It was her that would define the career of Professor Ian Roberts. Just ten years old, she was brought to the Emergency Care Doctor’s Ward on a sunny day in 1990.
It was her turn to be in the backseat of her parents’ vehicle when an SUV drove at 70 mph and overtook another car.
This resulted in a collision that caused a head-on collision. The car with the little girl was the one to suffer the most. At the scene, both her parents were declared deceased.
She survived the impact but suffered internal bleeding in her stomach – a result of the seat belt pressing into her abdomen.
He was certain she would survive. She was conscious and alert. Yet, an hour later his colleagues told him that the little girl had passed away. After major surgery to her stomach, she had suffered severe haemorrhage and was pronounced dead.
‘I was shocked that there was nothing we could do,’ says Prof Roberts – who has since become one of the UK’s leading experts on severe blood loss.
A drug that blocks the release of compounds that stop blood clotting could save a third of people suffering major blood loss – but only 5 per cent of British patients after being offered it (stock photo of car accident)
The occurrence of serious bleeds was common and it wasn’t clear why there weren’t simple ways to stop bleeding. We had many tools to do it effectively with relatively minor bleeds – so why not major ones?
“At that point, I was obsessed researching ways to prevent unnecessary deaths from blood loss.
But two decades later, Professor Roberts warns that similar scenes are still playing out across the country – despite a widely available and highly effective treatment.
TXA is an inexpensive drug which can be used to save the lives of up to three-quarters of those with major blood losses. It has no side effects.
The medicine, which costs £2 per dose to the NHS, can be injected directly into a muscle in the thigh – or via a vein in the arm – and blocks the release of compounds that stop blood clotting.
The treatment can be used worldwide to treat road accident victims and major trauma patients. New research shows that only five percent of British accident victims could benefit from it.
The stark findings, published by Prof Roberts and colleagues at the London School of Hygiene & Tropical Medicine, also revealed that only three per cent get the drug within the crucial first hour.
Tranexamic acid (or TXA) is a cheap, non-side effect drug that can help save up to a third people who have suffered from major blood loss.
The lack of drug use is now a key line of inquiry in the ongoing public inquiry into 2017 Manchester Arena’s terrorist attack. 22 people died at Ariana Grande’s concert.
Family members have criticized the paramedics’ care on the night. Prof Roberts wrote Sir John Saunders, suggesting that TXA could have saved more lives if it had been utilized efficiently.
Since that intervention, paramedics have been questioned on whether they treated patients with the drug – particularly with regards to the case of 28-year-old John Atkinson, who died following extreme blood loss from a leg injury as he lay on the foyer floor unattended for 47 minutes.
John was pronounced dead by his family, who accused the emergency service of giving John precious time to pass while they bled.
An inquiry revealed that the paramedic who was first at the scene of Mr Atkinson’s injuries had “lost” his drugs bag. However, the second one used TXA to stop the bleeding. This happened more than an entire hour after the incident.
Although John was not saved by TXA, John’s lawyer stated that there wasn’t enough evidence. However, he did acknowledge its existence in certain circumstances.
The reluctance to use TXA is resulting in hundreds of preventable deaths every year and is a national scandal, claims Prof Roberts, now professor of epidemiology at the London School of Hygiene & Tropical Medicine.
He states that ‘Our study of more than 100,000 trauma victims shows it is only currently provided to less than 10% of the patients who could benefit’.
“This statement is quite shocking considering that science has confirmed its life-saving properties.
“The problem lies in poor implementation. It is not being understood by enough people, or if it does get implemented it is too late. It is wrong that thousands upon thousands of people are dying every year from it.
Experts’ warnings come amid recent reports of a national ambulance shortage – with 160,000 patients facing long delays for urgent paramedic care every year. This situation could mean that even less people will receive TXA to save their lives.
According to NICE, Major Traumatic Injuries are the number one cause of death and the main cause of disability for people younger than 45 in the UK.
The Royal Society for the Prevention of Accidents estimates that more than 14,000 Britons will die each year due to injuries sustained in traffic accidents or falls.
