RI EMS using cheap, lifesaving drug on trauma patients

EMS director Matthew Bivens said TXA is "lifesaving," and has been "proven on battlefields in Iraq and Afghanistan"

By Wesley Sykes
South Coast Today

NEW BEDFORD, R.I. — It was early in 2016 when tranexamic acid, referred to as TXA, was first administered in the SouthCoast.

A New Bedford paramedic responded to a bar fight in the city that spiraled out of control. The male victim suffered multiple stab wounds to the chest.

Dr. Matthew Bivens, an emergency room physician and EMS director at St. Luke's Hospital, recalled the man was subsequently involved in another fight—this time fighting to hang on to his life. The New Bedford paramedic administered a vial of TXA mixed with saline intravenously over a 10-minute period en route to the nearly 30-minute ride to Rhode Island Hospital, where South Coast trauma patients go for treatment.

Despite his critical condition, Bivens said the man survived. The man may have lost his first fight, but it was his victory in the second fight that has helped kick open the door having TXA available to trauma patients across the state.

"TXA is lifesaving," he said. "It's been proven on battlefields in Iraq and Afghanistan and showed positive results in huge randomized trials."

Tranexamic acid is a cheap, generic drug that's been available since 1950s, according to Bivens. Simply put, the drug slows bleeding and reduces the need for blood transfusions.

Military surgeons have used it to save American lives in the battlefield. In Crash-2, a 2010 randomized control trial involving 20,127 patients from Europe, Africa and Asia, getting the drug within three hours reduced the risk of fatal hemorrhage by 30 percent. The Crash-2 study included 274 hospitals and 40 countries. Furthermore the study found patients suffering near-death vital signs have a one in 22 chance of survival with the use of TXA.

"It was a monumental study," Bivens said. "One of the best studies ever done in my opinion."

According to Bivens, in those randomized trials there were no reported side effects. Additionally, there have been no reported side effects for pregnant women or children, he said.

British ambulances have had TXA available to paramedics for years. A follow-up study, called Matters, looked at the fate of 896 British patients and found that severely wounded patients who got the drug had survival rates twice as high as those who didn't.

Yet, amid all the positive results, the United States has been slow to catch up to those across the Atlantic.

Bivens said one reason is a lack of marketing behind the product. At $10 a dose, this generic drug isn't currently owned by any pharmaceutical companies. Low profit drugs, such as TXA, simply do not receive big advertising budgets.

"That's kind of aggravating," Bivens said.

In an attempt to promote and educate the public about TXA, it was featured in the popular British medical drama, Holby City, in an episode in 1999 and subsequently mentioned in the BBC premiere showing of An Hour to Save Your Life in March of 2014. Here in the states, ABC aired an episode of the Catalyst called "Thin Blood" that focused on TXA in 2012.

"The low cost of TXA is why we had to pick it up and champion it," Bivens said. "There was no marketing behind it. If it was a thousand dollar drug we would've all heard about it."

In February of 2016, three local municipal EMS departments—New Bedford, Fairhaven and Acushnet, as well as Eascare and Alert private ambulance services—were granted access to use TXA by the state's Department of Public Health under a special project waiver obtained by Bivens. The drug has been used in trauma incidents ranging from shootings and stabbings to car accidents.

"We're giving it to major trauma patients," Mike Thomas, a New Bedford paramedic, said. "It clots blood faster so patients don't bleed out. Basically, if their blood pressure is low and their heart rate is high and they're in some sort of trauma we're using it."

Acushnet EMS administered TXA roughly a dozen times during the trial period. One of the first instances they used it involved a woman falling down about 14 steps and suffering a basal skull fracture and a wrist fracture.

"TXA is a great thing because you can just mix it in an IV bag and let it run for 10 minutes," said Brian Donohoe, an EMT in the SouthCoast for nearly 30 years. "It's kind of a set it and forget it type of thing. You don't need to worry about internal bleeding as much and you can focus your attention on other areas as needed."

Now, nearly a year and half after getting approval for the special project waiver, Bivens is knocking on the door of statewide use. Having already been approved, Bivens met with Sophia Dyer, Boston's medical director, and Mark Miller, the state director of the Office of Emergency Medical Services, on July 31 to discuss how to get the information out to the public.

"Now it's just a logistical issue," Bivens said. "You don't want to just declare something without rules on how to administer it and guidelines."

The state of Rhode Island has already adopted statewide use for TXA this year, Bivens said. Local trauma patients are transferred there and they received roughly 40 cases of people who had received TXA on SouthCoast. He added that Rhode Island nearly rewrote all of their emergency protocols across the board.

"(The special waiver project) was done in cooperation with Rhode Island trauma service, who've been hugely supportive," he said.

He is still collecting data on the exact number of lives TXA could save in Massachusetts, Bivens said, but of the 3,000 trauma deaths per year in the state, he estimates it could save roughly 40 to 50 lives annually.

"For a $10 drug with no side effects that nobody owns, that's a pretty incredible number," he said.

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