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With the Industrial Revolution and the invention of compressed air came mysterious symptoms of unknown etiology. Through careful observation and diligent work from physicians in the 19th century, the true nature of caisson disease was identified and described. By studying thousands of casualties, these scientists were able to identify the cause of caisson disease, develop effective treatment plans for laborers, and institute procedures to prevent this malady. Over the next 100 years, numerous advancements in diving medicine would allow for the creation of the highly accurate dive tables that we have today. Much of our understanding of decompression sickness, however, still stems from the observations and scientific endeavors of the 1800s.

Since ancient times, mythology has included tales of creatures made of an amalgamation of others, transferring body parts and skin. In the 1950s, with no other medical options for then incurable diseases, including nephritis, teams of scientists, surgeons, and generous patients started the field of organ transplant with the first successful kidney transplant in a human. The scientific discoveries and innovations since that first successful transplant in 1954 have turned the mythical concept of transplant into reality. The overall success and public acceptance of organ donation and transplant today is thanks to multidisciplinary teams of basic scientists, immunologists, surgeons, and public advocates. Today, research is propelling the field forward with advancements like face transplants, experiments of lab-grown organs, and much more. In the United States alone, over 800,000 patients have had their lives saved or significantly improved thanks to transplant since national recording began by the Organ Procurement and Transplant Network in 1988.

BACKGROUND Numerous advancements in hemorrhage control and volume replacement that comprise damage control resuscitation (DCR) have been implemented in the last decade to reduce deaths from bleeding. We sought to determine the impact of DCR interventions on mortality over 12 years in a massive transfusion protocol (MTP) population. We hypothesized that mortality would be decreased in later years, which would have used more DCR interventions. STUDY DESIGN This was a retrospective review of all MTP patients treated at a large regional Level I trauma center from 2008 to 2019. Interventions by year of implementation examined included MTP 1:1 ratio (2009), liquid plasma (2010), tranexamic acid (2012), prehospital tourniquets (2013), REBOA/TEG (2017), satellite blood station (2018), and whole blood transfusion (2019). Relative risk and odds of mortality for DCR interventions were examined. RESULTS There were 824 MTP patients included. The cohort was primarily male (80.6%) injured by penetrating mechanism (68.1%) with median (interquartile range) age 31 years (23-44) and New Injury Severity Score 25 (16-34). Overall mortality was unchanged [(38.3%-56.6%); P = 0.26]. Tourniquets (P = 0.02) and whole blood (WB) (P = 0.03) were associated with lower unadjusted mortality; only tourniquets remained significant after adjustment (OR: 0.39; 95% CI: 0.17-0.89; P = 0.03). CONCLUSIONS Despite lower mortality with use of tourniquets and WB, mortality rates due to hemorrhage have not improved at our high MTP volume institution, suggesting implementation of new in-hospital strategies is insufficient to reduce mortality. Future efforts should be directed toward moving hemorrhage control and effective resuscitation interventions to the injury scene.

