Insights in to trauma care with Alert Medic 1 and Dr. Zaffer Qasim.
By the end of the conflicts in Iraq and Afghanistan, the US military and its coalition partners touted a near 97% casualty survival rate. Coming on the heels of a number initiatives (they call them orders) that pursued zero preventable deaths from trauma on the battlefield, they seemed to have nearly conquered death on the battlefield. Yet, there remained certain seemingly unconquerable challenges in trauma management on the battlefield.
Some of those challenges carry with them a known and extremely high casualty rate. Large vessel disruptions, catastrophic blast injuries, and massive head trauma carry the bulk of the mortality in the military data. One subset of these patients, however, presents a unique challenge of getting the most meaningful intervention to the patient within a timeframe in which it will be beneficial: non-compressible torso hemorrhage. This problem still challenges the very well developed, managed, and resourced military trauma system.
The story is the much the same in the civilian sector. Mortality from trauma in America remains high and has remained relatively unchanged for several decades. Specific to mortality from preventable causes, the data ranges between 20–30%. Translation: an average of 1 in 3 patients dies from a preventable traumatic cause in America.
We can see that trauma systems in the US are not quite as close to zero preventable deaths from trauma as the military has been able to achieve. This is likely due to a number of challenges that exist in the civilian sector that the military does not have to contend with. These challenges range from heterogeneity between trauma systems and EMS systems (in some cases care delivered can vary greatly just between adjacent zip codes) to a lack of responding resources, and even transport times that deliver patients beyond the patient’s physiologic time needs.
In a conversation with Dr. Zaffer Qasim (aka @traumaphilly), recorded on the Alert Medic 1 podcast we attempted to unpack the challenges to achieving zero preventable deaths from trauma in the civilian sector. We also explored the ideas and interventions that are available to EMS and trauma systems that can bridge the gap between the point of injury and definitive care.
We discovered, to no one’s surprise, that there is no silver bullet solution for eliminating mortality form trauma. Not even in the military. But there are opportunities to capitalize on EMS and civilian responder’s actions at the point of injury. Specific to non-compressible torso hemorrhage (NCTH), there seems to be a few interventions that can buy back valuable physiologic time for the patient so that there is time for the most meaningful interventions to have their greatest impact.
These ideas and interventions are the dynamics of marginal gains in NCTH, and can make a significant impact on trauma care in the pursuit of zero preventable death from trauma.
Time as the Enemy and Overcoming the Tyranny of Distance
In trauma, time is of the essence, but we cannot control it. Once a patient begins to bleed, regardless of the mechanism of injury, every second we can save them in the prehospital phase will pay larger dividends in the surgical and intensive care phases of their clinical course.
Qasim et al, published a paper that (in my opinion) has one of the best graphical representations of the timeline of care for a trauma patient. It also provides us with a great frame of reference for where we may be losing time with these patients, and where we can focus our efforts to optimize the processes of responding, rendering aid, and delivering the patient to definitive care.

It is a sobering thing to see that on average a patient bleeds for 2 hours before there is definitive hemorrhage control. Even more sobering is the realization that some of these patients do not have that long. Some have mere minutes before they exsanguinate. Dr. Qasim’s research shows that patients suffering from NCTH tend to die within 6 hours. That does not mean we have 6 hours to deal with the problem, however, as there is an inflection point at the 15–20 minute mark where the mortality is significantly high if the bleeding is not controlled and judicious resuscitation buys back some physiologic time.
Dr. Qasim’s thoughts on what has the biggest impact:
“ You have to break down the system from the point of injury to the OR and find what you can really modify. Shaving off a little time here and there, you essentially win the race.”
It is important to note that Dr. Qasim brings our focus to shaving off time, not adding “fancy things” to the mix.
This begs the question though; shouldn’t we just scoop them up and provide a therapeutic diesel bolus on the way to the trauma center?
The good doctor says:
“No. What you do after the scoop is key. Instead of scoop and run we should think ‘scoop and control.’ “
It is not about how fast the patient can be delivered to the hospital; it is about what is done for them en route to the trauma center. Of course, there are examples of where the patient’s proximity to the trauma center really necessitates a load and go/scoop and run approach, but prehospital clinicians should be careful not to conflate scoop and run with a scoop and drive only mentality. In most cases, 5–6 minutes is plenty of time to get tourniquets on extremities and hemostatic dressings packed into wound cavities (too much time perhaps?).
What is a “scoop and control” approach? It represents a mindset that prehospital clinicians can adopt in these “time is of the essence” situations. It goes beyond just moving fast. You have to be good, fast. You have to execute on skills and interventions quickly, precisely, and while moving toward definitive care.
There is a “tax” that the patient pays with a “just get’em there” approach to trauma. A patient cannot bleed indefinitely and they cannot sustain stable vitals indefinitely in the presence of on going hemorrhage. Just letting them bleed on the way to the hospital because “we can’t fix that,” serves to exacerbate the situation. We must perform the most maximally aggressive care that is necessary to prevent delivering a patient who is in irreversible shock.
What can we do? How do we make the commute to the trauma center work for the patient beyond providing them with a transportation conveyance? External hemorrhage control techniques are an important part of trauma care, and treatment options like commercial tourniquets and hemostatic gauze are mainstays of civilian trauma care. For more difficult to control hemorrhage there are a number of compression devices out there that act as large aortic tourniquets that can potentially buy some time back for the patient.
Then there are more “fancy things,” to use Dr. Qasim’s words, like REBOA. REBOA has had some challenges in widespread acceptance in the US compared to its UK partners and the military experience with it toward the end of the GWOT.
But even these may not turn the tide. What can? At FAST 23, Dr. Qasim introduced the concept of the “spontaneous responder.” Lay people with hemorrhage control training that are nearly immediately available after a traumatic injury has occurred. The military had great success with similar programs like the Ranger First Responder and Combat Life Saver training that not only acts as a force multiplier for the constrained medical resources in those units, it also serves as a mindset shift that everyone has a responsibility to respond immediately to a wounded soldier and also ensures that they have the training and equipment to do so. The key element in the survival chain for a trauma patient, whether military or civilian, is the initiation of resuscitation as soon after the time of injury as possible.
What matters after the initial responders, professional or casual, have done what they can? EMS takes over by providing the next level of care, that in 2024 includes things like blood products, TXA, and rapid transport to a trauma center. We know that when blood products are initiated prior to transport and delivery to the trauma center outcomes are better. It can be debated whether or not TXA offers a similar benefit, but that is a debate for another day. While prehospital blood is gaining traction, and a lot of services are getting it done, it is not feasible everywhere, and the strategy in the back of the aircraft or ambulance may need to be modified to suite the operational reality. The overall goal is, within the realm of possibility, to deliver a trauma patient with the most meaningful and impactful interventions completed, and ready for the next phase of care.
The system described above, is only effective if it is getting all of these things done, and while shaving time off of the 2.7hr average time of bleeding. The clock stops when you stop the bleeding. When you can’t, as is the case with NCTH, you can still perform significant and meaningful interventions that buy back some physiologic time for the patient.
Every second counts.
IF you enjoyed this and want to dive a little deeper into the conversation between Dr. Qasim and the Alert Medic 1 crew. Check out the podcast on Spotify.

Reference:
Qasim, Zaffer; Butler, Frank K.; Holcomb, John B.; Selective Prehospital Advanced Resuscitative Care – Developing a Strategy to Prevent Prehospital Deaths From Noncompressible Torso Hemorrhage. SHOCK 57(1):p 7-14, January 2022. | DOI: 10.1097/SHK.0000000000001816