America is Bleeding, and Congress is Trying to Stop It

With 16 physicians in Congress, America has taken great steps toward putting healthcare providers in a position to address our nation’s most pressing healthcare issues. We have all heard about the most prevalent causes of death in America such as heart disease and cancer, but trauma is actually the leading cause of death for Americans aged 1-44. Whether it’s a car accident, a fall, or even gun violence, trauma kills over 200,000 people per year in the US alone. The figures abroad are in the millions. Every year, trauma-related injuries cost the US almost $700 million. Many of these deaths are caused by massive blood loss, and around 20% could be prevented. With millions of dollars and thousands of lives to be saved, Congressman and physician Dr. Brad Wenstrup (R-OH) and Congressman Alcee Hastings (D-FL) have introduced bipartisan legislation, the Prevent Blood Loss with Emergency Equipment Devices Act of 2019 (H.R.2550), also known as the Prevent BLEEDing Act, which would require blood loss equipment such as tourniquets (a device tightly wrapped around an arm or a leg to stop bleeding) and clotting bandages in public spaces like libraries, schools, and malls.

I sat down with the Chairman of National Stop the Bleed Month Andrew D. Fisher, a fellow Aggie, to talk about this bill and other ways we can improve trauma care in the United States. As a Major in the US Army, Andrew Fisher’s military and civilian experience is extensive. He has completed over 500 missions with a total of 30 months deployment in Iraq and Afghanistan as a physician assistant, and he is a recipient of the Purple Heart. Fisher’s military prowess led him to be named the 2018 U.S. Army Hero of Military Medicine. Now, at the age of 46, Fisher has over 40 publications in peer-reviewed medical journals and is in his last year of medical school at Texas A&M College of Medicine.

Many Americans know how to perform CPR, but Fisher points out that after receiving CPR, only around 10% of patients survive to the time of discharge. However, Fisher says that in the case of massive blood loss, the application of a tourniquet yields a higher survival rate. His previous unit in the US Army brought prehospital mortality from blood loss down to zero after proper blood loss training was given. So far, tens of thousands of people have been trained in bleeding control through National Stop the Bleed Month, and all the training has been completed for free and supported by the American College of Surgeons. Furthermore, traditional CPR/AED courses should add basics about bleeding control. A Texas study found that the mortality rate after a severe vascular injury to the arms or legs was 8% without the application of a tourniquet immediately after injury. However, the mortality rate drops down to 3% for patients who receive a tourniquet. Learning how to use a tourniquet could be vital in a deadly situation.

My own uncle passed away six years ago in a bus accident, and his life could have been saved through the use of a tourniquet. His arm was severely injured in the accident, and he was bleeding out. In a perfect situation, a tourniquet would have been available on the public bus. In this case, a bystander would have wrapped his arm above the site of bleeding, and the tourniquet could have stopped blood from leaving the major artery in his arm. Even where a tourniquet is not available, any type of band, scarf, or long piece of fabric can be used to tightly wrap the arm or leg above the site of bleeding.

When I asked Andrew Fisher about the Prevent BLEEDing Act, he said that he appreciates Congress’s efforts, but noted that the federal government is “a little late to the game.” Fisher pointed out that a few states, such as Georgia, have taken matters into their own hands by equipping every Georgia public school with bleeding control kits. Actions by the slow-footed federal government may not be the most desirable; however, the ratification of this bill would greatly advance bleeding-control education, provide a federal mandate for the availability of blood loss supplies in public spaces, and situate blood-loss prevention as a nationally recognized issue.

Mass shootings in public spaces, such as the Las Vegas Shooting in which 58 people were killed and 851 were injured, have become more common. Bullets can cause major bleeding in an extremity, and death can occur in minutes, which is why time is essential. After the horrific shooting at Sandy Hook Elementary School in which 20 children and 6 adults were killed, the Hartford Consensus was created to improve the response to mass casualty and active shooter events. The Hartford Consensus calls for bleeding control bags to be present in places such as schools. And although it’s debated whether or not teachers should be armed, there are no apparent downsides to having teachers learn basic bleeding control techniques in the case of an emergency.

