Interview Transcript

Interview Information:
Interviewer: ​Anna Shaw
Interviewee: ​Dr. Zain Hashmi
Interview Time: ​39:04

Transcription:
Anna: Hello, can you hear me?

Dr. Hashmi: Yes, this is Anna?

Anna: Yes.

Dr. Hashmi: Hey, how are you doing?

Anna: I’m good, how are you?

Dr. Hashmi: I’m good, sorry I was like...I’m coming back from this conference that I was telling
you about last time we met so I’m just at the airport. I have a few minutes to talk so I was like
‘this is the perfect time to do this’.

Anna: Okay, thank you so much for agreeing to do this.

Dr. Hashmi: Yeah, absolutely, my pleasure.

Anna: I just wanted to make sure that I could record this conversation?

Dr. Hashmi: Yes! That’s fine.

Anna: Okay, thank you so much. Whenever you’re ready, I can start.

Dr. Hashmi: Yeah.

Anna: Okay, I’m going to start with some smaller, lighter questions.

Dr. Hashmi: Okay.

Anna: What is your background?

Dr. Hashmi: So my background is in health care, broadly, but I am a surgical resident and I am
going into trauma critical care, which is basically the care of critically ill surgical patients and
patients who have had injuries. That’s primarily what I do from a clinical standpoint. From a
research standpoint, I study trauma systems and hospital and trauma center quality, how they
function, and how we can improve outcomes for patients who are critically ill or who have
sustained injuries. In a nutshell, that’s what I do from both a clinical and a research standpoint.

Anna: Okay, what interested you in emergency or trauma care?

Dr. Hashmi: So, when I initially started doing research, I was working with a surgeon who was
doing trauma/critical care research and his primary focus was to do healthcare disparities
research. And when I started looking into it, we found that- you know, people always assume
that when you get injured, regardless of your skin color, regardless of your insurance status, that
is one thing, because it is so acute, and you’re brought into the emergency room, that everybody
would have the same outcomes…

Anna: Right.

Dr. Hashmi: … and they would do well, but that’s not what we found. We found that
marginalized groups did much worse for the same level of injury as their non-marginalized
counterparts. So, patients who were of black or Hispanic ethnicity, they did much worse than
their white counterparts, having sustained the same level of injury, which was an unexpected find
because we thought that trauma and critical care was probably a great equalizer, but it doesn’t
turn out to be. So, that kind of got me interested into trauma critical care as a whole, from a
research standpoint, and once I started doing my residency it also got me interested from a
clinical standpoint because I like to take care of patients who come in extremis, it’s very
rewarding, to be able to help them in that situation and get them out of that hyperacute situation.

Anna: Interesting. So, as we discussed before when we met, I’m studying stay and play vs load
and go.

Dr. Hashmi: Right.

Anna: Do you have an opinion on which one is more efficient?

Dr. Hashmi: I don’t think that there has been a head-on comparison of the two strategies.
Anna Shaw: Mm-hm

Dr. Hashmi: But philosophically, in the United States and in much of North America, we have
done scoop and run.

Anna: Right.

Dr. Hashmi: And in Europe, they have primarily done stay and play. And a lot of that is how the
trauma systems matured and how the initial...implemented (inaudible- 4:54-4:58). I’m not sure
that there is hard science to say which of them is better or not because, frankly speaking, both
systems work. But there may be some inclination or some data recently that suggests select
populations, that is, patients who have penetrating injuries, they might do better with a scoop and
run strategy rather than a stay and play strategy. Now mind you, most of the trauma that we see
in North America, a substantial portion of it is penetrating trauma, that is, gunshot wounds or
stab wounds…

Anna: Mm-hm

Dr. Hashmi: ...versus in Europe, most of the trauma is blunt.

Anna: Interesting.

Dr. Hashmi: Or a lower proportion of trauma is penetrating in Europe compared to the United
States. So in the United States, overall, it’s about, maybe- it depends on where you are- but it’s
roughly between 10% to 20%. Urban environments have lots more penetrating trauma. In
Europe, it’s probably under 5% and they don’t have a lot of gun violence, so most of the
penetrating trauma is stabs.

Anna: Right.

