By Brent Crawford, MPA, NRP
For a patient suffering from exsanguinating hemorrhage, there is no substitute for blood. While this has been widely known for decades, most ground EMS programs have either not had the capability to carry blood products or entirely elected not to carry them at all.
Until recently most EMS programs have relied primarily on crystalloid fluids for their patients who required volume resuscitation. The obvious clinical issue with this practice is that crystalloids cannot transport oxygen.
According to Dr. James R Stubbs, a transfusion specialist at the Mayo Clinic, “as large blood volume replacement with crystalloid has been found to cause more harm than good, it’s fallen out of favor.”1
Nearly all current data suggest that whole blood administration if transfused early, can greatly increase outcomes for patients who have suffered significant blood loss. This begs the question, “If this practice can be such a significant difference-maker in saving a life, particularly in the field, then why are more ground EMS programs not carrying blood?”
Public Misconception
The public has a common misconception that most ambulances carry blood products. If they knew how far this was from the truth and how many painstaking hours go into developing a blood program, it would probably surprise the majority of them.
According to data provided by the Healthcare Resilience Task Force, “there are more than 23,000 licensed EMS agencies in the United States,” as of 2020.2 Of those licensed agencies, only 121 are reported to be carrying blood products as of September 2023, according to the National Institute of Health (NIH).3
Some data suggests that the number has increased mildly since last reported. However, today less than one percent of ground EMS agencies in this country are carrying blood.
According to Dr. Peter Antevy, “Numerous studies have shown that giving whole blood on scene can be beneficial, decreasing prehospital and early-hospital mortality by 48%, but, with very few exceptions, civilian patients have to wait until they arrive at the hospital to start receiving blood transfusions.”4
Why Not Carry Blood?
Even with that knowledge, there can be a multitude of reasons why an agency would choose not to carry blood products. Some of the main challenges are a limited blood supply, associated costs, the agency’s medical director or administration not wanting the complications of a new product as well as the necessary training and education involved with transfusing blood.
Thus, there are varying degrees of its adoption by agencies and states as well. Whatever the reason, the data is out there, and there is no denying that those EMS programs that can transfuse blood in the field are giving their patients a better chance of survival than those who do not.
Blood in Louisiana
Until recently, Louisiana was one of those states that did not have a ground EMS agency carrying blood products. This changed in October 2021 when New Orleans EMS would set the new standard for ground EMS programs in the state by incorporating the transfusion of blood products into their service.
Undoubtedly, New Orleans EMS was not the first ground service in Louisiana to see the need and benefits of carrying blood products, but they were the first agency that took the initiative to go out and make carrying blood a priority and reality.
It would be nearly three more years before another EMS ground service in Louisiana, Desoto Parish EMS (DPEMS), would take that same initiative and make carrying blood products their top priority.
Desoto Parish EMS
In the summer of 2019, DPEMS Supervisor Gordon Miller first proposed the concept of carrying blood products. Miller’s initial proposal, while generating interest and support from the agency’s medical director and administration, also came with questions and an inherent set of new risks for the agency.
For a mostly rural EMS agency, DPEMS is a clinically advanced and proactive ground agency. They were the first and still the only ground service in north Louisiana that has rapid sequence intubation (RSI) capabilities, which they implemented in 2012.
Their guidelines (protocols) allow their paramedics to have a level of autonomy not commonly seen in EMS. The agency is constantly looking for new and innovative ways to treat their patients whether that is a new medication, new device, or procedure, or in this case, carrying blood products.
Even with all the advancements DPEMS has made since its inception in 2001, in 2019, carrying blood seemed improbable. However, now that the idea had been proposed, Miller and his team began investigating what the criteria would be for a ground EMS service to carry blood.
A Sudden Stop
Unbeknownst to them, the entire process would soon be shelved for the next several years. By the end of 2019 and early 2020, the country and the world would come to a screeching halt due to a global pandemic.
COVID put everything on hold. Every EMS agency in the country was now concerned about supply chain issues, staffing, fuel shortages, and all the unknowns that came with the pandemic. DPEMS was no different. The agency was no longer focused on creating a blood program but instead shifted its focus and began concentrating on how to keep their service operational while also limiting exposure and maintaining the high standards of patient care they had set for themselves. Carrying blood would not be even mentioned again until late 2023.