Fisher emphasizes that one is unlikely to be a victim of a terrorist attack or a school shooting; however, the chance of being in a car accident is much greater. This is where the vitality of emergency medical technicians (EMTs)  and paramedics comes into play. These emergency responders are the first experts to the scene, and their actions frequently determine the life and death of a patient. One of the most common injuries from a major car accident is internal bleeding, which cannot be stopped through the basic application of a tourniquet. However, a procedure called REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) can be done by inflating a balloon in the aorta to temporarily stop blood loss. Currently, only trauma-related physicians are able to perform this procedure. However, Fisher along with countless others in the field of pre-hospital medicine, are calling for the training of paramedics to perform the procedure in a life or death situation. Fisher, a former paramedic, says that it is a challenging skill, but it may save more lives after traumatic injury. In addition to REBOA, Fisher believes that all paramedics should be trained on the administration of ketamine as a pain-reliever. Trauma related injuries can cause excruciating pain that warrants care, which is why first responders must be trained to administer safe pain-relievers to severely injured patients. Only half of paramedics report learning about ketamine during their training; however, ketamine has been vetted through research and has been shown to be a powerful and safe tool for pain relief in the pre-hospital setting. Fisher also believes that EMT standards should drastically increase to broaden their understanding of anatomy and pathophysiology, noting that professional hairdressers have to complete over 1000 hours for their program while based on national averages, EMTs only have to complete a total of 120-160 hours. Overall, furthering the knowledge and clinical skills of our medical responders has the potential to better stabilize patients before they reach the hospital and ultimately save lives.

Thousands of bills flow through our legislative bodies, and the majority of the bills signed into law are sponsored by Republicans and Democrats. The Prevent BLEEDing Act, which would appropriate $10 million to making blood loss supplies more accessible in public spaces, has already gained bipartisan support, and this bill along with other improvements in emergency medicine would have a positive impact on trauma care in the United States.

Major Fisher and I met to talk about trauma care and prehospital medicine

Sources:

Buckland DM, Crowe RP, Cash RE, et al. Ketamine in the Prehospital Environment: A National Survey of Paramedics in the United States. Prehospital and Disaster Medicine. 2017;33(1):23-28. doi:10.1017/s1049023x17007142.

Civilian Prehospital Tourniquet Use is Associated with Improved Survival in Patients with Peripheral Vascular Injury. Teixeira, Pedro G.R.Vu, Megan et al.Journal of the American College of Surgeons, Volume 226, Issue 5, 769 – 776.e1

DiMaggio C, Ayoung-Chee P, Shinseki M, et al. Traumatic injury in the United States: In-patient epidemiology 2000-2011. Injury. 2016;47(7):1393–1403. doi:10.1016/j.injury.2016.04.002

Hastings and Wenstrup Introduce the Bipartisan Prevent BLEEDing Act of 2019. U.S. Congressman Alcee L. Hastings. https://alceehastings.house.gov

Hax SD, Davis K, Stone B, Bledsoe B, Hodnick R. Ketamine’s Versatility Makes it a Powerful Tool for EMS. Journal of Emergency Medical Services. https://www.jems.com/articles/print/volume-42/issue-2/features/ketamine-s-versatility-makes-it-a-powerful-tool-for-ems.html. Published February 1, 2017.

Stop the Bleed – Georgia – Georgia Trauma Foundation.

Zero Preventable Deaths After Injury. Washington (DC): National Academies Press (US); 2016 Sep 12. 1, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK390332/

https://firstcareprovider.org/blog/tk-how-to

Giving Life Twice

Most mothers only give life to one child at a time, but about 800,000 women worldwide give life to two… and I’m not talking about twins. I’m talking about the donation of their umbilical cord blood, the blood that remains in the umbilical cord after childbirth. Most commonly, the umbilical cord and the placenta are thrown away after birth, but these organs contain precious stem cells that have the capacity to save lives… to give a second life to someone else.

