by Rose George
The composure was deceptive, said Brohi a few days later, when I asked him for a debrief. What seemed calm was actually the most aggressive trauma care you would ever see outside a military context. He calls it “hugely aggressive,” and “the extreme of trauma care.” By the end of that day, she had had 30 units of packed red blood cells, more than three times her own blood volume. Also, 31 units of plasma, 8 units of platelets, and 8 units of cryoprecipitate. In civilian hospitals, this is the gold standard of care, carefully developed over the last ten years at the Centre for Trauma Sciences. When patients were given a ratio of one to one to one (1 unit of PRBCs, 1 of plasma, 1 of platelets), survival rates increased. A study of 246 patients with massive blood loss at a US combat support hospital in Iraq found that the risk of death dropped from 65 percent to 19 percent when the plasma-to-red-blood-cells ratio was increased from 1:8 to at least 1:14.16
Her heart recovers enough to start beating, and she is taken upstairs to an operating room. There, Brohi takes over the cardiac massage. Everything that was done in resus and the operating room had the same goal: to get her heart to work on its own. One way to do this is to block off parts of the body, so that blood has less area to cover. The Royal London helped pioneer a balloon device called a REBOA (resuscitative endovascular balloon occlusion of the aorta)17 to do this: inserted into the aortic artery, it expands and blocks off the blood supply to the lower half of the body. You hope that the lower half of the body survives long enough for you to deal with bleeding in the upper half. It is all balance, risk calculation, courage. But REBOA can be used only on patients with a pulse. Here, instead, they had to do things manually. A surgeon dealt with her lacerated left lung by tying off its artery and taking it out of circulation. Someone opened up the abdomen to deal with the bleeding there. The liver was packed with gauze pads, to protect it. The spleen was taken out, as that’s what you do with damaged spleens. And, all the while, the blood. Not too much, not too little. A heart can be overfilled with blood and not be able to beat. If it is underfilled, it can’t beat. And this heart was so damaged already. Brohi’s hands were the best measure of this: he was operating by feel, telling the other operating staff what to do from what his hands were telling him: start to fill, stop filling, let’s give more calcium, let’s give more insulin. They carried on.
* * *
Death from bleeding is preventable. In theory. That is the awful truth of hemorrhage, and a source of extreme frustration. “Brain injury we can’t do a lot about,” says Brohi. “[But] if you get to people in time, know what to do with them, stop them bleeding, restore their circulatory volume, correct all the bad physiology that goes on, you could potentially save everybody.” The trouble is, he says, even now when we give them blood, it’s “a bit rubbish.” As Landsteiner proved, not all blood is alike. Red blood cells, plasma, and platelets are supposed to perform like whole blood. But some trauma experts believe that they don’t.
The problem is that in the 1970s blood met cancer. In the United States, the National Cancer Act of 1971 and President Richard Nixon’s declaration of “a war on cancer” started the chemotherapy era.18 Cancer patients were now getting treatment that attacked their immune system and their bone marrow, the blood factory. So they were hematologically compromised but they weren’t bleeding and didn’t need whole blood. They needed parts of blood such as platelets and plasma. The technology to separate and fractionate blood now existed. So did a sterile plastic bag, developed in the 1950s by Professor Carl W. Walter. It took him five years, $1.5 million, and the understanding that thermoduric fungal spores persisted on labels made from southern pine but that paper made from Maine pines was spore-resistant and suitably sterile.19 Now blood could be stored, transported, and transfused with much less risk. No more glass bottles and bungs. Fractionation technology could separate blood into red blood cells, plasma, platelets, cryoprecipitate, clotting factors. The era of component therapy (CT) began. CT meant choice: rather than having only whole blood, surgeons and doctors could pick and mix. It served chemotherapy patients—patients with chronic conditions including cancer still use nearly two-thirds of blood transfusions—and there was another issue. It could make more money. “You could break up this whole blood,” says John Holcomb, a trauma surgeon in Houston and a military surgeon for twenty-three years. “And sell six or seven components instead of just selling one. Think of it: you go and donate blood for free, and the blood banks can break it into five or six components. The business model is incredible.”
