In the September 2024 edition of the Journal of Trauma and Acute Care Surgery, Milfordet al., wrote “low-titer O whole blood (LTOWB) is the only practical solution prehospital.”
I am intrigued, curious, and unsure that I am prepared to accept this. Some readers of this article will nod. Some will rub their chins like a curious emoji. Some will sharpen their pitchforks. But only the emojis are correct. To be clear, your author is neither a clinician nor a phlebotomist (allow me to nip in the bud any stupidity along the lines of ‘why do you think you get to ask a question about X if you don’t wear Y patch.”)
All I am is a technologist who has been right a few times—and who has spent more time and money than I care to admit studying, then participating in, the lifecycle of innovation. The quoted phrase strikes me as an example of “we’ve always done it this way.”
“The only practical” is a siren song to those among us who live to challenge the limits of the “practical.”
Put another way: Remember the scene from The Simpsons Movie, when Homer Simpson told his son Bart that the latter was having “the worst day of your life…SO FAR”? “The only practical” anything simply means that something more practical hasn’t come along yet—but when that Next Thing does emerge, as quoted in the intro to the “Masters of Scale” podcast series from Reid Hoffman and Bob Safian, the crazy and disruptive becomes “just the way you do it.”
Shouldn’t we just retire words like “impossible” and “only” at this point? Haven’t we seen enough to realize that we have no idea what the limits of the “practical” are? Could I be any more optimistic that we have no concept about the limits of human ingenuity—and you should be, too, because science fiction keeps becoming real.
- Minority Report: Touch screens, iris scans, computers that read your thoughts. Check.
- Iron Man: Flying exoskeletons, robot soldiers, artificially intelligent friends and helpers. Check.
- The Matrix: Brain-computer interfaces, robots that traverse through subway pipes, hovercrafts, the body as a battery. Check…and all of this is a bit terrifying! (Learning while you sleep…kind of.)
- Twelve Monkeys: Let’s hope note, but honestly, watch this film all the way to the end and then think of COVID-19. We’re not as far away from any of it—except time travel—as we might like.
- Idiocracy: Cryogenics are a definite yes. Can anyone really argue that we’re living this movie now?
Once upon a time, no private company could become the leader in space travel—and there are all sorts of conversations happening about going to Mars and beyond (see: The Martian, even Interstellar). Once upon a time, real-time discrete data sharing from an ambulance to a hospital or health information exchange was a pipe dream.
Knowing a child’s “invisible” disabilities before arriving at the scene of an emergency? Wishful thinking…until the state of Oregon made it happen, and now more than four dozen fire and emergency medical service agencies (and their hospital partners) across the state are doing exactly that, according to the first annual report from the HERO Kids Registry at the Oregon Center for Children and Youth with Special Health Needs.
Funny thing: One of the leading authorities on prehospital LTOWB protocols remarked that his approach to pediatric dosing has “turned out to be ahead of its time, and correct.” I remember when California’s Local EMS Agencies—the state’s EMS oversight unit—initially refused to authorize his novel protocol and software, deeming it experimental.
Despite the resistance, the team persisted, believing in a better approach where none previously existed, and now the reviews are in: They were right. This doesn’t mean the traditional approach was wrong—just that it wasn’t the only right way.
I see similar resistance—and opportunity, and even a future imperative—in the accelerating discussion about whole blood. Some will say that limitations in blood typing make it impossible to know the patient’s required blood type in the field.
Milford et al. themselves reference hospital laboratories. Any statement about the necessity of a hospital laboratory obviously implies that a facility-based lab cannot become portable. The absurdity of such a statement may not need to be pointed out but I’ll do so anyway: blood gas and other point-of-care assessments also couldn’t happen portably…until they could. “Lab on a chip” technology isn’t even a new concept in the digital health ecosystem: Theranos may have been a fraud, but the idea of portable biochemical assessments has not been frontier medicine for going on two decades.
The limits of “only” and “practical” are just begging to be pushed especially in an environment where we aren’t yet using biometrics to ID patients without them talking to the crew. A gulf remaining between the possible and the current.
In 2012, the notion of being able to speak to your ePCR system was nuts — everyone other than Robert J. McCaughan, former chief of Pittsburgh EMS and vice president of Prehospital Services at Allegheny Health Network—thought I would only run with such a crazy idea because I wasn’t a medic. (Other people thought I was an idiot for suggesting that medics should not need to print out silly ECG strips. I got that one right, too. Let’s make a note to talk about digital triage tags, soon.)
Now, dictation in a charting system is table stakes and we’re nearing the point where the charting system will talk back to you, engaging in clinical dialogue out of which both the optimal protocols and the ePCR emerge like Athena from Zeus’s head.
Credit is due to another visionary clinician, Dr. Paul Paris (also of Pittsburgh EMS), who more than fifteen years conceived of software to would walk field clinicians through their clinical assessments in real-time, at the patient, thereby simultaneously improving both the quality of care deliver and of documentation, while facilitating education through muscle memory “reps” that were also correct every time.
Now then, let’s try the question again: What happens—what becomes possible—when we push past the only practical anything as it pertains to Type O blood delivery in the field? Don’t we owe it to our patients to at least evaluate before we put a strike through any notion as “impossible” (since few things truly are).