Harvesting umbilical cord blood and utilizing it for treatment is a relatively new scientific advancement that started in the late 1980’s. Scientists and doctors have realized that umbilical cord blood is rich in stem cells, specifically multipotent hematopoietic stem cells. These are big words to describe a simple yet incredible cell. Multipotent hematopoietic stem cells are cells that can give rise to all the blood cells, which is why these cells are invaluable to someone suffering from a blood disease. So, how does all this work and what does it treat? Well, first of all, the procedure is painless for both the mother and the child, and it takes 2-5 minutes. To collect the umbilical cord blood after a baby is born, the physician first cuts the umbilical cord then simply puts a needle into the blood vessels of the umbilical cord before drawing out the blood. This blood is then stored and frozen at -196°C. Mothers who have donated this blood have described it by saying that they did not even know it was being collected until after the doctor told them that they were done. After this blood is tested and stored, it can be matched with a blessed patient somewhere around the world who needs a blood transplant. Umbilical cord blood can be used to treat patients with various types of common blood cancers and diseases, such as leukemia, lymphoma, as well as sickle cell anemia.

Numerous advantages exist for umbilical cord blood, including the following:

  • No/very little risk to donor
  • Easily stored
  • Cells collected are immunologically immature and have a high growth potential
  • Low incidence of Graft vs Host Disease, which is a disease where the grafted stem cells detect the normal cells as foreign, resulting in the stem cells attacking the healthy body cells
  • Blood type matching is easier with stem cells harvested from cord blood compared to the conventional stem cells harvested from bone marrow

Now, you may be wondering where all this blood is stored, and this is where the debate comes in. There are two options you can choose from for where your cord blood goes: public banks or private banks. Public banks are completely free, and this is where your cord blood goes into a world registry where a matching donor can be found and treated. However, private umbilical cord blood banks make up a several hundred-million-dollar industry. When the private bank option is chosen, the blood is collected and stored for the sole use of that family. These blood banks say that their service is “biological insurance” for your kid if anything goes wrong in the future, and this is simply misleading. Numerous marketing techniques are used on pregnant mothers to sell them a cord-blood bank plan, but the chance of the child ever actually using this cord blood is trivial. Some studies show the rate of private bank blood used being 0.09% while other studies show that public bank blood is 30 times more likely to be used than private. Furthermore, numerous studies have shown that the quality of cells and the number of stem cells are lower when kept by private cord banks versus public. As one study published in the journal Transfusion said, “Quality parameters of privately banked umbilical cord blood are inferior to those stored in public banks.”

Very few blood diseases can be treated with one’s own umbilical cord blood because if the disease is genetic, then the stored blood has the same genetic abnormality, thereby rendering it useless for the kid. Almost 90% of transplants are between unrelated people with the remaining 10% being between family members, which is another powerful benefit of umbilical cord blood. For example, if you have a kid who has been diagnosed with leukemia, and you also have another kid on the way, then the umbilical cord blood for the second child can be harvested and used for the baby’s brother. This can be done through public bank systems at little to no costs. I keep talking about how public banks do not cost you anything because of the striking difference between public and private banks. Private banks are very expensive! For example, let me tell you about one of the several well-known private cord blood banking companies. According to the company’s website, to store your cord blood, the company charges $1,575 for the collection of the blood and an annual storage fee of $175. That already sounds like a lot, but a greater opportunity cost exists here. At the time of your child’s birth, if you put $1,575 dollars into a mutual fund that grows at a conservative rate of 8%, and you contribute just $175 to that fund every year, here’s how much your kid will have after….

20 years: $15,000

40 years: $80,000

65 years (retirement): $560,000

Many people never attain more than half a million dollars in their entire life, and now your kid can have it just for them at the time of retirement. The sad reality is that while 800,000 women have publicly banked their blood, 5 million have used private banks. Umbilical cord blood is much better off in the hands of a public bank, and this notion is supported by the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and many more. As Dr. Paul Harker-Murray at UT Southwestern said, “Umbilical cord blood is an underutilized medical resource with immediate life-saving clinical applications,” which is why it is so important for pregnant women to strongly consider donating their umbilical cord blood to a public bank.

