Tiffany Kieschnick remembers very little from that night in January 2019. Driving home in rush hour traffic, she suffered a mini stroke and passed out, flipping her car into a ditch at full speed. As first responders raced to extract Kieschnick from the wreckage they lost her pulse and went into furious revival mode.
Facing a patient with multiple fractures in her spine, ribs and facial bones, a ruptured spleen and major blood loss, paramedics transfused her with whole blood, intubated her, performed chest compressions and brought her back to life, all in under five minutes. By the time the helicopter arrived to airlift her to the nearest Level 1 trauma center, she had already received one full unit of blood and was waking up. That initial transfusion, supplemented with two more units of blood in the helicopter, was just enough to get her into the operating room alive. Doctors later told her with certainty that she would not be here today had it not been for the ability of the paramedics on scene to give her a whole blood transfusion.
Kieschnick’s experience was extreme but also indicative of an unfortunate reality. The trauma death rate is on the rise nationwide.1 Motor vehicle crashes alone killed 42,939 people in 2021, the largest number of fatalities since 2005 while the estimated number of people injured increased more than nine percent from 2020 to 2.5 million.2 The suicide rate is also climbing with suicide attempts at 1.7 million and 48,000 deaths in 2021, a 36 percent jump from 2000.3 So, too, firearm-related injuries.4 But for the first time in decades EMS clinicians now have an incredible tool at their disposal.
Numerous studies5 have shown that giving whole blood on scene can be beneficial, decreasing prehospital and early-hospital mortality by 48%6 but, with very few exceptions, civilian patients have to wait until they arrive at the hospital to start receiving blood transfusions. Changing that requires some regulatory overhaul but the biggest hurdle is funding. More than anything, for this valuable tool to be at our disposal EMS needs to be reimbursed for providing it, particularly by third party payers.
Giving paramedics the option to give blood transfusions is new. Using whole blood isn’t. For centuries, transfusing whole blood – blood that has not been separated into its components –
was standard medical practice. In the 1970s, however, both military and civilian protocols switched to administering separated blood components (plasma, platelets and packed red blood cells), a shift that took advantage of advances in blood separation techniques and sought to mitigate against the transmission of infectious disease, such as Hepatitis-C and HIV. Blood component therapy also reduced waste, increased storage times and enabled a personalized approach to resuscitation, which didn’t require a donor with the same ABO blood type.
More recently, with the introduction of blood screening capabilities and a series of conflicts in which major trauma from IEDs necessitated immediate blood transfusions, the military reverted to whole blood use and EMS clinicians are pushing for the same. Like soldiers in Iraq and Afghanistan, civilian trauma patients experiencing hemorrhagic shock often need massive transfusions and time is the enemy. For these patients, replacing blood with blood in the prehospital setting, as you would in the hospital, is intuitive, and by using only universal donor group O blood, which is subject to the same rigorous testing as component blood, you eliminate any risk of contamination. Also, it was discovered that in fact O+ is the most common blood type in the US, accounting for 37 percent of the population,7 and incompatibility reactions are no longer an issue.
The Heroes in Arms whole blood program in San Antonio, TX, the organization behind Kieschnick’s life-saving procedure, has been groundbreaking in this field.8 A robust collaboration between the San Antonio Fire Department, the South Texas Blood and Tissue Center, the Office of the Medical Director at the University of Texas and the Southern Texas Regional Advisement Council (STRAC), members meet every two weeks at a minimum to review the latest technology and best practices for storing, transporting and transfusing whole blood.
EMS Lt. William Bullock, medic officer at SAFD, believes Kieschnick to be the “first documented case of a blunt, traumatic cardiac arrest where a patient received blood in the prehospital setting and … ended up living and having very normal capacity of life,” but she is certainly not the last. The Brothers in Arms program has administered 1,395 prehospital transfusions and doubled the amount of lives saved since it launched in October 2018. Initially very focused on addressing traumatic injuries from shootings, stabbing and motor vehicle accidents, in the last year or so they have transitioned to the medical side, treating patients with gastrointestinal or obstetric hemorrhaging, for example, which account for some 24 percent of calls that lead to EMS blood transfusions. Lt. Bullock described a recent “double save.”
