Case Study: Eric Goralnick, MD, MS
Eric Goralnick, MD, MS, emergency medicine physician at Brigham and Women’s Hospital, notes an important distinction between the terms “emergency medicine” and “disaster”. As he describes, emergency medicine is a specialized profession where trained caretakers treat individuals who come through an emergency room. Disasters — whether natural, manmade, cyber, etc. — are large-scale events that have a broad impact and disrupt daily life. For the purpose of this conversation, we will refer to emergency medicine and how it pertains to trauma care.
Some responses have been edited for length and/or clarity.
Q: From an emergency medicine perspective, how many people are affected by traumatic injuries every year?
A: When I think about Stepping Strong, I think about trauma care and the more than 200,000 preventable trauma deaths annually [in the United States]. And that’s really the focus of our work at Stepping Strong and my work as it pertains to Stepping Strong in reducing those preventable deaths.
Q: Tell us about your innovative solution to help trauma patients and how it advances the field of trauma care.
A: In the aftermath of the marathon bombing, we aggressively tried to understand what we did well and where we could improve. Through these after-action reviews, one area, in particular, was really interesting and that was, of the individuals that were injured on scene, there were about 29 individuals that had visually bleeding extremities, 27 of them had tourniquets applied, and many of those tourniquets were applied by laypersons — non-medical, non-traditional first responders. And so, what that demonstrated to us, is that not only do people want to help, but people will help.
This idea of empowering the public with emergency skills to save lives is not old, but the idea that people will help and jump in was really something to see. We began to work with the military; we looked at the work that they had done and found that over the course of 16 years in Iraq and Afghanistan, they had reduced deaths on the battlefield by 44%. And we looked at our civilian society where, at the same time, events like the marathon [bombings] occurred, but in routine trauma, there were 200,000 preventable deaths every year from motor vehicle collisions, gunfire accidents, intentional events, and more. So we asked, “How do we translate the military work to the civilian world?” And one area was bleeding control.
With our first [Stepping Strong] Innovator Award, we learned what others were doing in this space. We conducted the first randomized controlled trial of a one-hour course, designed by the American College of Surgeons, to train the public in how to recognize life-threatening bleeding and apply a tourniquet effectively. We compared that to a study of people who had no training and received two just-in-time tools — one was a flashcard that demonstrated how to apply a tourniquet, and the other was a talking kit. What we found was that through the one-hour course, 88% of people, after one hour, could effectively apply a tourniquet in the right place, in the right amount of time, with the right amount of pressure. This was the first time that anyone had demonstrated that laypersons could do this with one hour of training. And so that then was an “aha” moment for us, not only (1) this is doable, but (2) those other two tools (the flashcard and the audio kit) were not as effective as we thought they’d be.
That started a journey. We retested those people between 3 and 9 months later and 54% could perform the same skill. This revealed to us that the course was not durable and, in fact, people would forget it. Although we found the just-in-time tools to be less effective, the course was hard to schedule, logistics are challenging, and it’s not really a long-term scalable solution. So what could we do? Our focus then became, “How do we develop and focus on just-in-time tools?”
With the support of the Stepping Strong Breakthrough Award, we started to understand some other challenges that were related to this Stop the Bleed work. There were many vendors out on the market with different types of tourniquets. So we then asked the question, “If there are a lot of courses being taught and there are a lot of vendors out on the market with different types of tourniquets, how do we navigate that? If you learn on one tourniquet, is that translatable to another type of tourniquet?”
We did a randomized crossover trial with 4 different types of tourniquets. We enrolled over 100 individuals and tested them after giving them a one-hour course. With the one-hour course, 92.2% got it right with the tourniquet we regularly use in teaching, 68.6% got it right with a tourniquet that’s very similar, and the other two types of tourniquets were worse than no training at all. Another surprise with this was that we gave people all the equipment they would need for an improvised tourniquet and actually, they did pretty well, 32.4% got it right.
Q: How has your work progressed to impact the field of trauma?
A: We did a public safety announcement that played at every Patriots game for several seasons. It talked about the importance of Stop the Bleed and where people could find information so they could sign up for classes and get equipment and other pieces. So, we’re really trying to combine a lot of our work to get this message out and to empower the public to save lives.
Q: Following your collaboration with the Stepping Strong Center, what additional opportunities have come from your research?
A: In 2019, we conducted the first National Stop the Bleed Research Consensus Conference. We had over 45 individuals that represented civilian and military leaders. It was public health leaders, military, civilian, emergency medicine, trauma care, and private industry. From that conference, we published work that helped guide where the gaps were in the implementation of Stop the Bleed for the next decade. And by the way, [Stop the Bleed] co-hosted with Stepping Strong for that conference.
Then, we got a grant from the Department of Defense, with our collaborators at Uniformed Services University. We worked with them on the development of a novel audiovisual tourniquet (video) — one that you could pick up with no prior training and use; another version of a just-in-time tool. What we found with this tool in a pilot study was that 93% of people, just by picking this device up with no prior training, could apply this tourniquet effectively, and they could do it in 74 seconds, on average. It was four times more likely that you would be able to apply this tourniquet effectively than a regular tourniquet with no training.
This then started to open up, beyond trauma care, what are the other challenges that we face as a nation, as a globe? There are thousands of cardiac arrests every single day, only 100 of those survive and every minute, 10% survival decreases, so CPR is definitely an area of opportunity. Another area is opioids. We’re living in a world of opioid crisis and one study came out that said almost 20%, roughly, of opiate deaths could be avoided if people had naloxone and they were available. We did some training and evaluations on our first combination class — that was CPR, AED, naloxone, and Stop the Bleed. And that course was done with staff at Massachusetts Medical Society and we just had that paper recently accepted that talks about those results.
And then we developed videos in Ukraine. With Nelya Melnitchouk, a surgeon at Brigham and Women’s Hospital, we made a couple of videos in Ukranian [language] on bleeding control. Those were distributed pretty broadly at a high-level number of views within the first couple of days. Then we partnered with YouTube, and we developed a series of chemical, biological, radiological, and nuclear preparedness videos — half for laypersons, half for traditional public safety professionals — and they range on a variety of different ways to empower the public to take steps to help each other. We also partnered with a couple of television shows, the American College of Surgeons, and others to do a video on Stop the Bleed that was in English, with Ukrainian subtitles, featuring actors and actresses from several TV shows. We’ve presented twice at the Clinton Global Initiative as part of what they’re now calling their “Ukrainian network” — 15 organizations that have all been doing work in Ukraine and working to learn from each other and partner, to help advance our work in different sectors.
So, we’re making an impact. But beyond videos, we really want to get back to measurements of effectiveness because we want to understand, “When you watch the video, how effectively can you perform these skills?”
Q: What is your goal for survivors who have experienced a traumatic injury? What does success in this work mean to you?
A: My goal is to reduce the number of preventable deaths due to emergencies by empowering the public to take effective action. My team believes that everyone can save a life and that’s really the journey that Stepping Strong helped launch with that initial investment and belief in this vision, and we’re doing it.