Sources:

Ballen KK, Verter F, Kurtzberg J. Umbilical cord blood donation: public or private? Bone Marrow Transplantation. 2015;50(10):1271-1278. doi:10.1038/bmt.2015.124.

Kurtzberg J. (2017). A History of Cord Blood Banking and Transplantation. Stem cells translational medicine6(5), 1309–1311. doi:10.1002/sctm.17-0075

Newcomb, J. D., Sanberg, P. R., Klasko, S. K., & Willing, A. E. (2007). Umbilical cord blood research: current and future perspectives. Cell transplantation16(2), 151–158.

Shenoy S. (2013). Umbilical cord blood: an evolving stem cell source for sickle cell disease transplants. Stem cells translational medicine2(5), 337–340. doi:10.5966/sctm.2012-0180

Sun, J., Allison, J., McLaughlin, C., Sledge, L., Waters-Pick, B., Wease, S., & Kurtzberg, J. (2010). Differences in quality between privately and publicly banked umbilical cord blood units: a pilot study of autologous cord blood infusion in children with acquired neurologic disorders. Transfusion50(9), 1980–1987. doi:10.1111/j.1537-2995.2010.02720.x

Waller-Wise R. (2011). Umbilical cord blood: information for childbirth educators. The Journal of perinatal education20(1), 54–60. doi:10.1891/1058-1243.20.1.54

The Green Mistake

Trends of leisure activities have certainly changed in this country over the years. And, generally speaking, it’s not the government’s job to tell you what you’re allowed to do for fun. People argue all day about the line between true freedom and government rules and regulations. And the best way we can think about this is to hope that our legislators on Capitol Hill are constantly thinking about the well-being of our people and the health of our nation. This short intro truly sums up a key issue on the floor of Congress. Currently, about 20 pieces of legislation have been drafted and introduced by veteran senators and presidential candidates such as Elizabeth Warren (D-MA) and Cory Booker (D-NJ) to legalize marijuana across this entire nation. This is a significant time in our country as 33 states have allowed for medical marijuana and 10 states have legalized recreational marijuana. The question of whether we become like Canada or stay away like Sweden has become a hot topic in the 2020 race for the presidency.

So, I want to talk about marijuana and give you the facts from scientific research that will either assure you of your beliefs or clear up some myths about the most commonly used illicit drug in America. I will only give you numbers that have come from reputable, peer-reviewed journals, which are products of years of painstaking research. I’ve had the marijuana debate with several people, and the proponents of marijuana legalization make 3 key arguments, each of which I want to address:

  1. Marijuana is not that bad for you, and it’s safer than alcohol.
  2. In states that marijuana has been legalized, marijuana usage, alcohol usage, and opioid usage have all gone down.
  3. Marijuana can be taxed and will provide great economic benefits to our country.

When comparing the effects of marijuana and alcohol on the body, it’s important to note that these drugs affect the body in different ways, and the amount of research done on alcohol far outweighs marijuana. You’ve probably already heard a lot about the negative effects of alcohol and the cognitive impairment it brings along, but what exactly does marijuana do to your body? Marijuana has been linked to some types of cancer (and cancer in offspring), chronic cough, cognitive impairments (in learning, memory, and attention), impairments in academic achievement, and development of schizophrenia. Scary, right? Well, what’s scarier is that in states that have legalized marijuana such as Washington, 8th grade and 10th grade kids perceive marijuana as less harmful and their marijuana usage has increased compared to pre-legalization. With all the country’s debate, kids don’t see marijuana as very dangerous, particularly because 10 states have legalized it.

I’ve heard numerous people say that marijuana helps them calm down, and this is supported by research, but only in the short term. Studies describing long term effects clearly state that marijuana is associated with anxiety, depression, poorer sleep quality, and organ damage. The few studies comparing the harmfulness of marijuana to alcohol have shown that marijuana is more neurotoxic while alcohol has greater negative effects on the liver. It is important to note that there is a consensus on the negative effects of alcohol on the health of the American people; however, the prevalence of alcohol usage makes banning the drug impossible. But, it’s not too late to fight marijuana. Instead of adding another addictive drug to the market, wouldn’t we want to keep it off?

