S2:E35 - "TXA, traumatic bleeding and EMS - A discussion with Dr. Steve McGraw, Luke Bowen and John Theut about the introduction of TXA for Southeast Michigan EMS agencies." Recorded May 5, 2021

In today’s episode, we discuss tranexamic acid, or TXA. TXA is a medication that helps prevent the body from prematurely breaking down clots. It doesn’t make new clots.  It protects existing clots as they are formed. TXA was originally developed for the treatment of hemophilia and to reduce bleeding in patients undergoing oral surgery. Eventually, it was shown to be an effective preoperative drug that minimizes the need for large amounts of whole blood during general surgery procedures. TXA is now being used by EMS to treat severely injured trauma patients in the field who have or are at risk for severe hemorrhage. 

Starting June 2021, TXA will be added to the drug box on my rig, along with every other EMS rig in Michigan’s Southeast Region, which includes over a half dozen counties in the area. This new addition to the box will affect thousands of EMS units, paramedics, and hundreds of EMS agencies.  If you are a paramedic in my area, I suggest you reach out to your EMS coordinator and find out if this change will impact your treatments.  This change impacts the following protocols for Southeast Michigan EMS providers:  1) Shock and 2) Southeast Michigan Medication Exchange and Replacement Procedure.  You can download these protocols at www.OCMCA.org/protocols. Or at the OCMCA EMS Protocols App, which you can download for free from Google Play or the Apple Store. 

To assist us in this discussion, we welcome back Dr. Steve McGraw, DO who is an ED physician at Ascension Providence Hospitals in both Southfield and Novi, Michigan, as well as the EMS medical director of the Oakland County Medical Control Authority (OCMCA), which provides oversight to 50 EMS agencies.

We also welcome  John Theut, MS, Paramedic, EMS-IC, the QA/QI Coordinator for the OCMCA right here in southeast Michigan.   

Finally, we welcome our MCA neighbor Luke Bowen, MBA, Paramedic I/C to the show.  Luke is the Operations Manager for the Macomb County Medical Control Authority, which is one county east of Oakland County, Michigan.   

In today’s episode, our guests help us describe what TXA is and what it does. Then, they’ll list and describe the indications and contra-indications. After that, we’ll get into the dose, route and method of delivery for TXA. And finally, our guests will list and describe adverse reactions and side effects that may be witnessed by EMS after administration of TXA.

Please keep emailing your questions, comments, feedback and episode ideas to the EMS on AIR Podcast team by email at QI@OCMCA.org.  Visit EMSonAIR.com for the latest information, podcast episodes and other details.  Follow us on Instagram @EMSOnAIR.

Contact the episode host or guests:
Geoff Lassers, AAS, Paramedic I/C
Host/producer, EMS on AIR Podcast
Firefighter/Paramedic, West Bloomfield Fire Department
EMS System Manager, OCMCA
Director of Education, American CME
Qi@ocmca.org

Steve McGraw, D.O.
Co-Host, EMS on AIR Podcast
Co-Medical Director, EMS on AIR Podcast
EMS Medical Director, OCMCA
steven.mcgraw@ascension.org

Luke Bowen, MBA, Paramedic I/C
Operations Manager, Macomb County Medical Control Authority
luke.bowen@mcemsmca.org

John Theut, MS, Paramedic, EMS-IC
QA/QI Coordinator, OCMCA
Shift Captain / EMS Coordinator, Ferndale Fire Department
Qi@ocmca.org 