The switch to CT was swift and apparently irreversible, and not just for cancer patients. Within a decade, no one was using whole blood to treat bleeding anymore. In Holcomb’s entire time at medical school, and even now, thirty-two years of medical career later, he has never seen whole blood used in a civilian setting. He has asked trauma surgeons who once happily used whole blood at the time why they abandoned it. “They don’t have a good answer.” It was like emergency medicine had flipped a switch, and no one protested. Holcomb calls it “unbelievable.” The dogma changed, and it was comprehensive and unquestioned, at least anywhere that could afford the technology to separate blood. Ten years ago, at a conference, Holcomb met “folk from the less developed world” who apologized for transfusing with whole blood. Holcomb stood up and said, “Don’t apologize. It’s a better product.”
Even a 1:1:1 ratio of blood components—1 unit of plasma, platelets, and red blood cells—is not the same as whole blood. It contains additives and anticoagulants that are not in blood. In a modern hospital ward, the red stuff dripping into veins looks like blood, but it is something different. Both Holcomb and Brohi think it is something that, at least for bleeding trauma patients, is an inferior product.
Mogadishu, on the night of October 3, 1993. Holcomb was two years out of medical school, a young surgeon working in a field hospital in Somalia. It was the night now mostly known as Black Hawk Down, though the more official name of events is the Battle of Mogadishu, and its story has been well told: a planned forty-five-minute operation that became a seventeen-hour battle; eighteen Americans killed and several hundred and possibly thousands of Somalis.20 Seventy-three Americans were injured and arrived at Holcomb’s field hospital. They were “a bunch of bleeding soldiers that were all blown up and shot up.” They needed transfusions, so the medics got out bags of fresh frozen plasma to thaw, because that’s what they had. PRBCs to bolster the blood, fresh frozen plasma to help it clot. A third of the plasma bags broke. They had no platelets, which have a shelf life of only five days and don’t survive transit to most war zones. No plasma, no platelets, nothing to help the bleeding soldiers to clot. Nothing to stop the bleeding.
Holcomb did what he thought was revolutionary. “We were all young surgeons and we were doing what we thought was crazy.” They drew blood from volunteers and used that. A third of the combat hospital personnel volunteered their blood and went straight back to work. The blood was matched using blood types inscribed on dog tags. As it turns out, this wasn’t revolutionary at all. Later, he read about whole blood use in the Civil War, the two world wars, Korea, Vietnam. In most major conflicts except the one he was in, the United States had given its shocked and bleeding soldiers whole blood because it made sense.
The soldiers in Mogadishu seemed to do better with whole blood, and it was enough for the US military to begin to trial what it called Warm Fresh Whole Blood, a rare example of plain speaking from medicine, a profession with a fondness for hermetic Latin and Greek. (Why say “hospital-derived” when you can say “nosocomial” or “hiccup” when you’ve got “singultus”?) The warm fresh stuff was drawn from a human there and then and put into another. Or it could be stored for up to twenty-one days. In the conflicts in Iraq and Afghanistan, 10,300 units of whole blood had been transfused by November 2016.21 In Iraq, a walking blood bank was used.22 Troops were prescreened before departure, then if their blood was needed it could be collected on the spot, screened for infection (HIV and syphilis tests take the longes
t, but still only twenty minutes), and transfused. This suited military ships, where the use of blood components was difficult: platelets’ shelf life was too short, and they were often days from the nearest blood bank. It made more sense to keep all of the components in human form and tap it when needed. In austere, far-forward situations or battlefields, there was another option, “buddy transfusion”: emergency medics quickly find a suitable donor nearby, usually from the casualty’s peers, and transfuse on the spot.23
The Norwegian special forces are the most far-forward with this: wanting to know whether turning their special forces into single transfusing units would affect their performance, they have bled special forces operatives, then sent them either walking up a steep mountainside with a 20-kilogram (40-pound) backpack, or on a combination of a punishing treadmill test and push-ups or pull-ups, or on a round of pistol shooting. Tests were done before and ten minutes after donating. All the operatives showed hardly any decrease in performance, although the study authors pointed out that the results should be taken with reservations, as they were done in nonstressed environments, and hardly anyone is as fit as a special forces soldier.24 The debate is ongoing, and in most militaries, fluids are still the most usual treatment for a severely hemorrhaging soldier. Holcomb sees a future where hospitals will have a two-track system: one blood bank for people for whom component therapy is perfectly good—cancer patients or other people needing large transfusions—and the other for severely bleeding trauma patients, for whom whole blood is better. He calls his presentations on the topic “Back to the Future.”