“We had an expectant mother that was full term pregnancy and she had placenta previa abruption, some very, very heavy bleeding. Upon contact with the unit, blood pressure was 50 over 20, which obviously is precariously low … and then with the child, you know, that was extremely concerning. We established access and started giving her the blood immediately on scene and then it continued en route to the hospital. In that case, the baby was delivered successfully. Mom had everything taken care of on her end and they spent a very short time in the NICU and ICU, respectively, and baby and mom went home, both healthy, happy within the week.
At all times SAFD is stocked with eight units of whole blood for its intensive care ambulances to respond to individual trauma patients. The program is also set up to respond to mass casualty incidents such as the elementary school shooting in Uvalde last May. Since meticulously planned response frameworks were already in place, the program was able to get 40 units of blood to the designated trauma center within 67 minutes of the request going out, saving numerous lives.
Setting up a prehospital whole blood program is no easy task. After financing, one of the biggest hurdles is securing a reliable source of low titer, O+ blood and finding a way to safely store that blood to meet AABB and FDA standards. The COVID-19 pandemic significantly impacted blood supplies nationwide and the healthcare system is still in recovery. Adding to donation shortages, hospitals often resist contributing supplies to whole blood programs due to stringent blood storage regulations and perceived chain of command vulnerabilities. With state of the art technology on coolers, however, including temperature monitors, alert systems and even recording devices that can export data on minute-by-minute storage temperatures to trauma centers, these concerns are largely moot.
The SAFD program enjoys an extremely close relationship with their blood center and attributes a lot of their success to San Antonio being “Military City, USA,” populated with trauma surgeons who strongly believe in prehospital care. They have also established a “Heroes in Arms” initiative, a group of citizens who donate blood exclusively and regularly to the SAFD. The blood is stored for use in the first two weeks of its 35-day life cycle then the unused portion (about 32 percent) is passed on to the regional trauma center where it is validated and on hand for 21 more days. This system has worked very well, and in recent months, it has boasted a zero percent waste rate.
SAFD and the Office of the Medical Director also collaborate with the Department of Defense to develop new, more efficient techniques and tools, such as wide-diameter tubing to boost transfusion speeds. SAFD EMS Chief Reynaldo Garza says that everything is about relationships and staying focused on their mission.
“I think everybody kind of shares the same objective as we want to reach out and stay on top of the cutting edge with the medical side of, of the whole industry and, and making sure we’re doing the right things for our patients out there, for the community at large.”
Across the country whole blood programs are being designed, created and fine-tuned and there has been much agreement over protocols, which is unusual for the EMS industry. Using the SAFD program as the gold standard, proactive EMS leaders in New Orleans, Oklahoma City, Austin, TX, Broward and Palm Beach counties, Florida, Jacksonville, NC Fairfax, VA and Washington state, to name a few, have pushed for this capability. The number of EMS agencies transfusing prehospital blood has grown from 7 in 2018 to 156 and counting.
They hope to bring what is standard practice in the emergency room or operating theater to the prehospital setting.
In New Orleans, some clever marketing language proved very effective at garnering support. The blood registry program under Dr. Megan Marino, medical director of New Orleans EMS, has just started. Among the 248 patients who have received prehospital transfusions so far, largely for gunshot wounds and stabbings, roughly ⅔ survived to hospital admission. A recent study NOEMS conducted with the Tulane School of Medicine showed that overall mortality was significantly lower in patients who received prehospital transfusions (13% vs 47%, p < 0.001). Dr Marino framed that improvement by saying “EMS is lowering the murder rate in New Orleans by giving blood in the field,” and was able to secure both some municipal funding and the city’s commitment to continuing the program.
Using SAFD as a model, NOEMS formed a partnership with a local blood supplier and a Level 1 Trauma center. They have equipped Single Paramedic Rapid Intervention Non-Transport (SPRINT) units with blood storage coolers, Lifeflow rapid infuser devices and a dedicated blood medic. The cost of the blood, tools and other medications given runs to $1,100 per patient, which is not currently reimbursable by insurance. To keep costs down, NOEMS has forgone expensive blood warming devices but haven’t found transfusing cold blood to be problematic.
Data from southeast Florida shows that trauma volume has increased substantially in the last 10 years, with penetrating trauma (largely from gunshot wounds) accounting for a significant portion of that increase.9 Young, healthy men are the primary victims, which aligns with national trends.10 Dr. Peter Antevy, who serves as a boots on the ground EMS medical director for Coral Springs-Parkland Fire Department, Davie Fire Rescue and Palm Beach County Fire Rescue, leads a team that has established their own whole blood program.