Transcript

Geoff Lassers: 0:10

Hello and welcome to the ems on air podcast. The mission of this podcast is to keep healthcare provider safe, informed and prepared. Today is May 25, 2021. This episode was recorded on May 5, 2021. I'm Geoff Lassers, And I'll be your host. Even though we're located in southeastern Michigan, and we mentioned our home state a lot. Today's content applies to em s on the national and even the global scale. In today's episode we discuss tranexamic acid or TXA. TXA is a medication that helps the body from prematurely breaking down clots. It doesn't make new clots it protects existing clots as they are formed. TXA was originally developed for the treatment of hemophilia and to reduce bleeding in patients undergoing Oral Surgery. Eventually, it was shown to be an effective pre operative drug that minimizes the need for large amounts of whole blood during general surgery procedures. TXA is now being used by ems to treat severely injured trauma patients in the field who have or are at risk for severe hemorrhage. Specifically starting June 2021. TXA will be added to the drug box in my rig along with every other EMS rig in Michigan's southeast region, which includes over a half dozen counties in the area. This new addition to the box will affect 1000s of EMS units, paramedics and hundreds of EMS agencies. If you are a paramedic in my area, I suggest you reach out to your EMS coordinator and find out if this change will impact your treatments. See the Southeast Michigan medication exchange and replacement procedure, the shock protocol and in the medication section under tranexamic acid. For additional details. You can download these protocols at ocmca.org/protocols or at the OCMCA protocols app, which you can download for free at the Google Play Store or at the Apple App Store. This app is available for Google Android and iOS devices basically go to Google Play or the Apple Store. You'll find it there. Me, I've never used TXA in the field. I've really only read about it and its effects on EMS trauma patients with severe blood loss. So to assist us in the discussion, we've invited our good old buddy Dr. Steve McGraw back to the show. Dr. McGraw is an ED physician at Ascension Providence hospitals in both Southfield and Novi, Michigan, as well as the EMS medical director of the Oakland County Medical control authority, which provides oversight to over 50 ems agencies. We also welcome back John Theut who is the quality assurance quality improvement coordinator for the Oakland County Medical control authority right here in Southeast Michigan. John is also a soon to be retired shift captain and the EMS coordinator for the Ferndale Fire Department. Finally, we welcome our MCA neighbor Luke Bowen as a first time guest to the show. Luke is the operations manager for the McComb County Medical control authority, which is one county east of Oakland County, Michigan, Oakland and McComb MCA's have a history of collaborating to develop education and em s improvement strategies. And we are happy to have Luke here today to represent his neck of the woods. In today's episode, our guests to help us describe what TXA is and what it does. Then they will list and describe the indications and contraindications. After that we'll get into the dose, route, and method of delivery for TXA. And finally, our guests will list and describe adverse reactions and side effects that may be witnessed by ems after the administration of TXA. Please keep emailing your questions, comments, feedback and episode ideas to the EMS on AIR podcast team by email at qi@ocmca.org. Also check out our website emsonair.com for the latest information podcast episodes and other details. Follow us on Instagram@emsonair. And please whatever podcast platform you use, subscribe to the podcast and leave us a rating and a review. It really helps us to grow this podcast. Thank you for listening to the EMS on AIR podcast. Enjoy the episode. Good morning everyone. How we doing? Doing well. Doing great. Very good. How are you? Fantastic. Well, let's get rolling today. Here we have two new guests actually one guest that's brand new one guy's been here before. Let's start with the new guy Luke Bowen. Can you introduce yourself to our audience of who you are, what you do and where you do it?

Luke Bowen: 4:34

Sure. My name is Luke Bowen. my current role is that of the operations manager for the McComb County EMS medical control authority. I am a paramedic. I'm an IC, I am currently teaching and McComb Community College entering my 35th year of EMS coming up this fall.

Geoff Lassers: 4:49

We appreciate it. So you kind of do what Lohn and I do in Oakland County and you're our neighbor. And john Why don't you go ahead and reintroduce yourself to our audience.

John Theut: 4:58

Hi, i'm john Theut , I The QA/QI coordinator for Oakland County Medical control authority, I'm also a shift captain and EMS coordinator for Ferndale Fire Department been there for 25 years. And soon to be not there very, very soon.

Geoff Lassers: 5:12

John is lucky enough to make it all the way through a full retirement here. He's got about another week to make it. So hopefully john gets through this was as smiling as he is right now and nobody can see it, but we can. Okay, so Dr. McGraw, welcome back to the show. You're always here, but he knows who you are. He's thee doctor McGraw. Can you start us off with talking about what TXA is give everybody an identification of what this medication is to kind of kick off our discussion.

