood cells starved of oxygen were producing lactic acid, making the body acidic (the medical term is acidotic). They were also releasing potassium. Too much potassium can stop the heart, which is why potassium chloride is a popular component of lethal injections. The reduced blood flow, along with the environmental context (many accident patients are lying on cold ground) lowered her temperature. Blood normally carries heat around; it stopped doing that. The colder she got, the worse platelets got at clotting. The worse the clotting, the more blood she lost, the colder she got. The more blood lost, the greater the acidosis. Everything was working together to make things worse. That is why these three conditions are known in trauma circles as the “lethal triad.”
She stopped talking and her heart stopped. It could not pump blood when there was not enough blood to pump. The medical team needed first to let her breathe, so they passed a tube into her windpipe. There was no point trying chest compressions: the pelvic trauma meant she had “bled out.” Her heart had nothing to pump and was still. Five years ago, she would have been declared dead at this point. But HEMS had two more options. First, they took her out from under the bus, they cut open her chest, and they manually massaged her heart to get it going. This is an emergency thoracotomy. Royal London has been doing the procedure since 1993, and now does about twenty a year. But it still looks awful and dramatic. The other option was a procedure HEMS began to do only in 2012. Passersby would think nothing of it. The groundbreaking thing was to give her blood, there and then.
* * *
The passage of medicine toward accepting blood transfusion was one of bumps and jumps. In the linear, smooth version, James Blundell’s nineteenth-century experiments led to blood transfusion being thrown into the darkness because no one could understand how to stop blood clotting. Then Karl Landsteiner shone a light, and all was well. In fact, the debate about transfusing blood continued throughout the nineteenth century after Blundell’s efforts, and medical gentlemen had regular spats in medical journals about its merits and evils. They were also debating what to transfuse. Blood clotted, so it was bad. But sometimes blood revived, so it was good. Saline was better, because what a bleeding person needed was volume. This made some sense: blood was not seen to be the highly complex living tissue that it is now, so to replace volume, why would the more straightforward saline not do instead? It did not spoil like blood; it did not clot and clump. It was easier all around. Supporters of blood transfusion scorned the London Hospital as being the headquarters of the “salino-alcoholic disciples,” but saline was more popular for a good while.11 Even Landsteiner’s discovery did not immediately trigger a rush toward blood transfusion: he ignored his findings for decades, as did most medical journals.
The usefulness of blood in transfusion was still being debated in the Second World War. The British used it; the Americans preferred plasma. Its proteins and clotting factors are useful. It worked very well healing burned people. But plasma cannot, alone, fix a body in shock. In 1944, Colonel Frank Gillespie, a British liaison officer stationed with American forces, wondered whether American shock victims were made from different stuff than the British. “I have often wondered at the physiological differences between the British and American soldier. The former, when badly shocked, needs plenty of whole blood, but the American soldier, until recently, has got by with plasma.” In Normandy he found “American surgical units borrowing 200–300 pints of blood daily from British Transfusion Units, and I’m sure they were temporarily and perhaps permanently benefited by having some good British blood in their veins.”12 This was happening elsewhere thanks to the efforts of Colonel Edward Churchill, who traveled around Europe reporting back that blood was better than plasma, but who was not heeded. After American medics resorted to doing stealth transfusions in stealth transfusion stations, policy changed and American soldiers were given blood from their own compatriots, not borrowed from the Brits. During the four years the United States was at war, the American Red Cross collected over 13 million units of blood, and blood taken from a donor on the Atlantic Seaboard could be in the veins of a wounded soldier the following day.13 The template seemed set. Blood worked. By the Vietnam War, 38,000 units of blood were transfused each month, the largest ever wartime blood program.14
Then came the rats. A notorious study in rat resuscitation in the 1950s seemed to demonstrate that clear fluids were better than blood. (Even though, Brohi says, the rats were first treated with blood.) But a switch was flipped, a new dogma installed, and resuscitation became associated with the clear stuff in bags, not blood. For the past few decades of trauma care, ambulances and paramedics have not given blood, not even to a severely hemorrhaging patient. They couldn’t: they didn’t carry it. Most ambulances still don’t. First they would check the airway, assess for injury, and then deal with bleeding by giving fluids. For decades, this was the standard protocol: liters and liters of clear liquid. It was thought to stabilize a patient long enough, by maintaining the blood volume, for them to get to hospital or to an operating room. But they were giving the wrong things, at the wrong time, in the wrong way.
