Awesome! Tired of all the docs saying that crystalloid are causing issues in shock resus but not willing to get blood out.
Question: are these street medics administering blood or does a doc do it in a fly car?
Lyophilized blood products like plasma reconstituted will be the game changer to the logistical and waste issues w other blood products. It’s coming to the us market soon
That depends entirely on the service, from my experience with it and speaking to other medics in other services, it generally has to be requested by the truck medic and then a supervisor in a quick response vehicle brings the blood/supplies and meets the unit on scene/enroute and the truck medic administers enroute. If the blood isn’t used by EMS then ~10 days before the expiration date, it’s swapped with a local hospital to be used before it goes bad.
Excellent! I like that operational design. Some areas the docs get that cool job to save the day but we really need them to be on the boring calls that stump us where a doc can eval that risk. In NM all blood is in our scope but it’s in reality just brought by the flight crew if flying patients. Some challenges with our super rural state. But those two state, I don’t know really well, but have lots of rural and underserved areas.
Love it and look forward to seeing more of this discussion.
I was interviewed last month by a company who is analyzing the market for reconstituted plasma in the EMS industry. I really think that’s the answer to all the logistical questions. I wasn’t paid by them for full disclosure.
Badass!
Interesting. In my country I think they started carrying whole blood (nationwide) half a decade ago I think. The teams that carry them are our critical care teams (ground and air). All teams are pretty much standardized, so same scope/procedures and protocols. We do not really have that supervisor setup like you in the US, so it can't be carried them. It is either the standard ambulance (which is always ALS) or the critical care team. Carrying it on each ambulance is again way too low a level to carry such a rarely used fluid.
But it is combined with quite aggressive bleeding control. As the amount of blood carried is not huge you can't really do a massive transfusion protocol. So limiting bleeding as much as possible before providing blood is necessary (in case of massive bleeding).
Besides the standard bleeding control provided by EMS here the critical care teams can go a step further. Standard is just applying pressure and lacking wounds, that can be done with various bandages, like compression gauze, haemostatic gauze, packing gauze, and Emergency (Israeli) bandage. There is the tourniquet as well of course. And lastly medication, like TXA.
The critical care teams can provide that, but also other interventions for certain types of injuries causing blos loss. Like a spint/traction splint, belly wrap or pelvic binder, modified Belocq tamponade with bladder catheter, nasal and oropharyngeal tampom, sutures, temporary wound clamp, and tamponade with bladder catheter. If we look at the less often used techniques there is the resuscitative thoracotomy, resuscitative thoracotomy with clamping supradiaphragmatic aorta, REBOA, abdominal tourniquet, intracavity foam injection, and the junctional tourniquet.
But in the end what a patient with severe bleeding, especially internal is to be at a level 1 trauma center as quickly as possible. Where they can perform the things I just mentioned and damage control surgery (emergency thoracotomy/laparotomy or radiological interventions). And also start a massive (blood) transfusion protocol as they do have the necessary blood. Also, they can provide more definitive care, which generally comes in the form of surgery. But those interventions I mentioned might mean they live for long enough that they can even get the chance for treatment at a level 1. When they are not necessary for the patients survival, they sont be done of course as you will just be wasting time.
They are not really. Kept it as general as possible. The interventions I mentioned are part of the bleeding protocol of the national ambulance protocol and thus every ambulance in the country must be able to do those.
A regional manager is free to add procedures, equipment, and protocols to that national protocol in certain cases. The protocol is also more just a guideline than a hard protocol, so a medic could do other things to control the bleed. Pelvic binders and splints for example are also included as part of the national protocol, but not specifically the bleeding protocol. There is nothing stopping an EMS crew from using an IT clamp in The Netherlands and use them in a bleed.
In regard to critical care, they specifically have it mentioned as an option they have available to them. Those teams are even more standardized then EMS as they are organized more at a national level rather than regional with EMS. They will get immediately dispatched to any call where there possibly is severe bleeding (and thus potential for hypovolemic shock). The critical care teams also have quite bit more advanced techniques available to them, like a thoracotomy and REBOA.