Dr. Steve McGraw: 5:37

Thank you, Geoff. First of all, I want everyone to understand while it may be new to us TXA (tranexamic acid) is actually not a new medication that's been around for many years. It's actually a product of a company that we're all becoming familiar with Pfizer. It is brand named le Seta. And what it does is it acts as a lysine analog. lysine is a very common amino acid, it's in a lot of enzymatic processes, and we have in our body, and it's an essential part of the clotting cascade that makes all of our blood clots that occur in our bodies work, you guys, I'm sure remember, we've talked about this in the past that the clotting is a delicate balance between clotting actively, you know, the cascade of things coming from platelets that allow a clot to form and a simultaneous unclotting or fibrinolysis effect, because we have to have that delicate balance. To be both fast, clotting has to be fast and effective when it's required, but also controlled so that we don't clot big things and big blood vessels and cause things like strokes and heart attacks. So it's this very fine tuned balance and you guys will remember that we give people TPA in the case of stroke, or used to give in the case of STEMI, because tissue plasminogen activator kind of accelerated, if you will, the rate at which clot is broken down, it's breaking down anyway. But if we activate plasminogen, we actually cause it to break down faster. This is kind of like that only the opposite way. The lysine analogue, that TXA, causes a decreased rate at which plasminogen is turned into plasma. And what does that do? It slows down that fibrinolysis effect. If you think about it, it's kind of like gently stepping on the brake of fibrinolysis, which tips the balance a little bit more towards clot formation. And I guess reason that's so important. If you think about it, all we're trying to do is take that delicate balance and tip it in one direction in the case of TXA so that the clots that are forming, are broken down less quickly. And that's effective too, because you can imagine that if we're experienced a life threatening bleed from say, from polytrauma, or in the case of Haemophilia, for which the drug was originally developed, there is widespread potential for bleeding. And what this really does is make whatever clot is being formed a little more capable of becoming a mature clot and not broken down by plasma. Because we decrease the rate at which plasma is derived from plasminogen. What we're really talking about is just tipping the scale, if you will, just a little bit towards the pro clot side and away from the fibrinolysis or the clot break downside. And all it takes is tipping that scale just a little bit, but have a large impact on someone who is experiencing life threatening bleeding.

Geoff Lassers: 8:31

Thank you, sir. Luke, can you kind of give everybody listening an opportunity to understand when they would use this the indications for TXA.

Luke Bowen: 8:40

Sure. And the indications are, as Dr. McGraw spoke about significant hemorrhage is an exciting drug to bring to ems. When we look at causes of death from traumatic injury, hemorrhage is only second to loss of airway. So these are patients that are high on that list of potential fatality for trauma. So we indicate the use for TXA with marked blood loss with a initial systolic BP of less than 90, what we do want to do is be clear and indicate that we are not using this for obstetrical bleeding or for internal gastrointestinal bleeding. So this is either internal or external hemorrhage from a tramatic origin.

Geoff Lassers: 9:18

So to paint the picture of these patients, we're talking about somebody who took quite a bit of trauma, maybe multi system trauma, with obvious bleeding, and we recognize that the potential volume loss of the blood is life threatening, and we want to slow that down with TXA. Would you say that's a good summary of what we're using it for?

Luke Bowen: 9:36

It is and that bleeding can be external or internal. So if you have somebody who's had trauma that has an acute abdomen, so their abdomen is rigid and distended, and they have low blood pressure, and they have all the other signs of shock, that would be an indication. Absolutely. So obviously, external blood loss, they were having a difficult time controlling with a traditional, you know, hemorrhage control methods of direct pressure and tourniquets, those kinds of things.

Dr. Steve McGraw: 9:56

I'm so glad you said that Luke because we all think of bleeding well Like a gunshot wound or a severed extremity or something like that. But as you point out, there can be intra abdominal or intra pelvic, during pelvic fractures, enormous loss of blood, even a fractured femur, you know, an isolated fall off a roof and an angulated femur, you can put several units of blood, as bones bleed enormously when they break inside somebody's thigh. We've all seen it, you know, it's that thigh that's really taut. They're in a lot of pain, put them in the hair splint and stretch their leg out now, you know, things seem like they're getting a little bit better. That's another example where there's significant volume, significant blood loss from any traumatic event that would be consideration for this particular medication.

Luke Bowen: 10:41

It's interesting, you mentioned pelvic fractures. When I asked my students how much blood volume will your pelvic girdle hold? And they don't have an answer my responses, all of it. So you're right potential for life threatening hemorrhage.

