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INTRODUCTION: The California Prehospital Antifibrinolytic Therapy (Cal-PAT) study seeks to assess the safety and impact on patient mortality of tranexamic acid (TXA) administration in cases of trauma-induced hemorrhagic shock. The current study further aimed to assess the feasibility of prehospital TXA administration by paramedics within the framework of North American emergency medicine standards and protocols. METHODS: This is an ongoing multi-centered, prospective, observational cohort study with a retrospective chart-review comparison. Trauma patients identified in the prehospital setting with signs of hemorrhagic shock by first responders were administered one gram of TXA followed by an optional second one-gram dose upon arrival to the hospital, if the patient still met inclusion criteria. Patients administered TXA make up the prehospital intervention group. Control group patients met the same inclusion criteria as TXA candidates and were matched with the prehospital intervention patients based on mechanism of injury, injury severity score, and age. The primary outcomes were mortality, measured at 24 hours, 48 hours, and 28 days. Secondary outcomes measured included the total blood products transfused and any known adverse events associated with TXA administration. RESULTS: We included 128 patients in the prehospital intervention group and 125 in the control group. Although not statistically significant, the prehospital intervention group trended toward a lower 24-hour mortality rate (3.9% vs 7.2% for intervention and control, respectively, p=0.25), 48-hour mortality rate (6.3% vs 7.2% for intervention and control, respectively, p=0.76), and 28-day mortality rate (6.3% vs 10.4% for intervention and control, respectively, p=0.23). There was no significant difference observed in known adverse events associated with TXA administration in the prehospital intervention group and control group. A reduction in total blood product usage was observed following the administration of TXA (control: 6.95 units; intervention: 4.09 units; p=0.01). CONCLUSION: Preliminary evidence from the Cal-PAT study suggests that TXA administration may be safe in the prehospital setting with no significant change in adverse events observed and an associated decreased use of blood products in cases of trauma-induced hemorrhagic shock. Given the current sample size, a statistically significant decrease in mortality was not observed. Additionally, this study demonstrates that it may be feasible for paramedics to identify and safely administer TXA in the prehospital setting.

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Enactment describes how we engage the situation to make sense of it. But by our engagement, we also change the situation. Our presence, alone, will change the situation. At times, we may fail to act. Here, we are at risk of interpreting this as a sense of personal "limitation" in what we can do. This will inhibit us in engaging in other incidents. Rather, we should understand that while we may often fail after engaging, acting is part of performing in uncertainty. In EMS, the system, as it's set up, can lead people to fail to act. For reasons specific to a system, the EMT or paramedic may not act for fear of doing something wrong. This failure to act reinforces the limitations one feels. When you avoid acting, you don't learn. By avoiding testing ourselves, we conclude that constraints exist. This is contrary to the historical approach public safety and EMS personnel use to learn. In the past, it was accepted that we learn what works through action. We also perceive, or sensemake, through interaction with the environment. We watch for responsiveness to our actions, such as cooperation from bystanders vs. defiance. However, this is influenced by how we approach the scene. One EMS provider may obtain cooperation while another experiences defiance. We bracket this information by placing it in context. This interaction is difficult to communicate to those not present at the incident, because they don't know when one "story" begins and when another leaves off. HROs have developed in organizations that adapted to time constraints in uncertain and hazardous environments. There, lessons were actually learned through the blood of live-or-die situations. Academics have codified these principles and concepts that are accessible to EMS caregivers. EMS can benefit from the principles and concepts of HRO through improved performance by individuals and stronger organizations.

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PURPOSE: To offer a theoretical explanation for observed physician resistance and rejection of high reliability patient safety initiatives. DESIGN/METHODOLOGY/APPROACH: A grounded theoretical qualitative approach, utilizing the organizational theory of sensemaking, provided the foundation for inductive and deductive reasoning employed to analyze medical staff rejection of two successfully performing high reliability programs at separate hospitals. FINDINGS: Physician behaviors resistant to patient-centric high reliability processes were traced to provider-centric physician sensemaking. RESEARCH LIMITATIONS/IMPLICATIONS: Research, conducted with the advantage that prospective studies have over the limitations of this retrospective investigation, is needed to evaluate the potential for overcoming physician resistance to innovation implementation, employing strategies based upon these findings and sensemaking theory in general. PRACTICAL IMPLICATIONS: If hospitals are to emulate high reliability industries that do successfully manage environments of extreme hazard, physicians must be fully integrated into the complex teams required to accomplish this goal. SOCIAL IMPLICATIONS: Reforming health care, through high reliability organizing, with its attendant continuous focus on patient-centric processes, offers a distinct alternative to efforts directed primarily at reforming health care insurance. It is by changing how health care is provided that true cost efficiencies can be achieved. Technology and the insights of organizational science present the opportunity of replacing the current emphasis on privileged information with collective tools capable of providing quality and safety in health care. ORIGINALITY/VALUE: The fictions that have sustained a provider-centric health care system have been challenged. The benefits of patient-centric care should be obtainable.

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