About ten years ago, a new way of thinking was resurrected (because it was actually an old way of thinking). “We’ve completely shifted,” says Brohi, “from trying to restore volume with whatever to trying to maintain competence of blood to form a clot.” Two three-word phrases can describe this approach. In the military, it is “damage control resuscitation.” Or as a guiding principle: “stop the bleeding.”
* * *
In London, at the accident scene, the HEMS team got out its blood bag. They did this because war, again, had changed the minds of medics. In Afghanistan, British MERTs—mobile medical emergency response teams—began trying to deal with all their hemorrhaging soldiers by taking blood to the soldier, not filling the casualty with fluids and transporting him or her to blood. It was no different from the Royal Army Medical Corps man with his transfusion kit, or the transfusion officer on a northern French beach, a blood bag hanging from a rifle stabbed into the sand. In Afghanistan, the Americans, seeing what a difference it made, followed suit. (Transports that carried blood were called “vampire flights.”) In 2012, HEMS began to carry “blood on board.” This was exactly what it sounded like. For the first time in its history, the service began to carry blood products on board the helicopter, in thermal containers used by the British military and nicknamed “Golden Hour Boxes.”15
That is why, on this London street, the woman could be transfused with three units of blood. Or near enough. In fact, the red liquid in the bags was something different. It was packed red blood cells (PRBCs), and it was a component of blood, but missing a few things: plasma, platelets, white blood cells. In the UK, all white blood cells must be removed from blood products b
ecause they can transmit vCJD. She couldn’t be given plasma because it is stored frozen and it would be logistically impossible for HEMS teams to carry and thaw it. Platelets need to be kept warm: same logistical obstacle. So PRBCs were the best option, and for the rest, she needed to be transported quickly to the hospital, where she could be given other products to help her blood clot, where she might have a chance. She was fortunate in only one thing that morning: that she was within the target area of the busiest trauma center in Europe. Within an hour, she was transferred to Bay Eight of the resuscitation room at the Royal London, and it was the best place she could possibly be.
The screen in Bay Eight reads CODE RED, 30S CYCLIST, TRAUMA CARDIAC ARREST, THORACOTOMY. The nurses had been talking while they waited for her to arrive: she was a woman who went under a bus. No, a young woman. Maybe a girl. A truck, not a bus. A cyclist. She was definitely a cyclist: the screen says this. Now she lies with her chest open, her feet yellow, and she has almost disappeared under all the people working on her. Someone says, Can we get some volume? Someone asks for insulin. Will someone fetch some bicarb? Let’s get her into bypass. No one shouts. Everyone is politely urgent: will you, would you, would you mind.
I thought she had been in the bay for at least half an hour. Perhaps even more. No, says Brohi, who was one of the fourteen staff involved in the resuscitation. She was in resus for only fifteen minutes. Time dilates in there, yet time is what they have least of. Priority: potassium, calcium, and blood. The anesthetist immediately checked the woman’s potassium levels, even though it was obvious they would be high. The dangerously leaking potassium could be addressed with insulin, and this was provided. A regular dose of insulin for a diabetic will be 10 units. By the end she had been given 9,000 units. She needed calcium to help with the derangement of her clotting, and she needed blood.
At the blood infuser, there are two nurses. Their job is to watch for the blood bags; to read the labels out to each other, the reassurance of repetition. O negative at first, as this is the universal and emergency blood and was stocked in the resus room fridge, the one with warnings not to waste blood because it costs £123 ($175) a bag. But then she was cross-matched and blood more suited was brought down from the blood bank. All must be checked. All must be right. Later, I learn that the IT system had gone down, so all blood orders had to be taken by hand to the blood bank, over the road in another building, not ordered by computer. First principles, Brohi calls it, and it worked fine. What was not fine was her heart: when she came in, it was flat, like a tire. It had stopped beating because she had no more blood in it to pump, and even the transfusions could not stop it from stopping. Now that it has blood, another surgeon keeps massaging her heart with his hands, and I watch all this furious calmness, dazed by it.