Dr. Hashmi: So it’s a lower acuity trauma. In both situations, a scoop and run or a stay and play
might be equivalent, but there may be a better role for the scoop and run in major vascular
injuries or major penetrating trauma involving gunshot wounds, which often causes more
damage than simple stab wounds.

Anna: Right. So, I read in a study that some of the subjects experienced head injuries, like blunt
head injuries, or hemorrhages. Do you think there is a difference in the support that would
benefit them, like basic life support compared to advanced life support in that situation?
Dr. Hashmi: It depends on what they are doing in the field. You’re talking about, again, stay and
play versus scoop and run, in that context, for those patients?
Anna: Yes.

[ The connection kinda cut out at this point so I mashed up what happened before and after to
make it flow better]

Dr. Hashmi: A patient, for example, who has a severe traumatic brain injury often may need
advanced airway protection. So there may be a role for initiating adjunct airways to protect them
from asphyxiation.

Anna: Right.

Dr. Hashmi: There may be a role for making sure that they don’t become hypotensive, or they
don’t have their blood pressures drop too low, but then there is the element of trying to figure out
how severe the injury is based on evident characteristics and whether they need a decompressive
craniotomy or procedure to help relieve the pressure that’s built up because of the bleeding in the
brain. I’m not familiar with the literature enough to again, say this has been studied, but I would
think that maybe there’s a role for protecting the airway and so long as you can do that- which
they often do here as well; even with the scoop and run strategy, sometimes they will intubate in
the field, sometimes they will put in an adjunct airway, which is not a definitive airway, some
sort of device which will keep their breathing going, and then bring them to the hospital, and
that’s still under the category of scoop and run. But I am not aware of any hardcore data that
suggests either strategy is better over the other.

Anna: Okay. Are there any specific protocol or procedures in place in the Baltimore area in
regards to scoop and run or stay and play? You talked about scoop and run being the more
common method used in the United States, is that the same in the Baltimore area?

Dr. Hashmi: I’m not aware if there are any mechanistic ways they are different. There may be
some differences between EMS companies but I think, by and large, most of them follow the
same principles: they make sure the scene is safe, get an initial set of vitals, then triage them to
the appropriate level of care, and then bring them to the hospital as expeditiously as possible. I’m
not sure if there are any major differences. Some EMS companies may want to start an IV, but
I’m not 100% sure if there is any major difference.

Anna: Okay. Some studies have concluded that prehospital intubation can lead to increased
mortality, do you think this is true?
Dr. Hashmi: It depends on what that context was and what the patient population was. Do you
know what patient population they were talking about in that study?
Anna: I think they were talking about patients with hemorrhages, I’m pretty sure.

Dr. Hashmi: Yeah, so again, patients who have a catastrophic hemorrhage would benefit from
expeditious transport. So long as you have a viable airway, meaning that you can bag-mask
them,

Anna: Mm-hm

Dr. Hashmi: and ventilate them without doing intubation, I think the mechanism for that
increased mortality has to do with the increased time it takes for the intubation to occur before
they can transport them, so I think it’s, again, because of the acute nature of that injury. You can
imagine an injury ranges from a wide variety of things. If you have a major vascular injury, you
have, like, minutes.

Anna: Right.

Dr. Hashmi: If you have a blunt injury, let’s say you have a broken leg, for example, a broken
lower leg, you may have a little more time compared to somebody who has a lacerated aorta, for
example. So it depends on the nature of the injury.

Anna: Right, so what factors of an injury affect the level of prehospital care, like which ones are
the most important, which ones would you look at- [here he had to talk to someone at the airport
so it's a little choppy sorry]

Dr. Hashmi- Sorry, hold on one second. Sorry, go ahead.

Anna: What factors of an injury or an illness affect the level of prehospital care that is
administered and which ones are the most important?

Dr. Hashmi: Things that kill immediately, so the things that can be prevented- there’s something
called compressible hemorrhage and there’s something called non-compressible hemorrhage.

Anna: Mm-hm

Dr. Hashmi: Compressible hemorrhage- well, let me backup a little bit. Any major hemorrhage
or hemorrhagic shock or any injury that leads to hemorrhagic shock, that’s something that will
definitely benefit from expeditious transport to the ED. Somebody, for example, that has a
ground-level fall, multiple rib fractures, that may not be a hyperacute situation, right?