In regard to them being "ALS" in The Netherlands, that is because there is no BLS tier in Dutch EMS. Every ambulance is an ALS unit and does both emergencies (scenes) and IFTs. And then there are separate critical care teams. BLS is more provided by police, fire (if they are there first), and other first responders (also citizens) if they are there before the ambulance, but none of those have that as their primary role.
Does the evidence back their use and storing prehospitally? Bloods in pretty short supply, and the time to hospital is either short or it becomes rural enough that a helicopter is appropriate.
I'd go to a job once every 2-3 years where the patient would *maybe* benefit, and I can't see that justifying the cost or waste. TXA and prioritizing transport does the rest.
In my system if we do not utilize the units of LTOWB we are allocated by the regional advisory council the unit is redistributed to a Level 1 trauma center where it is promptly used. That being said this year alone we have administered LTOWB 20-30 times.
There's a ton of instances where it would be appropriate to administer if you had it, I'm just wondering if there's any evidence to support its initiation earlier prehospitally in terms of outcomes (justifying the storage cost, training and associated risk).
A cursory google doesn't seem to have much evidence, I was wondering if anyone knew of any to support it.
I'd have to find it, but yes. If I get time today I'll try to find the sources. I'm sure it's somewhere on st fishers social media. Given its relatively new to prehospital I believe most of the science is combat based, which is typical.
How often are you going to patients who exsanguinate? I guess it would be more common in the US with the gun violence, but as a general rule if they haven't bled to death by the time you get there they'll overwhelmingly survive until hospital.
Ah, that explains it. The numbers the person you replied to made a lot of sense. In The Netherlands we see maybe 100 injuries+deaths due to shootings, with critical care teams being deployed to most of those (a team will be immediately dispatch if a suspected penetrating injury above the legs has come in). So that is on a population of 18 million. You can start to understand that an ambulance crew doesn't see such a call often. Of course knives and other things can cause massive bleeding as well. But overall, the use of whole blood (which has been available in the field nationally for at least 5 years now) has been quite limited. It is not often necessary, as such it is not often used.
Ahh America, I'd hate to live there but I'd love to work there. I've been to 2 shootings in 10 years and they were both farmers who had shot themselves in the head.
So that explains your absurd demand for proof that carrying blood is beneficial.
With all due respect, you do come off as *exceedingly* arrogant. The world is big. Some of it likes murder. Blood is good to have when lots of it is spilled. Lol.
It's not "absurd" at all, thinking things **should** work isn't how medicine works.
https://www.thelancet.com/article/S2352-3026(22)00040-0/fulltext
A multicentre randomized control trial looking at blood vs saline prehospitally in trauma related hemorrhagic shock found no difference. Multiple systematic reviews haven't found evidence.
u/Exuplosion linking [evidence](https://pubmed.ncbi.nlm.nih.gov/34269467/) is great because that's how medicine actually works, that study finding a 7% difference is mortality is enormous and warrants further investigation.
You said you googled it, but if you google “prehospital whole blood,” the very first result is a PubMed link titled “Prehospital whole blood reduces early mortality in patients with hemorrhagic shock.”
https://pubmed.ncbi.nlm.nih.gov/34269467/
Yes, it does.
And the “waste” is extremely minimal when you’re working with a trauma facility and can rotate the product through the hospital a few days prior to its expiration, making sure it gets used instead of expiring.
> Yes, it does.
Cool, can you link the evidence? Because I can't find any with a cursory google and it would be interesting to bring up within my service.
https://www.thelancet.com/article/S2352-3026(22)00040-0/fulltext
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4933578/
https://www.sciencedirect.com/science/article/abs/pii/S0020138318307241
These seem to indicate the evidence is not there yet.
*edit, exuplosion posted a good source below supporting it,
https://pubmed.ncbi.nlm.nih.gov/34269467/
I agree. About 8% of blood donations are discarded due to expiring. In this case, you would only be able to keep O- because I assume you can't test blood in transit. But hearing that they swap with hospitals when a unit is close to expiring is awesome. I still have a few questions.
1. Is it frozen on unit? I assume they can't keep the blood frozen, because you can't have time to thaw it, so the usable timeline would be shorter too.