Dr. Steve McGraw: 10:52

I love that Luke, yeah, be open minded to it. The other reason why I want people to be open minded, and now we're going to talk about this, but they're really you're not gonna I know one of the people think people think well, aren't we going to precipitate blood clots. And I want to point out that that's not how this works. This medication doesn't make you make a bunch of unnecessary clot, it kind of slows down the physiologic function of D clotting that occurs anytime a clot is formed. That's the fribanalysis, the slow breakdown of clot, it just slows that down by making plasmin less likely to be formed by plasminogen. It's a gentle application of the brakes. And there really isn't a downside to this. I've had conversations with people that would say, Well, what if I give this and the person turns out not to have been bleeding, you haven't done any damage, you're not going to suddenly develop a bunch of dvts and pulmonary emboli. That's not how this works. So it's a extremely safe drug from that respect, and really has upside as long as it's given early for people that need it the most.

John Theut: 11:52

Is there any type of hemorrhagic shock that we should not give this for? Can we do this for a patient that's having gynecological bleeding or gastrointestinal?

Dr. Steve McGraw: 12:02

It's not indicated in our protocols for GI, gastrointestinal, gynecologic bleeding, like postpartum bleeding. But having said that, it doesn't mean that they wouldn't be expecting that or even at least having it considered for them in the hospital. There are some caveats to its benefit and how it can be used in some of those situations. So really, in both of those cases, the first response would simply be crystalloid infusion followed by Pac cells and let the different elements of either of those environments be decided on at the hospital if they would benefit from TXA. This is been widely studied in EMS literature. And we know it does have an effect for traumatic hemorrhage. So pretty much anyone in that boat I would certainly consider it for.

Geoff Lassers: 12:46

So Luke, how do I give this medication? How's it

Luke Bowen: 12:47

So this drug will be given by paramedics, it's going packaged? What are we doing? We snorting this thing like narcan? And are we just showing it to them and magically going in? IM? IO? what are we doing with t is thing. to be carried in the southeast Michigan regional EMS drug box. So this is not a separate supply, it's carried going to be carried in our drug box beginning on or about June 1st. It's supplied in vials of 1000 milligrams or one gram. We've recently modified the drug Box contents, we used to have a 50 ml bag of normal saline, we've swapped that out for a 100 ml bag of normal sailin. So the paramedic draws up the one gram of TXA places it into the 100 ml bag of normal saline, and infuses it through their IV over 10 minutes. So it is really kind of a straightforward process or no reconstitution is just simply draw out of the vial into the 100 cc bag. infuse for 10 minutes.

Geoff Lassers: 13:38

And this isn't a weight based thing an age based thing. any restrictions in that regard? Or is it basically the same drug, same dose, same application every time?

Luke Bowen: 13:46

Absolutely. As you stated, same drug same dose every time one gram over 10 minutes IV infusion.

Geoff Lassers: 13:51

What should I expect to see change if anything in my patients, so every time I do a treatment, I'm always looking at this patient and constantly monitoring them for changes or not changes and noting that, what should I expect to see that I want to see happen?

Luke Bowen: 14:06

I'll comment briefly and let Dr. McGraw ad. But this patient is in shock. And it's taken them a while to get there with their hemorrhage. While this is going to slow the hemorrhage. It's not like correcting anaphylaxis where you're going to see an immediate improvement, the worsening of their shock is going to slow down. And maybe if you have a long transport time, 30 minutes, 45 minutes, 60 minutes, maybe you see their blood pressure, stop falling, maybe even stabilize a bit. But know that its impacts are long lasting and are going to benefit this patient over the next one, two and three hours. So don't expect their blood pressure to rebound to 110 over 70. We're just not going to see that that take a long time for them to compensate for that blood loss. But we really are having longer term impacts by slowing that hemorrhage.