And this brings the discussion to the next point made by proponents, which is that marijuana legalization leads to reductions in marijuana, alcohol, and opioid usage. Looking at the numbers, this simply is not true. Statistics from states that have legalized marijuana (even if it’s just medical marijuana) show that marijuana usage goes up after legalization. Furthermore, 22% of medical marijuana users have admitted to selling their drug to non-medical users! It’s a clear picture: greater availability leads to greater usage. Now, after marijuana was legalized in Colorado, Washington, and Oregon, a few articles came out saying that alcohol sales in the state would be hurt because people will be substituting marijuana for alcohol. Lawmakers for marijuana legalization treasured these initial numbers and predictions…. until the Distilled Spirits Council came out and said that the legalization of marijuana in these states had absolutely no negative effect on alcohol sales. In actuality, the Distilled Spirits Council reported that spirit sales have increased by 4% in Oregon, 5% in Washington, and 8% in Colorado since each state’s respective legalization date. This data, in addition to studies tracking adolescents over several years, have shown that alcohol and marijuana are not substitutes, but rather they are complements in deteriorating health.

Now, for opioids. So, opioid usage has gone down since recreational marijuana was legalized in 10 states. Big win for marijuana lovers? Well, not quite. During the same time that recreational marijuana was being legalized in some states, our nation began tackling the opioid crisis.

Legislators and our president realized that tens of thousands of people were dying from opioid overdoses. To tackle the problem, strict legislation was passed, in tandem with new rules by the CDC, to limit the amount of opioids prescribed to patients by physicians. This time, less availability led to less usage. Reductions in opioid usage has been a win for our nation, but we must take caution before we attribute that positive outcome to the legalization of a different harmful substance.

Lastly, we can talk about money. America is in a debt crisis. Our nation’s debt has exceeded $22 trillion, and we don’t have a bipartisan plan to pay off our debts. Is the legalization and taxation of marijuana the solution? The states that have legalized marijuana have raised over a billion dollars in tax revenue, but the reality is that much greater costs are being incurred. Health costs of marijuana use have already been estimated to be $4.50 for every dollar raised in tax revenue, and the costs associated with federal legalization are unknown. With all of this in mind, I encourage you to take an active role in politics by choosing candidates based on their views regarding issues such as marijuana that could greatly affect the well-being of our nation.

Sources:

Alcohol Clin Exp Res. 2016 Jan;40(1):33-46. doi: 10.1111/acer.12942. Epub 2015 Dec 21.

Am J Psychiatry. 2019 Feb 1;176(2):98-106. doi: 10.1176/appi.ajp.2018.18020202. Epub 2018 Oct 3

Ann Epidemiol. 2017 May;27(5):342-347.e1. doi: 10.1016/j.annepidem.2017.05.003. Epub 2017 May 10.

Drug Alcohol Depend. 2017 Jan 1;170:181-188. doi: 10.1016/j.drugalcdep.2016.10.025. Epub 2016 Oct 26.

J Subst Abuse Treat. 2017 Oct;81:53-58. doi: 10.1016/j.jsat.2017.07.012. Epub 2017 Jul 29.

JAMA Pediatr. 2017 Feb 1;171(2):142-149. doi: 10.1001/jamapediatrics.2016.3624.

JAMA Psychiatry. 2018 Jun 1;75(6):585-595. doi: 10.1001/jamapsychiatry.2018.0335.

Wilkinson S. T. (2013). Medical and recreational marijuana: commentary and review of the literature. Missouri medicine110(6), 524–528.

So, you’re unhappy with the US healthcare system…

Chances are that you are part of the nearly 80% of people who are unsatisfied with the costs of healthcare in our country. And it’s justified! Articles come out almost daily talking about the trillions of dollars spent on healthcare in the United States each year and the stark difference between costs of care in the US versus countries such as Canada. Even when we look back at history, it seems as if nothing has changed. In the 1940s, during Truman’s presidency, 82% of Americans said that hospital care and physician fees were too high. In 1990, papers were published saying that 89% of Americans were in favor of fundamental changes to our healthcare system. So why, after nearly 100 years, can’t we get it right? Movies such as Sicko have come out to show the public that healthcare in the US should be “free” like it is in Canada and that our government is cheating us! In no way is our healthcare system perfect (it has a great amount of room for improvement), but it’s all about perspective. With such a personalized service such as healthcare, it’s important to look at the issue from numerous angles before jumping on the ‘socialized medicine’ bandwagon.