Anna: Right.

Dr. Hashmi: So, you can take a little more liberty in that circumstance to maybe do stay and
play, and maybe in those circumstances, stay and play may not be completely detrimental or it
may not be inferior to doing a scoop and run. But in cases where you’re talking about
hemorrhage, major hemorrhage, then it depends on whether or not you classify it as compressible
or non-compressible hemorrhage. Compressible hemorrhage is bleeding from an extremity like if
you’re shot in an extremity or you’re broken extremity is bleeding, you can put a tourniquet on it
or back the wound or apply direct pressure.

Anna: Mm-hm

Dr. Hashmi: For compressible hemorrhage, you can do that. For non-compressible hemorrhage,
what you’re talking about is non-extremity wounds, bleeding from junctional areas, like groin,
[could not understand this word], or neck, where you cannot put a tourniquet on,

Anna: Right.

Dr. Hashmi: and you may not be entirely accessible to direct pressure, sometimes, and anything
in the thorax, or in the abdomen that’s bleeding, all those things- if you’re suspecting a major
vascular injury, or a shattered liver, or a shattered kidney, a shattered spleen that’s bleeding- all
of those things need immediate attention in terms of getting them to the ED or getting them to a
trauma center and getting evaluated, getting a CT scan, figuring out what the nature of that injury
is. So those are the set of patients with bad, blunt, internal organ injuries which are bleeding
internally, and penetrating injuries with a high degree of suspicion for penetrating vascular
injuries. Those are the patients that you don’t necessarily want to do stay and play for, and I
would imagine those people benefit from a scoop and run strategy. And even where stay and
play is practice, I think in those situations they do modify their protocol to as expeditiously
transport their patients to a hospital as they can, but I don’t know if there is any specific data that
compares the situation head to head.

Anna: Right. What would happen, hypothetically, if a person gets penetrating trauma in a very
rural area, where a hospital is like, say, more than 30 minutes away?

Dr. Hashmi: Uh-huh.

Anna: So would you then stay and play or would you still scoop and run to get them to the
hospital as fast as possible?

Dr. Hashmi: You would still scoop and run as fast as possible because there’s not much you can
do.
Anna: Right.

Dr. Hashmi: There’s not much you can do, in the current time, to stay and play. So, in that
situation, you would have to get them to the hospital as soon as possible. Now, the other thing
that you can consider is, at least in the U.S., you have different levels of a trauma center. Right,
so sometimes in rural areas, what you can do is you can have a level three center, for example,
level two or a level three center. Sometimes, if the situation in dire and there are resources
available at that center, with a surgeon and an OR available, you can transport them to a level
three center close by where they can do certain interventions to stop the bleeding or temporize
the bleeding enough for them to be transported to a higher level of care. That is something that
you can do. Now, in the UK, what they’ve started to do is something called a REBOA, which
stands for resuscitative endovascular balloon occlusion of the aorta, right, they put a catheter
through the groin and blow up the balloon in the main vessel that’s carrying blood to the heart,
and what that does is it curtails any hemorrhage in the abdomen or in the lower extremities. So at
least for that, they have that tool and there have been certain instances where they have been
doing that in the field, but in the US that’s still something that’s not done in the field setting
currently.

Anna: Right.

Dr. Hashmi: That’s sort of emerging technology.

Anna: Interesting. You mentioned earlier that a patient in a rural setting could be transferred to a
hospital for immediate care and then transferred again to a higher-level hospital.

Dr. Hashmi: Right.

Anna: Would there be any risk involved in transporting them from one hospital to another, could
that potentially worsen their position?

Dr. Hashmi: There are certain parameters that you want to make sure of to safely transport them.
But they need to be stable. Stable means that they need to be hemodynamically, relatively stable,
that their heart rate is not racing, that their blood pressure is not dropping, that you have a fairly
good al be temporary control over a major source of bleeding that you can transfer them to
another higher level of care. Sometimes, what happens is, also, in those rural settings, you can
send helicopters to expedite transport. That also happens.

