War on Shock

Dear Editors:

“At the instant a warrior confronts a foe, all things come into focus.”  — Morihei Ueshiba

War on crime. War on drugs. War on obesity. War on poverty. None of these compares to true war. But each suggests a total commitment to victory. Following the attacks of September 11th, I had the humbling honor of serving as an Army physician in the United States, Europe, Iraq, and Afghanistan. During those years I witnessed the relentless efforts of my primary care, emergency medicine, surgery, and critical care colleagues as they revolutionized the prehospital, operative, and intensive care unit management of polytrauma toward a goal of zero preventable battlefield death. Assumptions were aggressively challenged, unprecedented amounts of data were collected and analyzed, actionable research was conducted, incremental evidence-based changes were made, and outcomes were measured. And the process was repeated over and over and over and over again, and rapidly. By the end of the decade, new products were fielded, new techniques refined, and organizational innovations realized – from point of wounding overseas through postdischarge rehabilitation stateside. Several thousand lives were saved and tactical combat casualty care was rapidly modernized.¹ Considering the current unacceptably high mortality of cardiogenic shock and the absence of substantive widespread improvements in survival since the advent of early revascularization several decades ago, the time has arrived for the cardiovascular community to embrace this same “combat” approach to shock.

A Live Patient Above All Else. Trauma surgeons innovated the principles of damage control resuscitation and damage control surgery, first in the face of urban violence and more recently on the battlefield. Early recognition of trauma and shock facilitated early treatment. In war, this was achieved despite the challenges of time, distance, and insecurity. Restoration of normal physiology was prioritized over restoration of normal anatomy. Similarly, there is accumulating evidence that the next great leap forward in the treatment of cardiogenic shock is the early administration of circulatory and ventricular support to maintain vital organ perfusion and reduce myocardial oxygen demand – prioritizing normal physiology over normal anatomy – via new, rapidly deployable, user-friendly percutaneous mechanical devices.^2,3 Only by pursuing multiple lines of attack, rapid revascularization with restoration of coronary flow, circulatory and ventricular support, and anti-systemic inflammatory response syndrome (anti-SIRS) therapies, can we combat cardiovascular collapse and prevent ensuing lethal multiorgan dysfunction toward a long-term goal of meaningful survival.

Right Treatment, Right Time, Right Place. Battlefield care must match the tactical situation. In peace, medical therapy must be tailored to geography, resources, and capabilities. Mortality benefit with improved door-to-balloon times (our version of the Surgeon’s “golden hour”) has plateaued and we ought to now look elsewhere for solutions.⁴ New networks of partnered multidisciplinary care must emerge on a large scale to establish a linked regional system of community hospitals and large centralized centers of excellence emphasizing rapid triage, immediate transport, and expedited door-to-support for victims of cardiogenic shock. Patients must be identified earlier and care, particularly mechanical circulatory support, delivered more rapidly. This endeavor should emulate the highly successful and constantly improving military and civilian trauma system and the cardiovascular community’s historical successes in early revascularization for ST-elevation acute coronary syndrome.

Support, Move, Communicate. The timeless maxim of infantry assault operations is “shoot, move, and communicate.” An infantryman (or a medical professional) must perform his key principle duties with ease and expertise. She must move through her tasks as an individual and as a team member. And he must communicate his situation, position, ideas, and necessities to his own team members and other teams. Members of a cardiogenic shock community of care must likewise be experts of their own trade but also effective members of a larger multisite team. It is not enough to achieve culprit or complete coronary artery revascularization in the cardiac catheterization lab and then deliver a patient to the intensive care unit in a hypotensive and hypoperfused state of “permissive persistent shock.” We can’t just shoot/support, or move/revascularize, or communicate. We must do all three, together, and well, and we cannot stop until our desired end state, survival, is achieved.

Intelligence Preparation. The systematic process of collecting, analyzing, and disseminating critical information to guide successful military operational decision-making, known as intelligence preparation of the battlefield, is paramount. Poor battlefield intelligence leads to tactical blunders. In cardiogenic shock and acute myocardial infarction with cardiogenic shock, routine collection of comprehensive hemodynamic data via right heart catheterization and rapid bedside echocardiography is a necessary minimum step. While the indiscriminate use of right heart catheterization in all comers in the intensive care unit may have proven ineffective, this hemodynamic information is essential for data-driven management of cardiogenic shock.⁵ In the longer term, the large-scale collection of laboratory, hemodynamic, anatomic, and echocardiographic parameters will provide critical intelligence to guide future management strategies.

Team of Teams. Mirroring organizational innovations of elite military units, medical personnel must work to combine the adaptability, agility, and cohesion of small teams within large, well-resourced healthcare systems. Innovation and information sharing must be faster, flatter, and more flexible.⁶ Experts across the spectrum of care, to include emergency medical services, emergency medicine, nursing, cardiology, cardiac surgery, critical care, research, industry, and others, must collaborate in detailed and comprehensive data collection and analysis within a centralized national registry, performance improvement and quality assurance, and rapid and repeated ongoing dissemination of frequently updated best practices and innovations.

As a cardiovascular-care community, we have made incredible improvements in heart health over recent decades, and cardiovascular specialists have remained at the forefront of international medical advances. But our care for the cardiogenic shock population has been static, fragmented, and far too variable by provider, hospital, zip code, and time of day. Only with strong leadership, teamwork, and a national commitment to a joint integrated countrywide network of cardiogenic shock care, research, and innovation can we hope to achieve our desired goal of zero preventable death from cardiogenic shock. Now is the time. The decision is ours.

Alexander G. Truesdell, MD, FACC, FSCAI, FSVM

Virginia Heart

INOVA Heart and Vascular Institute

Falls Church, Virginia, USA

Email: agtruesdell@gmail.com

Dr Truesdell served in Infantry, Intelligence, Medical, and Special Operations units in the United States, Europe, the Balkans, Iraq, and Afghanistan between 1994 and 2009.

Disclosures: Dr Truesdell reports speaker’s bureau fees from Abiomed. He is the site PI of the SHIELD II trial (Thoratec PHP device).

References

1.     Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73:S431-S437.

2.    Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. N Engl J Med. 1999;341:625-634.

3.    Stretch R, Sauer CM, Yuh DD, Bonde P. National trends in the utilization of short-term mechanical circulatory support: incidence, outcomes, and cost analysis. J Am Coll Cardiol. 2014;64:1407-1415.

4.    Wayangakar SA, Bangalore S, McCoy SA, et al. Temporal trends and outcomes of patients undergoing percutaneous coronary interventions for cardiogenic shock in the setting of acute myocardial infarction: a report from the CathPCI registry. JACC Cardiovasc Interv. 2016;9:341-315.

5.    Atkinson TM, Ohman M, O’Neill WW, et al. A practical approach to mechanical circulatory support in patients undergoing percutaneous coronary intervention: an interventional perspective. JACC Cardiovasc Interv. 2016;9:871-873.

6.    McChrystal SA. Team of Teams: New Rules of Engagement for a Complex World. New York: Penguin Publishing Group, 2015.