Author(s): Taghavi, Sharven; Maher, Zoe; Goldberg, Amy J; Chang, Grace; Mendiola, Michelle; Anderson, Christofer; Ninokawa, Scott; Tatebe, Leah C; Maluso, Patrick; Raza, Shariq; Keating, Jane J; Burruss, Sigrid; Reeves, Matthew; Coleman, Lauren E; Shatz, David V; Goldenberg-Sandau, Anna; Bhupathi, Apoorva; Spalding, M Chance; LaRiccia, Aimee; Bird, Emily; Noorbakhsh, Matthew R; Babowice, James; Nelson, Marsha C; Jacobson, Lewis E; Williams, Jamie; Vella, Michael; Dellonte, Kate; Hayward, Thomas Z; Holler, Emma; Lieser, Mark J; Berne, John D; Mederos, Dalier R; Askari, Reza; Okafor, Barbara U; Haut, Elliott R; Etchill, Eric W; Fang, Raymond; Roche, Samantha L; Whittenburg, Laura; Bernard, Andrew C; Haan, James M; Lightwine, Kelly L; Norwood, Scott H; Murry, Jason; Gamber, Mark A; Carrick, Matthew M; Bugaev, Nikolay; Tatar, Antony; Duchesne, Juan; Tatum, Danielle | Abstract: BackgroundPrehospital procedures (PHP) by emergency medical services (EMS) are performed regularly in penetrating trauma patients despite previous studies demonstrating no benefit. We sought to examine the influence of PHPs on outcomes in penetrating trauma patients in urban locations where transport to trauma center is not prolonged. We hypothesized that patients without PHPs would have better outcomes than those undergoing PHP.MethodsThis was an Eastern Association for the Surgery of Trauma-sponsored, multicenter, prospective, observational trial of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. The impact of PHPs and transport mechanism on in-hospital mortality were examined.ResultsOf 2,284 patients included, 1,386 (60.7%) underwent PHP. The patients were primarily Black (n = 1,527, 66.9%) males (n = 1,986, 87.5%) injured by gunshot wound (n = 1,510, 66.0%) with 34.1% (n = 726) having New Injury Severity Score of ≥16. A total of 1,427 patients (62.5%) were transported by Advanced Life Support EMS, 17.2% (n = 392) by private vehicle, 13.7% (n = 312) by police, and 6.7% (n = 153) by Basic Life Support EMS. Of the PHP patients, 69.1% received PHP on scene, 59.9% received PHP in route, and 29.0% received PHP both on scene and in route. Initial scene vitals differed between groups, but initial emergency department vitals did not. Receipt of ≥1 PHP increased mortality odds (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.01-1.83; p = 0.04). Logistic regression showed increased mortality with each PHP, whether on scene or during transport. Subset analysis of specific PHP revealed that intubation (OR, 10.76; 95% CI, 4.02-28.78; p l 0.001), C-spine immobilization (OR, 5.80; 95% CI, 1.85-18.26; p l 0.01), and pleural decompression (OR, 3.70; 95% CI, 1.33-10.28; p = 0.01) had the highest odds of mortality after adjusting for multiple variables.ConclusionPrehospital procedures in penetrating trauma patients impart no survival advantage and may be harmful in urban settings, even when performed during transport. Therefore, PHP should be forgone in lieu of immediate transport to improve patient outcomes.Level of evidencePrognostic, level III.

Introduction Per police data, the case fatality rate (CFR) of firearm assault in New Orleans (NO) over the last several years ranged between 27% and 35%, compared with 18%-22% in Philadelphia. The reasons for this disparity are unknown, and potentially reflect important system differences with broader implications for the reduction of firearm mortality. Methods A retrospective analysis of police and city-specific trauma databases between 2012 and 2017 was performed. Victims of firearm assaults within city limits were included. Univariate analysis was performed using chi-square for categorical and t-test for continuous variables. Bivariate analysis was conducted using logistic regression. Results Per police data, the CFR of firearm assault was 31% in NO and 20% in Philadelphia. However, per trauma registry data, the CFR of firearm assault was 14% in NO and 25% in Philadelphia. Patients in Philadelphia were older, had higher injury severity score, and lower blood pressure. Patients in NO had higher rates of head injury. 51% of patients in Philadelphia arrived via police compared to Conclusions Our findings suggest that the major driver of increased mortality following firearm assault in NO compared with Philadelphia is death prior to the arrival of first responders. Interventions that shorten prehospital time will likely have the greatest impact on mortality in NO. This should include the consideration of police transport.

Introduction There is disagreement in the trauma community concerning the extent to which emergency medical services (EMS) should perform on-scene interventions. Additionally, in recent years the “ABC” algorithm has been questioned in hypotensive patients. The objective of this study was to quantify the delay introduced by different on-scene interventions. Methods A retrospective analysis of hypotensive trauma patients brought to an urban level 1 trauma center by EMS from 2007 to 2018 was performed, and patients were stratified by mechanism of injury and new injury severity score (NISS). Independent samples median tests were used to compare median on-scene times. Results Among 982 trauma patients, median on-scene time was 5 minutes (interquartile range 3-8). In penetrating trauma patients ( n = 488) with NISS of 16-25, intubation significantly increased scene time from 4 to 6 minutes ( P < .05). In penetrating trauma patients with NISS of 10-15, wound care significantly increased scene time from 3 to 6 minutes ( P < .05). Tourniquet use, interosseous (IO) access, intravenous (IV) access, and needle decompression did not significantly increase scene time. Conclusion Understanding that intubation increases scene time in penetrating trauma, while IV and IO access do not, alterations to the traditional “ABC” algorithm may be warranted. Further investigation of prehospital interventions is needed to determine which are appropriate on-scene.