[Here is where I didn’t have any more questions regarding my research alone, but I still wanted
to talk about data collection because we had touched on it when I met him earlier.]
Anna: You mentioned, when we talked earlier, that studying homicides in different areas of
Baltimore would be beneficial?

Dr. Hashmi: Uh-huh.

Anna: What happens when there’s a lot of injuries in one area? Does that change anything at all?

Dr. Hashmi: I don’t know. The honest answer is I don’t know. Let me rephrase. We don’t know.
Because the EMS system is so disconnected from what we do in the hospital, right now.

Anna: Really?

Dr. Hashmi: Yes. Believe it or not, there is no single database which captures data from point of
injury for a patient until they get rehabilitated back into society. Most of the data that we have is
hospital-based, like from the time they get to the hospital to the time they get discharged from
the hospital. That’s all the data we have. We don’t have long-term functional outcomes for these
patients and we don’t have data on how they initially were- or we do have some data but it is not
readily linked to the hospital records, so you can’t figure out what the delay was, the transport,
various things. There is some data; it is not great data.

Anna: How would getting that data help or benefit the whole system in general?

Dr. Hashmi: Having that data would be really beneficial because it would inform you of a lot of
things: the characteristics from the point of injury, where they were injured, what the situation
was, when the EMS picked them up, what the EMS response time was, what the scene time was,
what their recovery time was, when they got to the hospital, what did they do in the field, and
how all of those variables- think about it as a story, like what happened before they came to the
hospital that could impact how they do while they are in the hospital.

Anna: Right, and you said that could be linked to stay and play vs load and go, and I could
compare if there’s even a difference between the two or if there are the same outcomes with the
stay and play and scoop and run?
Dr. Hashmi: We don’t have data on- nobody does stay and play in the US, so everybody does
scoop and run, but the time of that scoop and run is what we don’t know, right?

Anna: Oh, okay.

Dr. Hashmi: We don’t know how much time was spent at the scene, or [couldn’t understand]. So
that is something that we just don’t know. There is a national database right now called
NEMESIS, which is national ems information systems, or something like that. Basically, it
records what happens before the patients come to the hospital. There have been very few studies,
I think there was one study published today in Jama Surgery, looking at NEMSIS linked to
in-hospital outcomes. You should read that study, I can forward it to you, that link.

Anna: Okay, that would be great!

Dr. Hashmi: That would be beneficial for you to understand exactly what that spectrum is. But,
you know, when we talk about trauma, we talk about in terms in phases of care, there’s
prehospital: whatever happens, before they come to the hospital, there’s the in-hospital period,
and then there’s post-discharge period. So right now, we know a lot about what happens when
they are in-hospital, but we don’t know what happens in the prehospital setting that impacts how
they do in-hospital. We have very a little data-driven understanding of that and the primary
reason for that is we don’t have a single record of a patient from point of injury to rehabilitation.
We have maybe two or three different data sets which may be linked, but the quality of that
prehospital data is not great to be able to do that. Ideally, you should have a single database
which captures data from point of injury till a long-term follow-up. We don’t have anything that
is like that in existence.

Anna: Is that just due to the time it would take to gather that data, is it that, or are there other
reasons?

Dr. Hashmi: It’s little to do with- there are some logistical problems with that, but it’s not
impossible to do.

Anna: Right.

Dr. Hashmi: It’s not impossible to do. That data exists in some way, shape, or form, but it is just
that a different organization controls that data, and there are issues with data sharing, there are
issues with data integration, there are issues with how that data is captured and the quality
assurance of how that data is collected.
Anna: Right.

Dr. Hashmi: So all of those things need to be considered- I mean you can collect data, the
problem is not that there is no data, there is some data, but it’s not good enough to be able to do
this. So it’s not integrated, one. Whatever data there is is not integrated. There is no one singular
registry to look at that. Secondly, the disparity data that exists in different datasets, there is now
some high-quality hospital data; the data that’s prehospital is not something that has been run
through a quality assurance mechanism as data.

Anna: Right.

