In treating victims of gun violence, replacing lost blood — lots of it — and doing it stat is critical.

St. Michael’s Hospital, and the field of trauma medicine in general, continues to make great strides on this front, says Dr. Sandro Rizoli, medical director of trauma and acute care services.

“One major difference is that today, when someone comes in, we start to give them a blood transfusion very early on,” he said, noting that until just over a decade ago, these patients were immediately given saline IV fluids with blood to follow.

But a 2007 study, of which Rizoli was a contributing author, showed that trauma patients suffering from major hemorrhagic bleeding have much better outcomes if they are immediately given massive blood transfusions.

“They do much better if they get blood from the start,” he said.

In what has been a record year for homicides in Toronto, the city has seen much gun violence. To date, there have been 95 homicides, more than half of them from gunfire.

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That’s the largest number since 2005, otherwise known as the Year of the Gun, when there were 53 shooting deaths in the city.

Another 175 individuals have been injured by gun violence this year.

Many of these survivors owe their lives to the health professionals such as Rizoli.

St. Mike’s — one of three trauma centres in the city — sees about one shooting victim a week and is able save approximately 80 per cent of them, Rizoli said.

The Star recently spent some time with a Rizoli and the team of trauma surgeons at the hospital to learn how they are trying to keep more of these patients alive.

Rizoli said it stands to reason that shooting victims are faring better today. The increase in gun violence sadly means trauma surgeons are getting much more experience in dealing with these patients.

“During my training 25 years ago, gunshot wounds were uncommon and many Canadian surgeons had to train in the U.S. to gain experience in treating them. The growth in the number of victims to gun violence and the progression to more lethal weapons had been fortunately balanced by enormous advances in trauma science and practice,” Rizoli said.

Advancements have been made in research, technology, drugs, hospital design, workflow, protocols and best practices, he noted.

Much of the learning has come from the battlefield.

“We have learned from wars that patients who have lost a lot of blood cannot clot appropriately,” Rizoli explained.

They suffer from what is known as “trauma-induced coagulopathy,” and if not treated quickly, it can lead to a patient bleeding to death.

“We give them blood, and tons of blood, to start with. Then we try to diagnose, as quickly as possible, exactly what is wrong with their coagulation,” Rizoli said.

They do this by using a piece of equipment, purchased by the hospital about five years ago, which quickly analyzes blood-clotting properties. Called ROTEM, short for rotational thromboelastometry, it guides health professionals in determining what blood products trauma patients require so that their blood clots properly.

St. Mike’s surgeons have recently begun to use another technique developed on the battlefield, this one to stop traumatic bleeding.

The minimally invasive procedure is known as REBOA, or Resuscitative Endovascular Balloon Occlusion of the Aorta. It involves running a catheter up the femoral artery and into the aorta. A balloon at the tip of the catheter is inflated, stopping the flow of blood.

The procedure can be done in the trauma bay. Previously, patients would have been moved to the opening room where their chests would be opened and aortas clamped. That took much longer, was more invasive and carried a higher risk of death.

Before using the new REBOA catheter on patients, St. Mike’s tested it out on a high-tech mannequin. The simulation served to educate those in the trauma program — including nurses, respiratory therapists and surgeons — on how it works.

“It’s like crash-testing a car. You wouldn’t drive a car if it hadn’t been crash-tested first. We do the same thing with new processes. We crash-test them and make sure they work like we anticipate they will,” said Dr. Andrew Petrosoniak.

He and colleague Dr. Chris Hicks are emergency physicians, trauma team leaders and simulation educators at St. Mike’s. Their work on simulation exercises has helped improve the workflow in trauma resuscitation care. It has also informed the design of a new trauma bay at the hospital, scheduled to open in 2019.

One of their exercises involved tracking the movements of three nurses treating a simulated trauma patient. It was videotaped and the movements of each nurse were followed, using an overlay tracing tool, with a different colour for each nurse.

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The end result looked like colourful child’s scrawl to the untrained eye. But to Petrosoniak and Hicks, it revealed how the nurses lost time criss-crossing the trauma bay to get different pieces of equipment.

If the equipment needed was closer at hand, nurses would need to criss-cross the room and seconds could be saved. There would be less risk of nurses bumping into each other and dropping instruments.

“So now we understand where they’re moving and we can improve their efficiency,” Petrosoniak said. “The whole point of efficiency is to get the care faster. If you are thinking about gunshot wound patients, time matters significantly.”

Hicks said the information has also been used in the design of the new trauma bay to show how much room is needed around each bed.

The pair have also worked on creating a new “massive transfusion protocol.” They examined steps taken by everyone involved in the transfusing large amounts of blood into trauma patients.

That includes, as an example, porters charged with picking up blood from the blood bank at the other end of the hospital and carrying it over to the trauma bay.

Petrosoniak and Hicks realized seconds could be lost by waiting for an elevator, so now porters must take the stairs. As well porters must announce themselves when entering the trauma bay instead of waiting to be noticed.

Through changes such as this, delivery time for blood has been cut by 12.5 per cent to nine minutes.

“In the past you might have been waiting for blood,” Hicks said, citing research showing that every minute blood is delayed results in a 5 per cent increase in mortality.

Trauma surgeons at St. Mike’s are also working to reduce the need for their services by campaigning to reduce access to guns. Two surgeons with much to say on this happened to be on duty the night of the Danforth shooting in July. Drs. Najma Ahmed and Bernard Lawless say that the Danforth shooting prompted them to increase their activism.

“I think there is greater public awareness that this is a public health crisis. I think there is also greater awareness that guns can be lethal beyond just crimes. They are very often used in adolescent suicide in Canada,” Ahmed said.

This past fall, she helped draft a position statement, calling for limited civilian access to firearms, and then assisted in getting endorsements for it from medical associations, including the Trauma Association of Canada and the Canadian Association of General Surgeons.

She and Lawless have also been lobbying politicians to take steps to crack down on gun violence.

“Dr. Ahmed and I have been contacting decision-makers at all levels,” Lawless said. “It’s going to take political fortitude to make change. When you look at this from a common sense perspective, it’s really not a difficult issue.”

Calling gun violence a “disease,” Ahmed said it makes perfect sense for physicians to be involved in trying to eradicate it.

“It has its own risk factors and own epidemiology, its preventable strategy,” she said.

Lawless said the profession has a long history in working on injury prevention: “Trauma surgeons have long played a role in injury prevention, whether it’s around seatbelt use, drinking and driving, and even working with engineers on how cars and roads are designed.”

Rizoli said diseases can be eradicated and points to smallpox as an example.

“No one should be injured by a disease that is completely preventable. No one in Canada should he a victim of gun violence. There could come a time when this could end.”