Project Description Narrative:
Violent injury disproportionately impacts Black communities. In the U.S., homicide is the leading cause of death for Non-Hispanic Black males between the ages of one and 44 years. In Milwaukee in 2022, 940/1075 (87%) of shooting victims were Black, and overall shootings have been up trending since 2019. While prevention efforts are critical, this project is targeted at the need to reduce mortality after injury has already occurred. The most common cause of preventable death after injury is bleeding. Some gunshot wounds are not survivable based on anatomic considerations, but of those that are, bleeding is the primary cause of death. A recent study of homicides in Milwaukee found that roughly 2/3 of penetrating trauma patients died as a result of thoracoabdominal gunshot wounds.
There is no method of controlling major thoracoabdominal bleeding in the prehospital setting. Control of bleeding in the chest and abdomen requires surgical exposure to repair or ligate bleeding vessels, and this cannot be achieved outside of the operating room. Mortality after bleeding increases as a function of time spent in uncontrolled hemorrhagic shock, and thus longer prehospital times are associated with higher mortality rates. Emergency medical services (EMS) transport is the standard of care for prehospital transport in Milwaukee, but other transport paradigms exist. EMS providers in Milwaukee provide invaluable services to acutely ill patients in the prehospital setting, but as no effective method of controlling thoracoabdominal bleeding outside the operating room exists, the chief role of EMS in this setting is rapid transport to the hospital. However, scenes of violence may be unsafe to enter; and thus, transport may have to wait until police arrive and secure the scene. When police arrive first, they must wait until EMS arrives to transport. Other cities have allowed police to transport patients with penetrating trauma when they arrive before EMS, including Philadelphia where ~60% of penetrating trauma patients are currently transported by Police units. Police transport is associated with shorter prehospital times and either no difference in mortality or improved mortality for some subsets of patients referent to EMS transport.
The intended impact of this project is to reduce mortality secondary to penetrating thoracoabdominal trauma in Milwaukee by reducing prehospital time. The project team’s central hypothesis is that referent to EMS-only transport, a First on Arrival Scene Transport (FAST) paradigm in Milwaukee would result in decreased transport time and therefore mortality. This project will characterize the current state of prehospital transport in Milwaukee as well as a future potential state in which First on Arrival Scene Transport occurs. Knowledge from this proposal will inform future externally funded cluster-randomized trials of prehospital transport models in Milwaukee with the ultimate goal of reducing mortality secondary to gun violence in our community.