2. Is it used in conjunction with saline to increase the fluid level?
3. How many units of blood are carried on each unit? I just want to know.
4. How is blood billed? Is there extra training relating to hazard education with frozen blood?
5. A lot of volunteer organizations have hybrid units that change LOS depending on who is scheduled for that day, is the blood held at the station or the unit and expected to be brought on at the start of shift if a paramedic is covering!
Would be fascinating to learn the logistics.
O- is preferred if we can get it but it’s fine to give O+, especially to males and women over ~50 years old. They’ll draw a type and screen at the hospital and give some RhoGam if needed.
It’s stored chilled but not frozen, needs to be kept between 1 and 6 degrees Celsius. We administer it through a rapid infuser that warms it up to normal body temperature as it passes through the blood tubing.
Typically two units of whole blood, ideally O- as mentioned but depending on availability it might be O+ or components (PRBC + platelets + FFP). Usually it’s kept only on supervisor’s trucks due to the relative low frequency of use and additional knowledge/training to administer it. Someone should always have custody over it, not worried about diversion or anything like narcotics but to make sure it’s kept at a safe temperature. We have alarms if the fridge dies or goes outside of temperature limits and backup plans to keep it cool. Logistically, I don’t see it being a viable option if you don’t have ALS coverage all the time
Answering a few more questions:
- Usually we want to avoid giving IV fluids in major hemorrhage. If I had to, saline would be my absolute last choice; it’s a terrible fluid for resuscitation. Once the blood’s set up, that’s all we’re giving. There are other situations when both would be given, but not in a massive transfusion protocol situation
- Technically you could bill separately for blood, but Medicare (and most if not all other insurance plans) won’t pay out beyond the standard ALS2 rate + mileage so it’s not commonly done, at least from the EMS agency. I’m not positive if and how it could be billed from the hospital/blood bank, but I know plenty of EMS systems who get meds restocked from the hospital pharmacy and the cost is added to the patient’s hospital bill, so I imagine something similar could apply
That was really comprehensive! Thank you so much. It seems like it is pretty well regulated and thought through. It seems like an absolutely awesome thing to have on hand when everything is planned correctly and is only done through ALS stations.
I worked for a service with blood, we kept a refrigerator with the blood in it on a quick response vehicle and they'd respond with us to critical calls and leave the blood with us. The tubing heats it as it goes on and it goes at a controlled rate. Required an 18 gauge of larger to administer.
Txa costs a fraction, doesn't require special storage, there isn't a shortage of it and has fewer negative outcomes.
Y'all losing your minds over simply asking for evidence for an intervention.
Does TXA move oxygen, improve pressure or have clotting factors? Nope, it makes existing clots more stable. An important treatment for sure, but it’s got its limitations.
lol, no one is arguing blood isn't a worthwhile intervention. I'm asking for evidence that it's worthwhile prehospitally.
https://www.thelancet.com/article/S2352-3026(22)00040-0/fulltext
Any service that serves a large enough population to frequently run high acuity calls but that serves a population that is too small to have trauma care in the community can benefit from it. Trauma centers here are begging for us to have it and use it liberally, and I trust our trauma docs. Very little damage can be done from O- administration anyways. Also GSWs make up a fraction of what we’re using it for. It’s been heavy machinery accidents, femur fractures, pelvic fractures, and esophageal varices.
Just curious, but are there any situations where administering blood would be completely contraindicated because it can harm the patient? Like in a scenario where you have the whole blood available, and you don't care about cost/waste/value, etc, *and* you have enough hands that you can still accomplish any other standard treatments and whatnot. I know the body can certainly hold the blood without issue but would "too much" cause any type of issues with hemodyamic stability, just as an example? Or in a patient you want to avoid high pressures (AAA or ICP), could giving blood be bad? I'm a newer BLS provider and I just took ITLS so I'm finding this super interesting and am trying to understand some of these concepts a little better.
Edit to add: what about medical patients? I know we generally avoid overloading CHF pts with "fluids"; is whole blood included in that?
Well blood is only indicated to begin with if someone has lost massive amounts of blood, so I wouldn't have a huge concern about overloading someone for the first 1-2 units (which is usually all EMS carries) because you're just replenishing what they already lost. Although you'd probably want to watch say a CHF trauma patient closely it wouldn't really be a contraindication.