Dr. Steve McGraw: 14:49

That's a really good point Luke, it isn't going to be a dramatic sudden change. And I think your example using say an epi pen and anaphylaxis is much more rewarding candidly to See that happened. But that's not what this is gonna look like. And if you're going to have a longer transport time, as you suggest, you might see a slowing down of their progression into shock. But it's still very worth giving. Every study that looks at when it can be given, the only conclusion they say is, if you don't give it within the first 24 hours, it doesn't really help. But most important, the earlier you give it, the more impact it does have. So one hour is better than two hours, two hours are better than three hours. And it clearly shows that the sooner you started that initial infusion, the greater chance you have of making a difference, the longer you wait, and the longer it's delayed, it has less likelihood of impacting the patient,

Luke Bowen: 15:41

those comments lead very nicely into the precautions and one of those is as EMS providers in the field, we would like to deliver this within three hours of the injury. So if we have a patient kind of like a stroke patient where we don't know their last normal, or we don't know when their traumatic injury was or the start of their hemorrhage was and it could have been 12 hours ago, then we want to be cautious and not use this drug we need to know. And that probably accounts for the majority of our trauma victims, we know when their dramatic injury was. So that's really not going to inhibit us too much. But you also mentioned that it's pretty quick to get started. But we don't want to delay transport, getting this patient to the trauma center is absolutely still crucial. So this is not something where we stand on scene, if our ambulance is available, and the patient is available to be transported. We don't stand on scene and administer this drug, get them in the ambulance and get them moving, get them toward the trauma center, and then get this drug infusing. So we don't want to delay transport. And those are some precautions that are listed directly in the protocol.

Geoff Lassers: 16:34

And IV. But also IO, I assume is still an acceptable route?

Luke Bowen: 16:38

Yes, it is.

Geoff Lassers: 16:40

Okay, and now obviously, you're saying that in the short transports, like I work for an agency, we have very short transport times, even when we bypass let's say, a level three or four trauma hospital for a level one or two, I'm still only going 15, maybe 20 minutes. So I have a very short time to my very good destinations. So I'm not going to see much of a change. But what I might see is reactions to the medication. Now every medication might cause an allergy or an anaphylaxis. And I know what to look for with that. And I'm assuming the first step is stop the medication. But what other adverse reactions or side effects might I expect? Or might I see other than the obvious anaphylaxis or allergy to the medication?

Dr. Steve McGraw: 17:21

You know, it's funny, Geoff, we actually don't typically see anything that looks truly like anaphylaxis from this. It's so much of an analogue or It looks so much the body like lysine, which is in you know, every one of our cells, there's not a significant chance that you're going to have true anaphylaxis what you sometimes see is almost a hypersensitivity reaction. There's even a particular kind of dermatitis, it's benign, and it fades, but the skin can have sort of a blotchy red rash. I think the other thing if it's infused more than over 10 minutes, if it's more quickly infused than that, say over a minute or two, there are times when it will cause almost like a histamine response, where people won't have anaphylaxis with all of its attendant problems and airway, but it can make them feel a little goofy, it's described as giddiness or dizzy. And they may even have some transient hypotension, which is going to ameliorate itself with time and with IV fluid. Presumably in a patient receiving this infusion, you will take the full 10 minutes because it's gonna make this much less likely to occur. And if it has any occurrence at all, it will be even more mild. That's really why the 10 minute infusion side of it 100 cc's infuse 10 cc's over the next 10 minutes per minute, you'll avoid any of the typical things that might make you uncomfortable like the giddiness they describe the rash can still occur, but it'll be very mild and limited. The other side effect if there is one is that if it's given quickly, or if it's given over a normal 10 minutes, some patients do feel somewhat nauseated, they may even vomit or tell you made them feel funny, meaning that you know maybe a dizziness or giddiness sensation, but it'll be transient, and it would be easily offset by a dose of IV Zofran. But again, if it sounds like I'm suggesting there are very few meaningful adverse reactions, that's because there really are, this is a very well tolerated medication, if administered under the appropriate guidelines for the appropriate reasons.

Luke Bowen: 19:19

I think one of the takeaways there is that it's easy to administer it too quickly. But it's not dangerous to administer it a little bit more slowly. These are traumatic patients who are critically injured, they're really sick. And these scenes are somewhat charged. And we all understand that we've all been there. You'd be better off just started off a little bit slow kind of gauge what it's infusing at again, it's about 10 ML's per minute, and then if it's going a little bit slow, that's fine. But if you realize wow, I've given 30 ML's in 20 seconds, you want to back that down so it's better off to give it over a little bit longer than 10 minutes, then dump it in in two or three minutes. So just keep an eye on it can be eyeballed You do not need an IV infusion pump for this. You can absolutely pull out your watch count the drips count Get the bag and infused safely but a little longer is better than really quickly.

