Convention suggests that a person who is shot or stabbed has a better chance of surviving if he receives a certain amount and type of care before reaching the hospital. A group of researchers in Philadelphia suspects that such assumptions could be flawed, and so for the next several years, they intend to test them out in a major citywide study.
The study, Philadelphia Immediate Transport in Penetrating Trauma Trial, will examine whether two procedures—placing breathing tubes or administering IV fluids—actually confer survival advantages on patients with penetrating injuries, defined as “gunshot, shotgun or stab wounds to the chest, abdomen or upper arms or legs.”
The study is designed to compare the benefits of IVs and breathing tubes of advanced life support with those of basic life support, where no such instruments are used but oxygen is administered through a face mask. Researchers hypothesize that patients brought immediately to the hospital without advanced life support will have a greater survival rate than those who do receive such care.
“For many people, including medical people, it's counterintuitive and scary,” said Dr. Zoe Maher, the study's principal investigator and a trauma surgeon and assistant professor of surgery at the Lewis Katz School of Medicine at Temple University. Still, the study's results could have local, national and even international implications for the way trauma care is practiced, she added.
Patients eligible for the study are limited to those in Philadelphia, with gunshot, shotgun or stab wounds with evidence of bleeding and brought to the hospital by an ambulance. One group of patients will receive advanced life support; the other will not. Both would receive the same care upon arriving at the hospital.
Researchers hope the study, led by Temple University Hospital and including six hospitals and all of Philadelphia's Level 1 and Level 2 trauma centers, will begin this year. They initially hoped to start in 2015, Maher said, but the researchers first must inform the community.
“This process of community consultation and our desire to really educate the Philadelphia community has taken longer than we initially anticipated," Maher said. Outreach has targeted at-risk and high-interest communities to educate them about the study, which includes an exception from informed consent, she added.
Those wishing to opt out of the study can fill out a form online. They then receive a wristband that they must wear for five years. “If you do not wear the wristband and are injured by gunshot, shotgun or stab wound you may be included in the trial,” the announcement added.
The study excludes patients injured in the head or neck. Prisoners, pregnant women and those under the age of 18 are also ineligible. It is designed to require a total of 1,036 patients, in order to detect whether basic life support confers a survival advantage over advanced life support.
“If there's harm to patients in either arm, the trial will also be stopped early,” Maher said.
Still, viewed by some as gambling with people's lives, the study has stirred some controversy. But if its results do determine that less care is better, even if only for certain types or degrees of injuries, it could help revamp trauma care to save more lives.
One school of thought in medicine posits that trauma victims fare better if they are rushed rapidly to the hospital instead of receiving advanced care along the way, in what could be a lengthier wait before arriving in the ER.
In rural areas far from hospitals, such advanced practices can be beneficial to patients, the Philadelphia study announcement noted. But in urban areas, “the advantage of these field procedures ... is less convincing,” it added.
“In fact, studies have shown that pre-hospital intubation clearly does not confer a survival advantage to penetrating trauma patients in urban locations,” the study's detailed description reads. “Yet pre-hospital procedures continue to be performed in urban Philadelphia on a regular basis.”
In 1994, the New England Journal of Medicine published the findings of a similar, three-year study in Houston that compared survival rates of trauma patients with penetrating torso injuries. It found that those who received delayed intravascular fluid resuscitation had a higher rate of survival, 70%, than those who received immediate resuscitation (62%).
A University of Pennsylvania study published in 2014 found that gunshot and stab wound patients who were brought to hospitals by police in Philadelphia were not any more or less likely to survive than those brought via ambulance. And among severely injured gunshot victims, those transported by police were more likely to survive, the study showed.