Rapid blood loss – both through the skin and internally when blood vessels or organs are ruptured – kills quickly, as it means there is less available for the heart to pump around the body, starving organs of oxygen and other vital nutrients.
Organs can fail without blood. The treatment of major blood losses has changed significantly over the last thirty years.
To maintain proper pressure around the organs, doctors used to inject additional fluids. Studies showed this made things worse.
Paramedics still have a number of other common treatments to stop blood loss. These include tourniquets, specialist dressings that prevent blood from leaving the body, as well as toursniquets, which are tight bands that restrict blood flow.
Japanese scientists then looked into treatments for women who had suffered severe hemorhage in their wombs and found that TXA helped blood clot.
A second study was done at Camp Bastion in Afghanistan in 2011. It found that TXA saved more major blood losses than it did without.
It has been used in surgery, maternity and emergency care for the last ten years.
Dr. Tim Nutbeam is an emergency physician in Plymouth who works alongside the Devon Air Ambulance. He says when I am called to an accident scene, TXA administration is “the first thing that I do”.
He says, “It’s such an essential part of the treatment.” It is now clear that we should give it sooner than later. It is not being used by healthcare professionals enough.
So, why is TXA so rarely used by medics properly? Experts believe that trauma patients are often stereotyped.
Prof Nutbeam says that trauma is a risk to bleeding death and doctors often think about a young person in a car accident or someone who has suffered multiple stab wounds.
Paramedics tend to be more inclined to provide TXA for young people and especially to young men. However, they are often reluctant to offer TXA to older individuals and women who could benefit.
A senior who has fallen on a slab of paving can sustain severe traumatic injuries as well as internal bleeding.
“But they aren’t the types of cases paramedics consider trauma so they will not think about giving the drug.”
These patients are often called’silver-trauma’ victims by experts. The NHS statistics show that one third of Britons older than 65 years old and half the elderly have had at least one fall in their lifetimes. The Government has revealed that falls are the number one cause of death for over-65s from injuries.
It is still a matter of debate whether the injury that needs TXA injection should be considered severe. TXA can be used in severe hemorhages.
Internal bleeding is difficult to diagnose without scanning. Many more people would be able to benefit if the term “severe” was removed from the guidance.
Professor Roberts says that TXA is free of side effects so it would not be a problem to give the drug for people with more severe or less visible injuries.
“Often, injuries can prove to be much more serious than first thought by paramedics, and it makes sense to give it just in case.”
Tony Stone, College of Paramedics Emergency Services Manager, said that it is sometimes difficult to identify an elderly patient at serious risk of major bleeding.
You can tell if you have pale, cold, or clammy skin. He states that it is not possible to tell if someone calls 999 from the phone.
Stone says that older patients may need to take medication more frequently. For example, beta blockers can be used to treat heart disease. This will slow down the heartbeat and mask the signs of internal bleeding.
Blood-thinning medications make it more probable that they will suffer from a devastating bleed.
The Emergency Medicine Journal published an article this month that revealed several reasons paramedics deny patients medication.
These included lack of TXA knowledge, confusion over when to give it and difficulties identifying people at high risk for life-threatening bleeding.
Experts believe that confusion could be caused by recent modifications to guidelines for paramedics regarding how to administer the drug.
Prior to that, it was administered slowly and for a minimum of ten minutes. After a study that proved it safe and efficient to inject TXA into the thigh, the paramedics’ guidelines changed.
British doctors now have a method to provide TXA quickly and efficiently in times of crisis.
Auto-injectors – pen-like devices, filled with a single dose of TXA – have been shown to be highly effective in early studies involving the military. This means that even if there are no medics available, people could be saved.
Professor Roberts is hopeful that such breakthroughs will be possible in the coming years. However, establishing targets to speed up the use of TXA would still save lives.
He states that the ambulances have already to reach a time target to transport stroke patients to specialized centres.
‘TXA is really important, but it is not the only step – the health system has to realign around that treatment.
“We have to be clear about who gets the drug and if they get it.