Unknown: 20:04

I like that you said that luke because there isn't a penalty if it takes you 15 minutes, I want to point out to by you guys giving this as the patient is arriving. Remember we said the sooner you start the clock on this, the better off the patient will be. And some studies have shown patients that would have wound up in the ICU for a lot longer when they got TXA either were in the hospital in the ICU for a shorter period of time or avoided ICU care in some cases entirely. There's a real advantage. Remember, also that while you give the first gram, they're going to receive additional doses of medication over the next 16 to 24 hours in the hospital, what you've really done is started that effective, meaningful treatment upstream when they hadn't lost as much blood as they might otherwise. And that's really going to help not only what the patient ultimately experiences, but in fact help the hospital and you'll save their administration of blood products, they'll have shorter length of time when they're in the ICU or in the hospital overall, which means they have a less of a likelihood to get hospital acquired infections, or fall and get injured in a hospital or all the things that can happen when we're at a tertiary care facility. So you're really going to manifest all of that benefit by starting the infusion is early as you can, and doing it exactly as you described Luke, err on the side of taking at least or more than 10 minutes, no one's gonna criticize you for taking 15. And even if they did go in a little bit quick. Remember, the side effects are going to be ameliorated by slowing down or stopping the medicine and giving IV fluid or zofran for nausea. It's all achievable. And if you needed to, you could always get online medical direction and say we gave the patient this and they started having this rash. Should we stop the infusion? Should we continue with it? Should we just monitor it? You could always ask that question because in the end, your ability to even offer this to the patient is a net benefit, it's like extra credit.

Luke Bowen: 21:52

I would also add that you know, these are really sick patients and even arriving at a trauma center. There aren't 25 staff members all waiting around with a single task to do for this trauma patient, there is a lot to get done very quickly. And if we can check a box for him and get this infusing, that's one less thing that has to be done within the first two minutes of arrival. So again, we're starting that clock sooner and 10 or 15 minutes really does matter.

Geoff Lassers: 22:15

Yeah, time is tissue. I don't think this is any different, right? So to add to that, this is a medication that's being utilized throughout the nation and really throughout the world in a pre-hospital setting. It's not new, but it is new to our area. Luke, you talked about the Southeast Michigan drug box, this medication is going to go in there, what geographic locations will have this?

Luke Bowen: 22:36

Southeast Michigan regional drug box covers, I always get the number wrong either 10 or 11 counties from St. Clair County all the way out through Washington, Livingston County, cut down to Monroe, and then back up the river. So it's either 10 or 11. MCA is the drug is being placed into the drug box for that entire area. But each MCA has to adopt the protocol and virtually all of them are. And you will know that because you will receive education and you'll receive information that you are indeed starting this on June 1, there are one or two MCA's that at the moment are not adopting it. And they simply will not use the drug. We have done that in the past where a drug has been in the drug box, but is not allowed to be used by certain a MCA. So we've done it before the state's fine with that. But know that if it's in your MCA, you will have been notified well in advance. Let me add one more little detail there. We're doing this as a rolling implementation. So on June 1, when a drug box is exchanged at a hospital and restocked, they will add TXA, we're not going to recall all the boxes and put TXA in the boxes on June 1. There are drug boxes that sit for even weeks at a time in a backup unit, or it's an agency that doesn't utilize drug boxes very often. So it could be a week or two weeks, we are going to ask agencies maybe at the two week mark to look at your drug boxes. And if it hasn't been refilled since June 1, put it in rotation, get it on a truck and get it used and get it into the hospital to get the TXA in that drug box.

John Theut: 24:02

So Luke is the thought that hopefully by July, all the drug boxes would have this in it in circulation. And that could be expected that when you open one, you'd find it is that the hope?

Luke Bowen: 24:12

that is the hope we are not doing any kind of special stickering or labeling of the boxes. So in theory, and it's a theory, if the box was filled on or after June 1 it should have TXA hospitals have to check a whole bunch of drugs in that drug box. It is possible and we're not going to be too upset about it if a box was exchanged, let's say on June 3, and they just simply didn't drop the TXA in and being a new drug like this, though, as important as it is to have. We haven't had it until now. So if it's there, fantastic use it. If it's not, it would be nice to notify the hospital when you exchange that drug box or however, maybe notify your MCA. I had a box was exchanged on June 10. There was no TXA. Let your MCA's follow up a little bit and see what's happening with that. But yeah, we would love to have it kind of by July 1st. All of them cycled through and work with the agencies, again, who may have boxes not exchanged very often to get them into rotation.