A New Start
Unlike in 2019, by 2023, dozens of EMS agencies across the country were now carrying blood products including an agency in Louisiana. This would make Miller’s second proposal for DPEMS to develop a blood program much easier. Even with all the data from the field surrounding positive outcomes with early blood transfusion, being able to pull that information from an agency in the same state was an invaluable resource.
Just like in 2019, Miller would once again make DPEMS carrying blood products his top priority. He collected the data, crunched the numbers, and spent countless hours talking to multiple blood banks in their area and even a few outside of the state.
What started as a hypothetical in 2019 would regain traction in late 2023 and eventually become a reality on May 13, 2024. That is the day Desoto Parish EMS would become only the second ground EMS agency in Louisiana to carry blood products.
The First Blood Transfusion
While other EMS services in more urban areas may transfuse blood products several times a month, it would be nearly four months after activating their blood program before DPEMS would transfuse their first unit of blood and plasma.
On September 30, 2024, at 2:32 a.m., DPEMS would respond to an MVC rollover at high speeds, with patient ejection. Upon arriving on the scene and locating the patient, it was estimated they had been thrown 15-20 yards from their vehicle.
The patient had several life-threatening injuries, including obvious bilateral femur fractures, one of which was an open fracture. The patient was rapidly loaded into the ambulance and transport was initiated to the level-1 trauma center, nearly 20 minutes away.
Despite the patient’s injuries, they were initially assigned a GCS-15. During transport, the patient began to show signs of clinical deterioration. The patient had a drop in their GCS, became pale, and tachycardiac. Due to fear of internal bleeding, the decision was made to transfuse blood and plasma.
Following the transfusion, and many other life-saving interventions taken by the DPEMS crew that morning, the patient’s status had greatly improved upon arriving at the trauma center.
Following multiple surgeries and several days in the hospital, the patient was discharged back home. Without the ability to transfuse blood products, there is little doubt this patient may have had a devastating outcome.
Long Process
The entire process that started in late 2023 would take nearly six months to complete. While DPEMS does not have nearly the run volume as EMS agencies in many of the larger metropolitan cities in Louisiana, they can now offer their patients’ blood and plasma, something those agencies cannot.
DPEMS medical director Dr. Patrick McGauly stated, “We are a smaller service, and we may only get the opportunity to administer blood a few times each year, who knows; but, for those few patients, there is no doubt that we are giving them a better chance of survival than we ever have before.”
With more agencies and medical directors across the country trying to implement a blood program at their own service, the hope is that, in the near future, the aspect of every ground EMS service carrying blood in some capacity will be the standard and not the rarity it is today.
About the Author
Brent Crawford is a nationally registered paramedic and the training officer for DeSoto Parish EMS in Louisiana. He also serves on the Louisiana EMS Task Force and is a commissioned member of the Louisiana Emergency Response Network (LERN). He possesses a Master of Public Administration degree from the University of Louisiana at Monroe and a Bachelor of Science degree in Unified Public Safety Administration from Northwestern State University.
References
- A reemerging role for whole blood in modern trauma care. 7 May, 2022. Retrieved from https://www.mayoclinic.org/medical-professionals/trauma/news/a-reemerging-role-for-whole-blood-in-modern-trauma-care/mac-20531706
- Dr. Jon Krohmer, Kate Elkins. Healthcare Resilience Task Force: EMS/911. 2020. Retrieved From: https://www.ems.gov/assets/COVID-19_EMS_911_Briefing.pdf
- Levy MJ, Garfinkel EM, May R, Cohn E, Tillett Z, Wend C, Sikorksi RA, Troncoso R Jr, Jenkins JL, Chizmar TP, Margolis AM. Implementation of a prehospital whole blood program: Lessons learned. J Am Coll Emerg Physicians Open. 2024 Mar 21;5(2):e13142. doi: 10.1002/emp2.13142. PMID: 38524357; PMCID: PMC10958095. Retrieved From: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10958095/
- Antevy P, Gilbey, B. With Trauma Deaths on the Rise, EMS Is Developing Prehospital Blood Transfusion Programs to Improve Survival and Recovery Rates. 11 June, 2024. Retrieved From: https://www.jems.com/patient-care/ems-is-developing-prehospital-blood-transfusion-programs/