Dr. Hashmi: We need to have all of those boxes checked before we draw meaningful conclusions
from that data in the prehospital setting. There’s another document from the National Academy
of Science and Engineering and Medicine. They recently- and by recently, I think it’s 2016- they
published this document which is called Civilian Military Relationship for Advancement of
Trauma Care: The Road to Zero Preventable Deaths After Injury. Basically, it’s almost like a
[couldn’t understand] paper, which sets out eleven or twelve recommendations for developing a
modern trauma system. So, I would highly encourage you to read that document, even if you
read a summary of that, it will give you a good understanding of where we are currently with the
trauma systems.

Anna: Okay.

Dr. Hashmi: And what the challenge is, and what the opportunities to work on those challenges
are and what the experts have recommended.

Anna: Okay. That’s all I have, question-wise, thank you so much for doing this, I know it was
kind of an inconvenient time for you…

Dr. Hashmi: No, it was actually a perfect time for me.

Anna: Oh, okay. Thank you so much for giving me this opportunity.

Dr. Hashmi: Absolutely, absolutely.

Anna: And I would love those articles that you mentioned.

Dr. Hashmi: Yeah, I can send you that. When do you want to talk about the research and stuff
that you want to do?
Anna: I’m not sure- I know I’m going to start my data collection soon.

Dr. Hashmi: Okay.

Anna: Right now, we’re organizing how we’re going to go about collecting it.

Dr. Hashmi: Right. Before you start collecting data, you need to have a plan, right?

Anna: Yeah, that’s what we’re doing right now.

Dr. Hashmi: So, we need to come up with that plan.

Anna: Okay.

Dr. Hashmi: Because, in data collection- once you have a plan, and once you have a strategy to
know what to collect and how to analyze it, data collection becomes a lot easier.

Anna: Right.

Dr. Hashmi: I would advise you to brainstorm about having an objective, what you intend to
achieve.

Anna: Okay.

Dr. Hashmi: So right out a question. What is the question that you want to answer.

Anna: Mm-hm.

Dr. Hashmi: A question that is answerable, and then you find a question to see what’s doable.

Anna: Okay.

Dr. Hashmi: And then you figure out “alright, what data points do I need to answer this
question?”, “how do I collect them?”, “is it logically and logistically possible to collect them?”,
and “once I have that data, how do I analyze it?”. And once all of those boxes are checked off,
then you go collect the data. Because if you collect the data upfront, without doing all of those
steps-
[the audio cuts out here and I ask him to repeat it]

Dr. Hashmi: We need to do all of those things, the brainstorming about the question, about what
data points we need, how we are going to analyze it before we actually collect data.

Anna: Right, right.

Dr. Hashmi: I actually- remember when I last spoke to you, I was talking to you about Dr. Haut,
who wrote that paper recently about prehospital transport for penetrating injuries in the urban
setting,

Anna: Yeah.

Dr. Hashmi: which basically showed that transport by private vehicles led to better outcomes
compared to EMS transport.

Anna: Mm-hm.

Dr. Hashmi: And presumably that was because primary vehicle transport was much faster. That
was their hypothesis, but they didn't have the data to test the hypothesis and show that it was
actually the case. So if we can show that, that that was due to reduced time that it took, I think
that would be really valuable knowledge.

Anna: Okay, so I would be collecting data on the times between private transport and EMS?

Dr. Hashmi: Yeah, I mean, let’s figure out a question. So, when you write a scientific question,
you have a question that is SMART, right there’s an acronym called SMART, so you’re question
has to be SMART.

Anna: Uh-uh.

Dr. Hashmi: By SMART, I mean specific, measurable, it has to be actionable, reproducible, and
it has to be time-competent, meaning it that it can be done in a timely fashion.

Anna: Right.

Dr. Hashmi: So, the question, in this case is, for example, I mean, I’m just thinking out loud right
now, is “how much time does private transport take versus EMS transport?”.
Anna: Right.

Dr. Hashmi: Right, so now if you wanted to be more specific, you say, “for penetrating injuries
in an urban setting, or in Baltimore, which is an urban setting, how much time does private
vehicle transport take versus an EMS transport to the nearest hospital?”

Anna: Right.

Dr. Hashmi: One way you can do that is, from Google Maps, you look at, look at representative,
I think Baltimore Sun or maybe the Baltimore Police might have that data on recent shootings in
the area.