The Palm Beach portion of the program has been up and running since July 2022 and has already administered over 100 units of whole blood. They boast a 90 percent survival rate for patients who were transfused prior to cardiac arrest. Likewise, the Broward Sheriff’s Office has administered over 200 units of blood and are now working to expand their coverage to all areas of the county. In short, and similarly to other whole blood programs, they are seeing mortality rates of 13 percent with pre-hospital transfusions compared to 47 percent without it.
Antevy is also a pediatric emergency physician and has been very vocal that whole blood should not be limited to adults. On scene for the horrific mass shooting at Marjory Stoneman Douglas High School in February of 2018, he witnessed firsthand the loss of so many young lives. That harrowing event drove him to set up a regional whole blood program and to be a local and national advocate. He is committed to providing access to both adults and children and his program is currently transfusing whole blood to hemorrhaging trauma patients over five years of age with low titer O+ blood.
Dr. Paul Pepe, a national leader and multi-decade researcher in the field of emergency medicine and trauma care, is also the original founding member of the National Association of EMS physicians and he now leads a global alliance of the jurisdictional EMS medical directors responsible for the 911 system protocols for the nation’s largest cities. An in-the-trenches field responder, he has been studying, scrutinizing and driving initiatives, not only to make the use of whole blood the national standard, but also to optimize appropriate utilization for those who will benefit.11
“Based on the data we’re seeing, prehospital whole blood transfusion is now feasible, safe and life-saving, but it also brings with it, extra work, budgetary impact and the need for closer cooperation with blood banks, hospitals, public officials and on-going analysis of the optimal use of such precious resources,” said Pepe. “Nonetheless, the terrible reality is that my family, your family and our neighbors everywhere, through no fault of their own, are all at some very finite risk for a severe internal hemorrhage incident and need for the earliest possible infusion of blood, be it the result of an impaired driver, a distracted texter, or the active shooter du jour at the mall, high school or hometown parade.”
Through his scientific research and various leadership roles, Dr. Pepe became a contributing member of the Trauma, Hemostasis and Oxygenation Research – Association for the Advancement of Blood and Biotherapies (THOR-AABB) Working Party. This association of leading trauma surgeons, transfusion specialists and EMS Physicians has established and published a “living document” to promulgate timely best practice recommendations for implementing a national prehospital blood transfusion program.12 The document includes best advice on how to use, and yet know the limitations of, metrics such as each patient’s shock indices (heart rate/systolic blood pressure) before and after treatment and also how to correlate outcomes accordingly. Most importantly, it helps communities to further justify and expand their prehospital blood programs.
EMS clinicians have consistently proven themselves to be both adaptive and proactive in the public health and safety arenas. With more and more lives being lost to traumatic injury, they now have the ability to give whole blood on a much larger scale. Moreover, accumulating military and civilian experiences are showing that prehospital whole blood transfusions spare multiple in-hospital transfusions and shorten the hospital stays of hemorrhagic patients.12 In other words, these programs save lives and save blood.
For her part, Kieschnick still regularly connects with her donors, hosts blood drives and has become a spokesperson for the cause.
“I believe I was saved for a reason and the reason is to share my story to help save more lives.”
Contacts
Peter Antevy, MD peter@handtevy.com
Lt William Bullock william.bullock@sanantonio.gov 210-274-9487
Chief Reynaldo Garza reynaldo.garza@sanantonio.gov
Bryony Gilbey bryonygilbey@gmail.com 914-274-0023
Tiffany Kieschnick 210-383-8449
Megan Marino, MD megmarino@gmail.com
Paul E. Pepe, MD, MPH dr.paulpepe@gmail.com
James Roach, MD Jim_Roach@sherrif.org 954-494-8866
References
1. Mortality Dashboard. National Center for Health Statistics: Centers for Disease Control and Prevention [Internet]. 2024 May 14; cited 2024 June 10. Available from: https://www.cdc.gov/nchs/nvss/vsrr/mortality-dashboard.htm#
2. Stewart T, Overview of motor vehicle traffic crashes in 2021 (Report No. DOT HS 813 435). National Highway Traffic Safety Administration. 2023 April; cited 2024 June 10. Available from: https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/813435
3. Suicide Prevention. Centers for Disease Control and Prevention [Internet]. 2024 June 10. Available from: https://www.cdc.gov/suicide/?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fviolenceprevention%2Fsuicide%2Findex.html
4. Mortality Dashboard. National Center for Health Statistics: Centers for Disease Control and Prevention [Internet]. 2024 May 14; cited 2024 June 10. Available from: https://www.cdc.gov/nchs/nvss/vsrr/mortality-dashboard.htm#
5. Brill JB, Tang B, Hatton G, Mueck KM, McCoy CC, Kao LS, Cotton BA. Impact of Incorporating Whole Blood into Hemorrhagic Shock Resuscitation: Analysis of 1,377 Consecutive Trauma Patients Receiving Emergency-Release Uncrossmatched Blood Products. J Am Coll Surg. 2022 Apr 1;234(4):408-418. doi: 10.1097/XCS.0000000000000086. PMID: 35290259.