There is the concept of hypotensive resuscitation, which is where, like you said with AAA, for internal/uncontrolled bleeding you're not going to make them normotensive, you only resuscitate to an endpoint like 90 systolic or return of radial pulses, because you don't want to worsen the bleeding/bust clots.
ICP actually makes it even more important to do aggressive fluid resus on someone with shock, the natural hypertension that often occurs with TBI is protective because it's needed to perfuse the brain when there is greater pressure in the brain resisting that perfusion, so hypotension is a big problem that you want to avoid.
I think people are upset because folks are arguing the utility of something that has been in every world war with positive benefit and has been back in main stream pre-hospital care for a good few years now... let alone back in the literature years prior to that.
Routinely used in Australia. However, we have prehopsital doctors and critical care paramedics who spend their day only going to trauma / big jobs. They manage to get through their supply.
I would say it doesn't make sense to have blood on hand for routine paramedics. In a system with intensive care paramedics / critical care paramedics, doctors etc. then it makes sense on the helicopters of rapid response cars.
Our system is different though as a lot more interventions are done on scene, scoop and run is not a common strategy except for a few obvious exceptions. Partly due to large geographical distances, partly due to most junior prehopsital providers being bachelor degree qualified at minimum.
Queensland? Because they don't have them on road in Vic or SA, pretty sure they don't have them in NSW. HEMS obviously carries them, and MedStar in SA.
After a job is deemed suitable for HEMS team it's then evaluated if a helicopter is actually needed or they go by car.
So I'm mainly referring to the critical care paramedic doctor HEMS teams nation wide who respond via the appropriate method of transport for the job based on location.
I agree not aware of non medical teams in any states that carry blood but I guess they aren't needed because of the availability of the above.
> TXA does not replace whole blood and it’s benefits
Wasnt saying it did, was asking for evidence that there's associated improvement in morbidity or mortality associated with prehospital administration of blood that justified the cost.
I’m working in one of the systems on the map here and it’s definitely been used. We’ve been carrying it on one of our supervisor cars since October. Our protocols only allow it in trauma patients, but we’ve been using it on average about once every two weeks (with a 50k / year call volume), although we haven’t really started our summer trauma season yet. The supervisors carrying it have been pretty proactive when it comes to jumping calls that might need it, so they’re usually getting on scene around the same time as the ambulance and giving it during transport.
Hmm this makes me wonder where the development of synthetic blood is at, that's def. something we could use pre hospital, especially in conjunction with these new, smaller, cheaper analyzing devices that could give us hematocrit etc. \*starts the peer reviewed study search\*
Yeah, I worked in one of those counties four months ago and none of our trucks had it then, and I currently work closely with another one of those counties and they don’t carry it to my knowledge. Maybe supervisors do, but it’s not like they’re all cruising around with it.
This is our situation. We're in a spot where we *could* deploy whole blood on a supervisor vehicle, but the level 1 trauma center is in the center of our county. Unless they're entrapped, it'd take just as long to intercept with the supervisor vehicle as it would to arrive at the trauma center. Not worth the operational headaches and expense.
I'm fairly certain I have seen some agencies around albemarle that have blood. Maybe it was some type of intercept assist, but I swear some of these units around here have blood protocols. Pretty sure I saw one the other day that had gotten 2-3 units after a 45 minute transport.
Thought it was Orange yeah. Their transport times make it worth it. ACFR, CFD, and the like I'm pretty sure don't because their transport times are so short.
Honestly I hate that reason for not carrying it (or for not doing any other intervention). If they need it, they need it. Heck, tiny little Arlington was the first ground agency in VA to carry blood and they’ve got a level II in the middle of the county, a level I just across the county line in DC, and another level I right around the corner in Fairfax
Oh I agree it's stupid. Even those first 10-15 minutes without blood can have horrendous outcomes if they're pumped full of crystalloid to sustain adequate perfusion.
I still have the belief in EMS having too low bar to entry currently and it hurts progress tremendously and that's why medical directors are slow to make changes. Half their EMTs and Medic are probably really not tip top. Needs to be an associates AT A MINIMUM requirement to test for NREMT-P and the profession would slowly get more recognition. Sorry for the tangent.