Anna: Yeah.

Dr. Hashmi: So they may have a crime date map, or even the EMS companies might have that,
and see where the incidents occurred in Baltimore,

Anna: Mm-hm

Dr. Hashmi: And what does Google Maps tell you as to their driving distance. Let’s say, for
example, you have a, let’s say, last week, there was a shooting in Inner Harbor, at 5 p.m. What is
the driving time, at 5 p.m, from Inner Harbor, to, let’s say, shock trauma, right?

Anna: Mm-hm.

Dr. Hashmi: That would give us a specific, measurable, quantifiable value of the time it takes for
a patient to arrive in a private vehicle.

Anna: Right.

Dr. Hashmi: We can add to that the actual time it took for EMS transport to do that.

Anna: Oh, yeah, yeah.

Dr. Hashmi: So we can go to, and I can talk to Dr. Haut about this more, or we can, if you want,
we can set up a meeting with Dr. Haut, and discuss this. He was, I spoke to him at the
conference, I met him, and I was telling him about this whole project, and he was very excited to
do this, and he was happy to mentor the both of us on this.
Anna: That’s great!

Dr. Hashmi: Yeah, so we can set up a time and actually meet with him to discuss this.

Anna: That would be amazing.

Dr. Hashmi: And he may have more insight because he’s been doing this, obviously much longer
than I have been; he’s my mentor, so…

Anna: Yeah.

Dr. Hashmi: It would be good to have his insight into this, but let’s have this proposal, let’s work
on this, why don’t you write out a brief, one-page proposal on all that we’ve talked about, and I
can refine it and then we can set up a time with Dr. Haut and we can discuss it. My plan with that
is that we should target, first of all, your thesis, right, that you need to do this for, right? Which
was, when, in June?

Anna: It’s around the end of the year, it’s a little before that.

Dr. Hashmi: Okay, end of the academic year, you mean?

Anna: Yeah, at the end of the academic year.

Dr. Hashmi: End of the academic year is when?

Anna: It ends in the middle of June.

Dr. Hashmi: Middle of June, okay, so maybe let’s call it in May, then, right?

Anna: Yeah.

Dr. Hashmi: Well that’s fine, we have plenty of time, the conference that I just went to will be a
great place for you to present that. And I’m fairly certain that this will perfect for presentation at
the conference, for sure.

Anna: Okay!

Dr. Hashmi: So, it will be great for you to present at a national conference, as a high school
student, that’s phenomenal.
Anna: Okay….
Dr. Hashmi: So, no pressure.

Anna: Yeah.

Dr. Hashmi: We can make this happen.

Anna: Okay, that’s great!

Dr. Hashmi: So, first thing’s first, let’s do the proposal, let’s write a one-page proposal and send
it to me, then I’ll work on it and then we’ll set up a time with Dr. Haut and we’ll get this rolling.

Anna: Okay, when would you like the proposal by, around what date?

Dr. Hashmi: Whatever is feasible for you, I mean the sooner the better, I mean if you can work
on it over the weekend and send it to me early next week, that would be great.

Anna: Yeah, I can do that.

Dr. Hashmi: If you want to send it to me sooner, whenever, but I just want to make sure that we
do it soon enough that we can the pieces in place and do this.

Anna: Okay, thank you so much!

Dr. Hashmi: Yeah, absolutely!

Anna: Alright, I’ll let you go because I know you have a flight to catch.

Dr. Hashmi: Sure.

Anna: Okay.

Dr. Hashmi: Alright. Talk to you soon, Anna. Thank you.

Anna: Bye, thank you!

Dr. Hashmi: Bye.

Reflection:
Overall, I think the interview went well. Dr. Hashmi provided me with a substantial
amount of information, and he gave in-depth responses to all of my questions. There were a few
technical difficulties, such as the phones cutting out, but it otherwise progressed smoothly. In my
next interview, I would try to ask more follow-up questions and I would try to avoid repeating
the same responses. The hardest aspect of the interview was mentally editing my prepared
questions in accordance with that Dr. Hashmi said while he was talking so I was ready to speak
when he was done.