6. Hazelton, Joshua P. D*; Ssentongo, Anna E. DrPh, MPH; Oh, John S. MD; Ssentongo, Paddy MD, PhD; Seamon, Mark J. MD; Byrne, James P. MD, PhD; Armento, Isabella G. BS; Jenkins, Donald H. MD; Braverman, Maxwell A. DO; Mentzer, Caleb DO; Leonard, Guy C. BS; Perea, Lindsey L. DO; Docherty, Courtney K. DO; Dunn, Julie A. MD; Smoot, Brittany BS; Martin, Matthew J. MD; Badiee, Jayraan MPH; Luis, Alejandro J. MD; Murray, Julie L. BSN, RN; Noorbakhsh, Matthew R. MD; Babowice, James E. DO; Mains, Charles MD; Madayag, Robert M. MD; Kaafarani, Haytham M.A. MD, MPH; Mokhtari, Ava K. MD; Moore, Sarah A. MD, Madden, Kathleen MD; Tanner, Allen II MD; Redmond, Diane MSN; Millia, David J. MD; Brandolino, Amber MS; Nguyen, Uyen BS; Chinchilli, Vernon PhD; Armen, Scott B. MD; Porter, John M. MD. Use of Cold-Stored Whole Blood is Associated With Improved Mortality in Hemostatic Resuscitation of Major Bleeding: A Multicenter Study. Annals of Surgery 276(4):p 579-588, October 2022. | DOI: 10.1097/SLA.0000000000005603
7. Facts About Blood and Blood Types. American Red Cross [Internet]. Cited 2024 June 10. Available from: https://www.redcrossblood.org/donate-blood/blood-types.html
8. Winckler, CJ; Miramontes David, Bullock, William. System Report: The San Antonio Fire Department Blood Delivery Program. EMS World. 2022 Aug 11; cited 2024 June 10. Available from: https://www.hmpgloballearningnetwork.com/site/emsworld/original-contribution/system-report-san-antonio-fire-department-blood-delivery
9. Roach, James. Penetrating/Burn Injuries.
10. Accidents or Unintentional Injuries. National Center for Health Statistics: Centers for Disease Control and Prevention [Internet]. 2024 April 26; cited 2024 June 10. Available from: https://www.cdc.gov/nchs/fastats/accidental-injury.htm
11. Pepe PE, Roach JP, Winckler CJ. Prehospital Resuscitation with Low Titer O+ Whole Blood by Civilian EMS Teams: Rationale and Evolving Strategies for Use. Cited 2024 June 10. Available from: https://useagles.org/wp-content/uploads/2020/04/Prehospital-Whole-Blood-ISICEM-art-4 20.pdf
12. Yazer MH, Spinella PC, Bank EA, Cannon JW, Dunbar NM, Holcomb JB, Jackson BP, Jenkins D, Levy M, Pepe PE, Sperry JL, Stubbs JR, Winckler CJ. THOR-AABB Working Party Recommendations for a Prehospital Blood Product Transfusion Program. Prehosp Emerg Care. 2022 Nov-Dec;26(6):863-875. doi: 10.1080/10903127.2021.1995089. Epub 2021 Nov 19. PMID: 34669564.
13. Petrowski R. Whole blood for trauma resuscitation research published in JACS. UT Health Houston. McGovern Medical School. 2022 May 16; cited 2024 June 10. Available from: https://med.uth.edu/blog/2022/05/16/whole-blood-for-trauma-resuscitation-research-published-in-jacs/