Opposition may come from blood bankers, committed to a logistic and financial model that sends out blood as components. But Karim Brohi believes that they will inch forward to a different way of doing things. There is more and more research showing that stored blood is inferior to fresh blood for certain patients, whether you divide it into components or not. First, red blood cells are always mixed with a storage medium (saline, adenine, glucose, or mannitol), which impedes their ability to deliver oxygen. Second, blood ages, as we do, and gets weaker, as we do. This is called “storage lesion.” It may not affect cells’ ability to carry oxygen but, says Brohi, “they are very bad at delivering it. They don’t give it up to the tissues that they are supplying.” Some research into storage lesions has concluded that nitric oxide is to blame. This, usually present in red blood cells, is what enables them to dilate capillaries so they can deliver oxygen. It is the pathfinder, the gate opener. But only three hours after being drawn, blood used in transfusions was found to have lost 70 percent of its nitric oxide. After a few days it was 90 percent.25 Other studies have found that the age of red blood cells made no significant difference to outcome. The debate continues, with the only agreement being that storage definitely does something to blood. The storage lesion issue, Brohi translates for me, “really just means ‘use fresher blood.’”
* * *
After four and a half hours, the operating room team at the Royal London closed her up. Her heart was beating, again. Brohi, who knew that hardly anyone survived that level of blood loss, still thought she might make it. It would be extraordinary but not impossible. Research done at the Centre for Trauma Science has flourished alongside the creation of the London Major Trauma System, a logistical program that means that critically injured trauma patients, rather than being sent to the nearest hospital, are now always sent to London’s four dedicated major trauma centers.26 The research, the logistics, the damage control resuscitation: something is working. In the last five years, London’s trauma network has cut death rates in severely hemorrhaging patients by more than half.27 In 2009, 34 percent of trauma victims in the London trauma system died of hemorrhage. In 2015, it was 18 percent. When three men decided to mow down then slash and stab people on a night out in London Bridge, in the summer of 2017, the major trauma centers received forty-eight casualties. Many had severe and complex injuries. Some, ten years ago, would have been judged unsurvivable. All of the casualties lived.28
In the early afternoon, after surgeons had closed their cuts and invasions, her heart stopped again. She died, too young. In the case of the woman, or anyone else who had that level and depth of injury, there is nothing that they could have done better. Many emergency services, says Brohi, would not have done a roadside thoracotomy on her “because the outcomes are dismal.” In most places in the world, she would not have made it to hospital. “I don’t think there are many services in the world that would put that amount of effort into a case like hers.”
A few days after the Code Red, I tell Brohi that when I left the hospital that day and took a tube home, I was still so shaken I missed my stop twice. I tell him that since then, I’ve been scared at pedestrian crossings. I tell him it left me unsettled, uncertain. I lost the armor that protects me from the inevitable statistics, that allows us to walk and cycle on roads with buses and trucks and believe they won’t kill us. I ask him what the clinical staff do to deal with cases like the cyclist, and that I heard them talking about it all day long. She was young, like they are. It was tragic. They are human. He says you decompress however you can. “Phone. Pub. Wife, husband. Alone.” They were upset because “the thing about her is that she was a talk-and-die. She didn’t have a big head injury. If you could get it right, she could be a survivor and she could have gone back to work. That’s what hurts people most, that she was talking under the coach and then she died. She was salvageable, so why can’t we save her?”
