Daniel Spaite, MD, Endowed Research Professor of Emergency Medicine, College of Medicine-Phoenix at The University of Arizona talks about a new set of guidelines that is saving traumatic brain injury patients.
Interview conducted by Ivanhoe Broadcast News in May 2019.
Tell us a little bit about EPIC.
SPAITE: The EPIC program is one that, in conjunction with the Arizona Department of Health Services which is the state health department and the University of Arizona, ended up being over 130 EMS agencies from across the state that implemented the pre-hospital (meaning what you do before the hospital) Traumatic Brain Injury Guidelines for caring for patients with traumatic brain injury across the entire state of Arizona. We used a train-the-trainer type of style because there were so many providers to train. We ended up with over 600 master trainers and over 11,000 EMTs and paramedics across the state that were trained.
What is different and what’s the effect been?
SPAITE: Well, the traumatic brain injury guidelines for the pre-hospital, or out-of-hospital, aspect of caring and the 9-1-1 system, those have been out since approximately 2000. And the most recent update was in 2007 and, based upon those guidelines, it really boils down in the field to three simple things. That is, preventing what we’ve termed the three H-bombs which is nice because it’s easy in the heat of battle to remember the H-bombs. The first is to prevent hypoxia, which means low oxygen in the blood. And that’s done by giving very high-flow oxygen to the patients. Also being prepared to do advanced airway procedures if you need to. So that you prevent, or if they are hypoxic – sometimes when you show up on scene they already are hypoxic, you rapidly treat the hypoxia. That’s the first H-bomb. The second H bomb is the aggressive prevention and treatment of hypotension, meaning low blood pressure or shock. The third H bomb is hyperventilation which means breathing too fast or too deeply. And if you put a tube into the patient’s windpipe to help them breathe, then it’s very important to actually breathe at a completely normal rate. That’s a gigantic reversal from the historical treatment. Historically, they thought that putting the tube in the windpipe (or intubating) and hyperventilating was the best thing for the brain. But the reason why it drops the intracranial pressure is, unfortunately, it causes constriction of the arteries so that you don’t get good flow to the brain when you hyperventilate. So, very carefully preventing hyperventilation is the third H-bomb that we prevent and correct.
What’s the effect been over the last seven years?
SPAITE: The core of the data collection was for three or 3 1/2 years after the implementation which primarily happened in 2012. And the change is absolutely remarkable. In patients with severe traumatic brain injury, it doubled the severity-adjusted odds of survival in the entire state of Arizona and the severe group represents over 3/4 of the patients. So it’s a very large percentage of the traumatic brain injury patients who benefit. In the patients who were severe and had to be intubated or ventilated, the adjusted odds of survival tripled. So that’s just a remarkable finding. In healthcare you tend to have outcome changes that are very incremental. So someone identifies a new antibiotic, for instance, and it may drop mortality in something like bacterial meningitis by 10%. And that’s a really big deal, right? That makes it into large journals and that actually usually pretty quickly changes care because it’s very convincing and a 10% decrease in mortality is a big deal. So to have the relative odds of survival not just increase by 10%, but by 100% it is really remarkable. So it’s a quantum leap in outcomes.
So it seems like other states should be chomping at the bit to do this as well.
SPAITE: Yes. That’s one of the things about this. It’s not a special grant that got us million-dollar pieces of equipment that can only be used in places where you can get really expensive equipment. This is three simple things that almost all EMS systems already do. They can put on high-flow oxygen. They know how to start I.V.’s and give I.V. fluids. And most EMS systems know how to intubate the patient and then properly ventilate. This is a second aspect of EPIC that’s really remarkable, I like to call it the “Unobtainium” drug. This is not the million-dollar Unobtainium that everybody seems to be looking for – that if you give it, it’s the magic bullet but it costs gigantically. This really can be done anywhere with a few simple changes and just a few simple widgets. It costs a few pennies more than what’s being used already in the field. So it’s three simple interventions, but done right that, has had this dramatic effect. The other thing that’s really remarkable is when you think about the severe group, they, on average, were hospitalized at the trauma center for 6 1/2 days. So that was the average period of time of the acute care for these traumatic events. And on average it was only the first 25 minutes that the paramedics and EMTs took care of the patient. So imagine it being so powerful that the first 25 minutes of care actually doubled the adjusted odds of survival at the end of 6 1/2 days. It’s really remarkable and that is because the neuron dies so quickly…if you wait to treat the brain-injured patient until they get to the hospital, the brain cell begins to die in four or five minutes and it’s too late. No matter how good the neurosurgeon is, if you’ve already got dead brain cells, they can never get it back. They can do surgery but they can never get the brain back.
Are other states asking for this information?
SPAITE: Absolutely. Because EPIC was funded by the NIH and because it’s been a state-wide program and because we ended up with over 20,000 TBI patients, which is by far the largest pre-hospital traumatic brain injury study in history, all eyes have been on EPIC in EMS. Some of the states have actually started moving toward the guidelines because they are the evidence-based guidelines. We didn’t make up anything new. We just implemented the guidelines. And so now what we have is a large number of the states that are downloading the stuff. We make it all available through the website. We have nothing to sell. Literally, we just make everything available – all of the teaching, the training and so forth. And, in fact, I’m getting communications from Australia and Europe and really all over the world because they just can’t believe the simplicity that makes such a powerful difference.
And what’s the website?
SPAITE: It is www.EPIC.arizona.edu.
What haven’t I asked you that you would like to include in the story?
SPAITE: Traumatic brain injury is the number one cause of death under the age of 40. That’s an astounding thing to think about. Given all the ways people can die from – it is a gigantic public health issue. The second thing that a lot of people don’t understand about TBI is that there are over five million Americans who live with massive disabilities of traumatic brain injury. So for instance, in the state of Arizona this would be a typical story that we never hear: There would be an 80-year-old married couple who retired in Arizona, who brought with them their 61-year-old child. And since the age of 3 when they had their TBI, this person has had no intellectual development and is literally like a 3-year-old. That’s been their entire life. So traumatic brain injury is an incredibly devastating health issue. And then the final thing is that 40 years of attempting to do things in the emergency care of traumatic brain injury has led to the testing of more than 50 different drugs, many, many different procedures and equipment and, at best, they were not helpful. Some of the studies were stopped because the experimental drug or treatment was actually harmful. So there has been nothing for 40 years. So here we are, nearly a 1/2 century of basically a graveyard full of drugs and procedures that did not work. And now, all of a sudden, we have something that comes along and dramatically changes the outcome for traumatic brain injury patients.
So beside survival, is it better survival? Is it not losing all that brain function as well?
SPAITE: In our original proposal we wanted to do functional neurological outcome testing at 12 months, but that part of the study was not funded. What we do have hints of though is that, if you can move the needle on mortality, the likelihood is probably high that you have improved outcomes in people who have less severe than a mortal injury.
END OF INTERVIEW
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