The U-M’s new chief of general surgery seeks to extend the window of opportunity for treatment of traumatic injuries.
The first 60 minutes following a traumatic injury represent the “golden hour” for saving a life, says surgeon Hasan B. Alam, M.D.
“A lot of people have studied the complications associated with later stages of injury, the pneumonias, the infections — but the real need is up-front,” he says. “You have to first survive the injury to have the delayed complications. And the window is pretty short.”
Alam, the new head of the Section of General Surgery at the University of Michigan Health System, has focused a large part of his career around developing and refining lifesaving interventions aimed at this critical period.
“It’s all about how we can buy more time,” Alam says, “how we can keep injured patients alive, get them to definitive care, resuscitate them better, and control bleeding much better.”
For about half the people who succumb to injuries, it’s not that the wound is too grievous to fix, but that it simply couldn’t be done quick enough.
“Bleeding we can stop,” Alam says. “And if we can sustain the patient through the first few hours, not only will they recover, but they can return to being contributing members of society. It’s very rewarding in that sense, to save a 20- or 30-year-old who’s got a family and can make a productive contribution to society for the next 30 or 40 years.”
While cancer, heart disease and respiratory failure are among the leading causes of death for older Americans, injuries round out the top five for all age groups — and more young Americans die from injuries than from all diseases combined.
“If you’re between ages 1 and 34, it’s injuries that kill you,” he says.
Alam, the Norman Thompson Professor of Surgery, was recruited to U-M in October 2012 from Massachusetts General Hospital, which had tapped him to help establish the new Division of Trauma, Emergency Surgery and Surgical Critical Care. He was also a Professor of Surgery at the Harvard Medical School.
What was the draw to Michigan?
“Michigan is a place with a long tradition and proud history, and an academic presence second-to-none. When I saw the facilities, the resources and people, the history and academic mission —it was one of those offers you just can’t refuse.”
Alam has led a peripatetic life. Born in Pakistan, he emigrated to the U.S. and now his family has settled at points along the east coast. By the time he reached 10th grade, he’d attended eight schools — a side-effect of his father’s military career.
“For me, it’s always about the new challenge, and what you want to do next — not just tomorrow, but next year, a few years from now,” he says. “The position Michigan offered me came with new challenges — more administrative responsibility, a larger group of people, and thinking about things I had never thought about before. That was very attractive.”
Alam received his surgical training at the Washington Hospital Center in Washington, D.C., followed by a postdoctoral research fellowship at the Uniformed Services University of Health Sciences (USUHS) in Bethesda, Maryland. He then served as a faculty member at Georgetown University and USUHS.
It was during his time in D.C. in the 1990s that he met his wife, Tracy, with whom he now enjoys daughters ages 8 and 11. It was also during that time that Washington was known as the murder capital of the nation, amidst a crack cocaine boom that even felled the city’s mayor.
“We saw a lot of penetrating trauma,” Alam says. “But if someone comes in stabbed in the heart or shot through the chest and you do the right thing in the right time frame, that patient can walk out of the hospital three days later.”
As the ’90s gave way to a new millennium, another kind of violence became important: terrorism and wounds inflicted on the battlefields of faraway countries. Alam cared for some of the survivors of the airliner crash into the Pentagon and these world-changing events soon shaped Alam’s trajectory as well. “Sometimes you can’t plan — it’s just how things happen,” he muses.
Alam was studying how to best resuscitate patients after massive blood loss when the U.S. Navy asked him to turn his attention to hemostatic dressings that could be carried by soldiers to control bleeding on the battlefield, rather than back in a field hospital staffed by trained medics.
“Very rapidly we were able to come up with advanced dressings, test them in animal models, and within a few months they were approved by the FDA,” Alam says. “Within six months they were being used by special operations forces in Afghanistan.”
Soon after, troops were deployed to Iraq and all marines carried the new dressing kits in their backpacks. They could be applied to wounds by injured soldiers themselves or by their comrades, stopping the flow of blood and buying precious hours until advanced medical treatment could be obtained. One of the first dressing kits off the assembly line today sits on a shelf in Alam’s office at the Medical School.
More recently, the Defense Advanced Research Projects Agency and the Office of Naval Research, which have funded high-risk, high-yield projects such as the unmanned drone and the Internet, are currently backing a Surviving Blood Loss program.
“What we’re working on are self-protecting strategies using drugs — fluidless resuscitation,” he says. “The whole premise is to create a pill or injection that you can keep in your backpack and that doesn’t have a huge logistical burden — it’s not heavy or something a medic has to administer — that can keep you alive after massive blood loss for three or four hours, until definitive treatment can be rendered at higher echelons of care.”
These are exactly the type of advances that have the potential to transform lives on the home-front as well, he adds. “If you come up with something that’s going to save the lives of those we put in harm’s way, all the things that we learn from that will spill over into the civilian sector. The only winner in war is trauma care.”
Unlike with blood loss, the other most deadly complication from trauma — traumatic brain injury — is not so easily solved. “We have no specific treatment for TBI; it’s all supportive care,” Alam says. “Either you’ll live or you’ll die, your brain will survive or not.”
But just as with his self-protecting strategies for blood loss, Alam and his colleagues are looking at a pharmacological intervention to protect the brain as much as possible. The Army and Department of Defense are funding the work, and he notes results over the last two years have been promising.
It doesn’t stop there. In a scenario that seems more sci-fi than science, Alam is also researching the possibility of suspended animation.
“If you’re bleeding to death,” he says, “maybe I can’t fix problems within the first few minutes, but what if I could put you in a state of suspended animation and buy two or three hours? If we can just cool the body down to 10 Celsius, with essentially no signs of life — no heartbeat, no brain activity or blood flow — for two or three hours and fix the injury, then bring the patient back to life, we should be able to take a 100 percent lethal injury and convert it into being 90 to 100 percent survivable.”
If these possibilities sound far-fetched, it’s worth noting that both the fluidless resuscitation and suspended animation studies also have the financial backing of the National Institutes of Health.
“Trauma care over the last 10 years has really been revolutionized based on the lessons we have been learning on the battlefield,” Alam says. “I never tire of talking about our work. It’s like your kids — you never get tired of showing pictures of them.”