Knowledge of what happens in the body immediately after trauma—the “bad physiology”—is still opaque. This is not for want of trying. I lose count of the number of journals devoted to care that is critical, emergency, resuscitative, trauma. But it is difficult to carry out good, robust research on a just-injured body: How can you ask for patient consent to do randomized control studies on a person who has just hit a wall at eighty miles per hour? Trauma doctors in Maryland want to study whether inducing hypothermia in trauma patients, and lowering metabolism, can give doctors more time. A longer golden hour. To do this, they have to hand out pre-consent forms in shopping malls and hope that someone who takes one will then have a terrible accident and be a candidate.29 Good research is usually retrospective (examining cases that have already happened), which is considered a lesser standard.
The Royal London now has funding to do a study into the efficacy of whole blood in transfusions. The University of Texas Health Science Center in Houston, where Holcomb works, has begun trialing whole blood in the hospital and on its air ambulances. Over the last decade, medicine has begun to notice that transfusion, one of the most common medical procedures, and one thought to do unquestionable good, needs better scrutiny, more money, more attention. “Trauma,” Brohi wrote in a journal on traumatic injury, “is one of the greatest killers of humanity.” Population growth and climate change are going to make trauma more common and more severe. Yet, “despite its high global impact, trauma remains low on governmental priorities, a side concern for funders and of only passing interest to most scientists.” In the UK, where forty-six people are killed each day by injury, trauma science still gets only 1 percent of medical research funding.30
I ask Brohi how trauma care will be different in ten years. Perhaps hospitals will differentiate between different types of blood for different people: not just cross-matching, but oxygen-delivery matching. I’m expecting a technical answer about science and oxygenation and coagulation. But he says, “I hope they will have banned buses and trucks from London so they don’t come into contact with cyclists and pedestrians. They obviously can’t share the road.” As for science, “in terms of treatment, we need a better way to protect the cells and to deliver them what they need while we’re fixing people.” He thinks trauma care will be more personalized, less one-red-bag-fits-all. As Londoners keep falling from windows or getting stabbed and shot and crushed and run over, trauma teams will keep fixing them, as best they can. Because each time it happens, each Code Red or Code Black or bul
l’s-eye or one under, each catastrophically injured human being they encounter, “we just get that little bit better.”
The circulation of blood, by A. J. Defehrt, 1762
NINE
BLOOD LIKE GUINNESS: THE FUTURE
The Canadian border official has been taking demeanor lessons from the Americans. His is icy, unwelcoming, as solid as his shape. He begins his quiz: Why are you here? How long for? What do you do? How can you prove it? To look at a plasma clinic; not long; I am writing a book about blood; the Internet will vouch for me.
He looks at me, granite. I wait to be refused, expelled, taken to the special room where the undesired go (there is always a special room). I expect sanction, reproach, or worse.
He says, “Will there be vampires?”
My relief feels like cool water. I babble like cool water. Yes! Clinical vampirism is a thing. There’s an underculture in New Orleans of people who drink blood.1 A young man has changed his name to Darkness Vlad Tepes after the original prince Dracul (a vile tyrant, and a Transylvanian, but not a vampire) and says he is bullied for it. And it’s been found that vampire bats feed other vampire bats who haven’t fed, and isn’t altruism in vampire bats fascinating?2 But the border agent looks disappointed. He wanted Twilight, Buffy, True Blood, and Tom Cruise, white sharp teeth and fairy tales, not teenage goths and desmodonitae. A scan, a stamp, a stare, and he lets me go.