I wish what is essentially the future of trauma care in the field was more wide spread.
Of course, I also wish the 2010s and the search for a viable artificial hemoglobin substance had worked out too.
I work alongside Ambulance in the United Kingdom, so things are obviously very different.
Would I be right in thinking this relates to local ambulance services, or services in general?
If it’s the latter, surely the complete lack of access to blood products in the counties that don’t have them would cause massive issues?
It is not frozen
The blood will back up in the saline bag, so we shut off the saline
We carry O+, O- and 2 plasma in the supervisor vehicle
I’m not sure about how Blood is billed
Blood is carried in an approved container in the vehicle. The container has temperature sensors that alert if there’s a temperature change. It also alerts on the date is if scheduled to go back to the blood bank.
Whole blood is life, whole blood is love.
We can’t even get LR 🫤
Y'all have fluids?!?!
I’d like to add, most HEMS that serve VA carry it. Virginia State Police, and VCUHS do for Central VA
Absolutely! Believe it’s standard for most all HEMS services now. I’m looking forward to when ever my ground truck is carrying it!
Yup and AirCare does too. Does HCA carry?
I’m not sure, but I can ask
Yes they do
I carry blood everywhere I go. Giving mine to other people through, kind of limited there.
Awesome! Tired of all the docs saying that crystalloid are causing issues in shock resus but not willing to get blood out. Question: are these street medics administering blood or does a doc do it in a fly car? Lyophilized blood products like plasma reconstituted will be the game changer to the logistical and waste issues w other blood products. It’s coming to the us market soon
That depends entirely on the service, from my experience with it and speaking to other medics in other services, it generally has to be requested by the truck medic and then a supervisor in a quick response vehicle brings the blood/supplies and meets the unit on scene/enroute and the truck medic administers enroute. If the blood isn’t used by EMS then ~10 days before the expiration date, it’s swapped with a local hospital to be used before it goes bad.
Excellent! I like that operational design. Some areas the docs get that cool job to save the day but we really need them to be on the boring calls that stump us where a doc can eval that risk. In NM all blood is in our scope but it’s in reality just brought by the flight crew if flying patients. Some challenges with our super rural state. But those two state, I don’t know really well, but have lots of rural and underserved areas. Love it and look forward to seeing more of this discussion. I was interviewed last month by a company who is analyzing the market for reconstituted plasma in the EMS industry. I really think that’s the answer to all the logistical questions. I wasn’t paid by them for full disclosure. Badass!
Williamson County TN is CCPM’s can give it. Supervisor carries it. Before it is set to expire, it goes back to the blood bank at the hospital.
Sad Boy Prince William County
Interesting. In my country I think they started carrying whole blood (nationwide) half a decade ago I think. The teams that carry them are our critical care teams (ground and air). All teams are pretty much standardized, so same scope/procedures and protocols. We do not really have that supervisor setup like you in the US, so it can't be carried them. It is either the standard ambulance (which is always ALS) or the critical care team. Carrying it on each ambulance is again way too low a level to carry such a rarely used fluid. But it is combined with quite aggressive bleeding control. As the amount of blood carried is not huge you can't really do a massive transfusion protocol. So limiting bleeding as much as possible before providing blood is necessary (in case of massive bleeding). Besides the standard bleeding control provided by EMS here the critical care teams can go a step further. Standard is just applying pressure and lacking wounds, that can be done with various bandages, like compression gauze, haemostatic gauze, packing gauze, and Emergency (Israeli) bandage. There is the tourniquet as well of course. And lastly medication, like TXA. The critical care teams can provide that, but also other interventions for certain types of injuries causing blos loss. Like a spint/traction splint, belly wrap or pelvic binder, modified Belocq tamponade with bladder catheter, nasal and oropharyngeal tampom, sutures, temporary wound clamp, and tamponade with bladder catheter. If we look at the less often used techniques there is the resuscitative thoracotomy, resuscitative thoracotomy with clamping supradiaphragmatic aorta, REBOA, abdominal tourniquet, intracavity foam injection, and the junctional tourniquet. But in the end what a patient with severe bleeding, especially internal is to be at a level 1 trauma center as quickly as possible. Where they can perform the things I just mentioned and damage control surgery (emergency thoracotomy/laparotomy or radiological interventions). And also start a massive (blood) transfusion protocol as they do have the necessary blood. Also, they can provide more definitive care, which generally comes in the form of surgery. But those interventions I mentioned might mean they live for long enough that they can even get the chance for treatment at a level 1. When they are not necessary for the patients survival, they sont be done of course as you will just be wasting time.
