Trauma Lessons from the Battlefield

Paramedics charge through the doors of one of Canada’s busiest emergency departments pulling a 21-year-old man on a stretcher, his blood spilling from multiple gunshot wounds to his chest and abdomen. 

The paramedics have done all they can in the ambulance, but Matthew* is in shock when he arrives at St. Michael’s trauma bay. By now his heart is nearly emptied of blood. He goes into cardiac arrest. 

The trauma team springs into action. They start chest compressions and massive blood transfusions. They administer a compound to slow bleeding. With no other options, they open his chest and perform compressions directly on his heart. At the same time, they clamp his aorta to preserve what little blood he has for essential organs: heart and brain. 

“He was bleeding from all over,” recalls Dr. Sandro Rizoli, St. Michael’s former director of trauma. “When they are so near death like that, we have only one thing on our minds: stop the bleeding. They have to survive so we can treat the injuries.” 

Matthew was suffering from what surgeons call “trauma-induced coagulopathy.” In other words, he was losing so much blood, so fast, that his body was no longer able to clot. Over 24 hours, Dr. Rizoli and his team gave the man enough blood to fill his body 10 times over. 

“He survived,” says Dr. Rizoli. “He went back to the O.R. multiple times and stayed in hospital about four months. But he walked out. He was one of those incredible cases.” 

He was also one of 57 gunshot victims raced to St. Michael’s in 2018. It was a bad year for gun violence in Toronto, with more than half of the city’s 96 fatalities due to gunshot. But at least, Dr. Rizoli and his team can take pride in the fact St. Michael’s trauma survival rate is among the top in North America. About 80 per cent of its gunshot victims survive.

There’s also a kind of grim advantage to Toronto’s rising gun violence. Trauma surgeons in Canada no longer have to travel to the U.S. to learn how to treat gunshot patients, observes Dr. Rizoli, whose own expertise comes from his native Brazil. 

While Toronto’s gun violence is nowhere near that of major cities south of the border, St. Michael’s new trauma bay is sorely needed. More spacious and designed with the most up-to-date life-saving technologies, it’s expected to open later this year. 

The trauma bay will be housed in St. Michael’s new twice-as-large Slaight Family Emergency Department, which is opening in stages. Meanwhile, the emergency team is already basing its treatments on the latest trauma research. 

Some of that research comes from Dr. Rizoli, who is also a scientist at the Li Ka Shing Knowledge Institute. In 2007, for instance, he was part of a team that found patients with major blood loss fared better when given blood right away, rather than saline fluids. Patients stopped bleeding faster, had quicker recovery times and fewer complications. 

It’s precisely the opposite of prevailing wisdom at the time, which held that saline should be administered first because trauma patients lose large volumes of fluids outside blood vessels. But by sheer necessity, the troops in Iraq and Afghanistan during the early 2000s had to improvise. Unable to carry litres of saline fluid along with the rest of their equipment, medics instead transfused critically injured soldiers with fresh blood taken directly from other soldiers. The injured soldiers did better than they would have with saline.  

“On the battlefield, you have walking blood banks,” says Dr. Rizoli. 

It’s not the only battlefield lesson. St. Michael’s doctors are also using a method to stop traumatic bleeding called resuscitative endovascular balloon occlusion of the aorta, or REBOA. It involves inserting a catheter in the groin and threading it up into the artery just below the heart. Once in place, a small balloon inflates at the catheter’s tip. This stops the blood flow to all organs except the heart and brain, and keeps the patient alive long enough to deal with their injuries.

And another battlefield practice? St. Michael’s is the only hospital in Canada that uses simulation education to train trauma doctors in techniques used in the military and police for handling high-stress emergencies. It's called stress-inoculation training. “It sounds hard-core,” says Dr. Hicks, a trauma team leader and simulation educator. “But nobody actually gets injected with anything.”

Instead, doctors are taught how to use visualizations and breathing exercises to centre themselves. Then they use these techniques in increasingly stressful trauma simulations. 

“Medicine has been remarkably slow to embrace the psychology of performance,” says Dr. Hicks. “Traditionally we say during stressful situations, ‘Just suck it up. Your training will take over.’” Again, battlefield studies show this is wrong. 

“Special ops in the military have acknowledged that it’s hard to lie in a foxhole for 72 hours without eating or going to the bathroom and still point your gun and fire it effectively,” says Dr. Hicks. “You require psychological skills to manage that challenge.”  

Today, he and Dr. Andrew Petrosoniak, also a trauma leader and simulation educator, are on the leading edge of stress inoculation training for medical professionals. They share their curriculum with other hospitals around the world.

“This psychological training is not happening anywhere else,” says Dr. Hicks. “We are developing our ER and trauma room in a way no one else is doing.” 

*Patient’s name has been changed to protect his privacy