Lessons learnt in the Iraq war are helping save the lives of seriously injured patients here.
Lifesaver: Dr Kerry Gunn in surgery at Auckland Hospital.
Auckland City Hospital emergency department, October 2008: a woman is rushed in with massive abdominal bleeding after a car accident on the Northwestern Motorway. The emergency team are braced.
Usually what lies ahead is four or five hours of frantic efforts to stabilise the patient’s condition while trying to operate.
A series of shouted phone calls are made to the blood bank to urgently send up more red blood, or platelets, or plasma. But it’s like trying to fill a leaky bucket, the blood runs out as quickly as it is pumped in. In 70% of cases like these, the patient bleeds to death.
Today, though, the team is ready with a new tool. Anaesthetist Dr Kerry Gunn calls the blood bank and activates a massive transfusion order for many litres of blood. This is a radical departure – blood banks have always hoarded their stocks jealously, and doctors are sparing in their requests.
The call, though, is “like a free key to the front door of the Treasury”, says Gunn. “A torrent” of blood products arrives in the operating theatre.
The transfusion is aggressive and fast. And instead of leaning heavily on red blood cells as the main ingredient, the recipe calls for an equal mix of red blood, precious platelets and plasma. The result is something like whole blood.
Two things stand out for Gunn from that day. One is the unusual sense of calm in the operating theatre.
Instead of repeated panicked calls for a few more ladlefuls of blood, all the blood they need is already on hand. The second is that the patient stabilises and stops losing blood. “She was in intensive care for three or four weeks, but the bleeding did not kill her. Historically, in most cases, it would have killed her.”
Auckland Hospital has been in the first wave of hospitals, with others in the United States and the United Kingdom, in trying the new technique.
First used in the US defence forces’ surgical wards of Iraq, the technique has produced profound results.
Initial research suggests the death rate from bleeding in extreme trauma cases can be slashed from 70% to 30%. Last year massive transfusions were used for about 90 patients in Auckland hospitals, and about 50 patients elsewhere in the country, with most major hospitals now using the procedure.
Although initially used for accidents, the technique has been extended to other situations where a patient is dying from blood loss: in haemorrhages during childbirth, or during an operation.
The average human body contains five litres of blood, and in massive transfusions typically five to eight litres are pumped in – but sometimes up to 50 litres is needed. This is a precious commodity indeed, the product of between 20 and 120 donations to the New Zealand Blood Service. So great is the volume being pumped into the patient that it can take up to four lines – in the arms, in the neck and the groin – and a line can be as thick as a garden hose.
The turnaround in survival odds is all the more remarkable for the fact it hasn’t been the product of an expensive new drug or a million-dollar machine. Instead, it has been a curious case of going back to basics.
As an anaesthetist, Gunn is responsible for keeping the patient alive during surgery, including the blood supply. He chairs Auckland District Health Board’s blood transfusion committee. Medics, he says, have for years been haunted by a sense of failure about blood loss in patients with major trauma and shock.
“We couldn’t understand why you could lose a huge amount of blood in a normal operation, and the blood would clot by itself. But somehow if you’re on the side of a road after being hit and thrown out of a car, you’ve lost a litre of blood or more on the side of the road, yet at that stage you’re not already starting to clot.”
What was only discovered six or seven years ago was that shock and tissue injury trigger the body to release a flood of anti-clotting agents, so the blood won’t clot. No wonder these patients were behaving like leaky buckets.
What had been making it worse was emergency rooms had been pumping the body full of saline fluid in an attempt to get blood pressure back up, to help blood and oxygen return to tissues. In fact the fluid was diluting clotting factors in the blood, making matters worse.
The focus shifted to how to get the blood to clot again. There were plenty of dead ends, says Gunn: new drugs that didn’t make much difference. But the US military in Iraq, battling to save the lives of soldiers with serious blast injuries, had more freedom to up-end tradition. And as in World War II, their donors were other soldiers, donating whole blood that hadn’t been separated into its parts.
The US medics found that by aggressively treating soldiers with whole blood that still contained the plasma and its clotting agents, survival rates soared. “It’s just taken a long time for the penny to drop as to exactly how good whole blood was. This was the lightning bolt that made all of us in civilian life look up and think: how do we apply this, and is it safe?” says Gunn.
There is still debate over exactly what the right formula is. But it is clear that using equal parts red blood, plasma and platelets is a vast improvement over the old ratio of only one part plasma to eight parts red blood cells.
The other change of focus has been to limit surgery to only life-saving essentials until the patient has begun clotting properly. Other operations can be done progressively in following days.
Auckland art teacher Philippa Dyer probably wouldn’t be alive without the new transfusion technique. On the morning of Anzac Day 2009, she was travelling to a morning service with her sister, husband and brother-in-law. In a collision with an overtaking car, Dyer’s sister was killed and Dyer sustained massive bleeding from abdominal injuries, broken ribs and a pierced aorta. She had 11 operations and was off work for a year, but is now back teaching secondary school students almost fulltime. “I have been given another chance. I’m never going to take another day for granted.”
Christchurch mother Cynthia Sandford also benefited from the new technique after suffering a massive haemorrhage from complications in her pregnancy. She underwent an emergency caesarean and hysterectomy, losing an estimated 7.5 litres of blood of the nine litres pregnant women carry. The bleeding continued, and Sandford lost another three litres despite transfusions.
Sandford’s husband was told to bring the two older children in to see their mother, in case she didn’t make it. “I wasn’t ready yet to die. I knew it was at that point. I was struggling to be coherent.” But she made it back, and wanted to talk about her experience as a way of thanking those who had donated blood.
The NZ Blood Service took a leap of faith, says Gunn, not knowing whether the new procedures would drain blood banks dry. Has it? Funnily enough, no. It turns out patients with major trauma were using a lot of blood anyway; it was just that most of it arrived too late.
“In the old days we would throw as much product as we could get into the patients and they would still die in front of our eyes. Now, far more frequently, you finish the operation and the patient has stopped bleeding at the same time. It’s a dramatic change.”
To donate blood, phone 0800 488 325. Donations are particularly welcome over the holiday period.