Geoff Lassers: 25:07

Very good. Any closing thoughts?

Dr. Steve McGraw: 25:09

I just want to reassure our providers that we have the same kind of education we're going to be rolling out amongst the hospitals as typical as it can possibly be we'll do a good job and making sure nurses and physicians know that this is coming online and the MCA's where it does, but also recognize that not everybody works full time. And you may inadvertently come across someone who's unfamiliar with it. That'll be the chance for the provider to say, Well, this is a new protocol we're following for trauma traumatically injured patients in Oakland County. And, you know, we followed our protocol and administered 1000 milligrams of TXA to this patient, because we know that if it's given within, especially within the first hour, it has significant impact on morbidity and mortality for the traumatically injured, give you a chance to help educate somebody that maybe isn't quite up to speed as we all learn to do something different. Whenever something is brand new to ems remember, it's also new to the hospital in that sense to every hospital has tranexamic acid has been using it in various situations. But having providers do it, it bodes very well for the future. And it means that our MCA's in our Southeast Michigan region are embracing the technology in a way to help our patients, all we have to do is help the hospitals figure that out sometimes to.

Luke Bowen: 26:20

my closing comments would be that this discussion has occurred in what's called the RTAC, the regional trauma advisory committees. So within the MCA's in our area in our regions that are covered by the drug box, the trauma programs, the trauma surgeons have been made aware, we asked for their support for this. So most of them will never say all, if at least heard that, hey, TXA is coming to the field in Southeast Michigan sometime this year. So it's not going to be foreign news to them that TXA is out there. So we did engage the trauma surgeons as well as the emergency departments in this discussion, looking forward to seeing its use seeing its efficacy, we will be looking at every use of TXA. So each medical control authority will be looking at each use of TXA going to be really easy to query by just looking at the medications given list. And we will do a little bit of work to see were there any adverse reaction side effects. And we might even go as far as looking at the patient outcome and trying to put some real data together. So each MCA will be looking at the use of TXA.

Geoff Lassers: 27:19

And maybe we can get some of those case studies on the EMS on AIR podcast to talk about each one of those administration's and follow up with the patient outcomes, and really talk about how this is affecting their home area.

Luke Bowen: 27:29

That would be fantastic. Might be several months till we have enough cases to look at. But absolutely, it would be exciting.

Dr. Steve McGraw: 27:35

a new protocol for Oakland County. And I'm hopeful that there will be a lot of questions from our providers and physicians and nurses at the symposium. Not because it's so much that it's brand new, but but rather how is this gonna play a role in our system? What can we do to support our providers that are doing it? What is the science behind it? But most importantly, you know, how can we make best use of this new protocol, I'm excited to actually be able to one of the people who's presenting it, and if people don't have an opportunity and haven't had an opportunity yet to sign up, consider signing up for the symposium. It's coming up this June.

John Theut: 28:16

And as always providers, this is a great opportunity, we always have to make sure we're documenting the side effects and the effects of a medication both negative and positive. Make sure in your documentation, you're putting this information down so we can determine whether this is a good drug for us to be using in the field and hopefully, maybe some other MCA's and maybe some other areas across the country. We'll see this and add this if it's appropriate to do so.

Geoff Lassers: 28:45

That is all for the show today, everyone. Thank you for listening and thank you to Dr. McGraw, Luke and John for coming on the show. again see the Southeast Michigan medication exchange and replacement procedure, the shock protocol and in the medication section under tranexamic acid. For additional details. You can download these protocols at ocmca.org. Or you can just download the OCMCA EMS protocols app, which you can get for free at the Google Play or the Apple Store. Please keep emailing your questions, comments, feedback and episode ideas to the ems on air podcast team by email at QI@ocmca.org. Check out our website emsonair.com for the latest information podcast episodes and other details. Follow us on Instagram @emsonair and please whatever podcast platform you use, subscribe to the podcast and leave us a rating and a review. Thank you for listening to the EMS on AIR podcast. Stay safe and have a great day.