Dancing with Death: Pitt Researchers Pioneer Life-Saving Intervention
by Jill McDonnell
Sixty years ago, Dr. Peter Safar was sitting in his office at the University of Pittsburgh developing the technique known as Cardiopulmonary Resuscitation (CPR). He would later develop the first intensive care unit in the United States and become known as the father of modern day resuscitation. Today, Pitt trauma surgeons are continuing Safar’s legacy by finalizing his concept for a unique trauma procedure called Emergency Preservation and Resuscitation (EPR).
During cardiac arrest, the role of CPR is to manually contract the heart to force blood through the body. However, if a trauma victim has undergone severe blood loss and there is little blood left to be circulated through the body, CPR is a lost cause. This, Safar noted, was the biggest problem with CPR. While he tried to improve the technique, Colonel Ronald Bellamy, head of the U.S. Department of Defense, studied autopsy trends from the ongoing Vietnam War and realized that the majority of American soldiers were dying from massive blood loss. Bellamy enlisted the help of Safar and the two conceived the idea of "suspended animation," now called EPR for risk of sounding too much like science fiction.
"This is not Disney," says Dr. Patrick Kochanek, who has been the Director of Pitt’s Safar Center for Resuscitation Research for the past 20 years. By combining Kochanek's expertise on brain trauma with Dr. Samuel Tisherman’s dexterity as a world-class trauma surgeon, Safar formed the perfect trio to make EPR a reality. Kochanek notes, "The main goal of EPR is to try to save critical trauma victims who are dying from bleeding."
During EPR, an ice-cold saline solution is flushed into the aorta. By lowering the body temperature by 15 degrees Fahrenheit, the surgeons induce a state of temporary stability. Kochanek interestingly notes, "That state happens to be a period of full arrest. It seems like an odd state of stability!" Inducing hypothermia slows down all cellular processes, giving trauma surgeons up to an extra hour to stop the source of the bleeding while the heart and brain are protected from further injury. According to Kochanek, "it's not that different from cooling someone down for open heart surgery. It's just a matter of doing this after you've been injured rather than before you do heart surgery." After surgeons address the bleeding with what is generally called “damage control surgery,” the body is rewarmed just as it is in open-heart surgery.
Every step of the research and implementation thus far has been done at Pitt. Animal trials began 12-15 years ago, and the extensive pre-clinical studies were "amazingly effective," according to Kochanek. A human trial of EPR’s effectiveness was launched at UPMC and a second site is expected to open soon at Maryland Shock Trauma in Baltimore. By far the biggest hurdle for the trial is choosing the right patient. Candidates for the first trial of EPR will have massive internal bleeding, but it is crucial that the patient has no brain damage. Preservation cannot fix irreversible neuronal cell death caused by five to six minutes without oxygen. "The classic candidate was Princess Diana, who was talking at the scene and didn't have a brain injury but had internal lacerations,” says Kochanek.
Currently in Baltimore, the trial is undergoing community consultation, which includes public sessions to teach the community about EPR. It is very important that the community support this research since candidates will not be in a state to give consent. "The concept, the tools, all of the pieces are there, and they know everything works,” says Kochanek. “Getting the logistics of it in the complex setting of an ultra-critical crisis resuscitation is what is the hurdle." Tisherman's team is currently undergoing extensive training to be prepared for the perfect candidate.
Possible complications from EPR are no different than complications for any major trauma surgery. Kochanek doesn't believe there will be any ethical controversies because people understand that these patients will die without EPR. He explains that surgeons are going an extra mile to save a life through this intervention. “Most in medicine would say ‘wow!,’ that's not unethical, that's laudable."
In the future, Kochanek sees EPR being used in combat zones and possibly even for cardiac arrest patients who cannot otherwise be resuscitated with conventional approaches. "I think that if a few examples work for patients that the surgeons felt they were just going to give up on, then that will really be revolutionary," Kochanek said.
Featured in the New York Times, US World and News Report and even the hit drama "Grey's Anatomy," EPR is taking the world by storm. "We did everything that we could" is an infamous phrase in medicine and it seems that Pitt may have just found something else to try.