Socialized medical systems are monetarily cheaper. This is a fact. Regardless of what those on the right or left try to say, there is simply too much published evidence showing that administrative costs in the US healthcare system are far greater than any nation embracing a socialized system. However, these studies are only comparing costs in dollars spent, while in reality, there is a price for time and an incalculable value for life. A socialized medical system may cost less on a balance sheet, but it would be a disservice to the American people to base the future of our healthcare system on whether the expenses are higher on a balance sheet. Let’s talk about Canada as an example for what all this means. Canada has a single-payer healthcare system, meaning that medical coverage for all citizens is publicly funded. Those public funds come from Canadians’ tax dollars, so healthcare is not “free,” but rather everyone is paying for each other as a collective. This single-payer system does not incentivize physicians to see more patients or work longer hours because each physician is on a salary that stays the same whether they see five patients or twenty patients in a day. Because of this and numerous other factors, average wait times to see a family practice physician, see a specialist, or even visit the emergency room are considerably longer in Canada compared to the United States. Although sources vary, the average wait time to see a physician in the US is 3-4 weeks while in Canada, estimates of averages are as high as 18 weeks. These long wait times frequently result in physical and emotional stress for a patient, loss of work productivity, time, and money. Worse, thousands of patients have died simply waiting for care. All this begs the question: what are the real costs of socialized medicine?

There are numerous issues with our healthcare system that must be focused on instead of fundamental shifts that have a slim chance of passing in Congress. The real issues can be seen right here at home. Various hospitals, whose main goals are to maximize profits, call themselves non-profit hospitals in order to avoid paying taxes. Researchers have found that non-profit hospitals act incredibly similar to for-profit hospitals and the “community benefit” promised in exchange for their tax exemption is questionable. Another issue is that we have physicians who practice defensive medicine by ordering many unnecessary tests because they look at patients as potential litigants. Studies have shown that up to 90% of physicians practice defensive medicine due to fear of litigation, and this greatly increases the overall costs of our healthcare system while also failing to benefit the patient or the physician. Arguably the most important problem with our healthcare system is a near total lack of price transparency. If every hospital clearly laid out the fees associated with each medical procedure, market forces would come into play and drive down the price of healthcare for all of us. By keeping prices secret, which is supported by large hospital lobbying groups, hospitals gain while we as healthcare consumers pay an absurd amount for our care.

We all haven’t mined for coal or dealt first-hand with our debt crisis, but all of us have received healthcare from the United States healthcare system, and that’s what makes healthcare such a personal public policy issue. And it would be wrong for me to say that we are not happy with the quality of care provided. Physicians, nurses, and other medical staff in the United States provide excellent care that even attracts individuals from other countries when dire medical attention is needed. Americans highly rate the quality of care provided to them, but like most large-scale systems, improvements can always be made. It is important, however, to make and fight for those improvements with caution because the health of the American people and our nation are at stake.

Sources:

Blendon RJ, Benson JM. Americans’ Views On Health Policy: A Fifty-Year Historical Perspective. Health Affairs. 2001;20(2):33-46. doi:10.1377/hlthaff.20.2.33.

Woolhandler S, Himmelstein DU. The Deteriorating Administrative Efficiency of the U.S. Health Care System. New England Journal of Medicine. 1991;324(18):1253-1258. doi:10.1056/nejm199105023241805.

Health Aff (Millwood). 2014 Sep;33(9):1586-94. doi: 10.1377/hlthaff.2013.1327.

Sekhar MS, Vyas N. Defensive medicine: a bane to healthcare. Ann Med Health Sci Res. 2013;3(2):295–296. doi:10.4103/2141-9248.113688