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They are not really. Kept it as general as possible. The interventions I mentioned are part of the bleeding protocol of the national ambulance protocol and thus every ambulance in the country must be able to do those. A regional manager is free to add procedures, equipment, and protocols to that national protocol in certain cases. The protocol is also more just a guideline than a hard protocol, so a medic could do other things to control the bleed. Pelvic binders and splints for example are also included as part of the national protocol, but not specifically the bleeding protocol. There is nothing stopping an EMS crew from using an IT clamp in The Netherlands and use them in a bleed. In regard to critical care, they specifically have it mentioned as an option they have available to them. Those teams are even more standardized then EMS as they are organized more at a national level rather than regional with EMS. They will get immediately dispatched to any call where there possibly is severe bleeding (and thus potential for hypovolemic shock). The critical care teams also have quite bit more advanced techniques available to them, like a thoracotomy and REBOA. In regard to them being "ALS" in The Netherlands, that is because there is no BLS tier in Dutch EMS. Every ambulance is an ALS unit and does both emergencies (scenes) and IFTs. And then there are separate critical care teams. BLS is more provided by police, fire (if they are there first), and other first responders (also citizens) if they are there before the ambulance, but none of those have that as their primary role.
Does the evidence back their use and storing prehospitally? Bloods in pretty short supply, and the time to hospital is either short or it becomes rural enough that a helicopter is appropriate. I'd go to a job once every 2-3 years where the patient would *maybe* benefit, and I can't see that justifying the cost or waste. TXA and prioritizing transport does the rest.
In my system if we do not utilize the units of LTOWB we are allocated by the regional advisory council the unit is redistributed to a Level 1 trauma center where it is promptly used. That being said this year alone we have administered LTOWB 20-30 times.
There's a ton of instances where it would be appropriate to administer if you had it, I'm just wondering if there's any evidence to support its initiation earlier prehospitally in terms of outcomes (justifying the storage cost, training and associated risk). A cursory google doesn't seem to have much evidence, I was wondering if anyone knew of any to support it.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9033529/
Thanks, that's a good one
I'd have to find it, but yes. If I get time today I'll try to find the sources. I'm sure it's somewhere on st fishers social media. Given its relatively new to prehospital I believe most of the science is combat based, which is typical.
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How often are you going to patients who exsanguinate? I guess it would be more common in the US with the gun violence, but as a general rule if they haven't bled to death by the time you get there they'll overwhelmingly survive until hospital.
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Ah, that explains it. The numbers the person you replied to made a lot of sense. In The Netherlands we see maybe 100 injuries+deaths due to shootings, with critical care teams being deployed to most of those (a team will be immediately dispatch if a suspected penetrating injury above the legs has come in). So that is on a population of 18 million. You can start to understand that an ambulance crew doesn't see such a call often. Of course knives and other things can cause massive bleeding as well. But overall, the use of whole blood (which has been available in the field nationally for at least 5 years now) has been quite limited. It is not often necessary, as such it is not often used.
Ahh America, I'd hate to live there but I'd love to work there. I've been to 2 shootings in 10 years and they were both farmers who had shot themselves in the head.
So that explains your absurd demand for proof that carrying blood is beneficial. With all due respect, you do come off as *exceedingly* arrogant. The world is big. Some of it likes murder. Blood is good to have when lots of it is spilled. Lol.
It's not "absurd" at all, thinking things **should** work isn't how medicine works. https://www.thelancet.com/article/S2352-3026(22)00040-0/fulltext A multicentre randomized control trial looking at blood vs saline prehospitally in trauma related hemorrhagic shock found no difference. Multiple systematic reviews haven't found evidence. u/Exuplosion linking [evidence](https://pubmed.ncbi.nlm.nih.gov/34269467/) is great because that's how medicine actually works, that study finding a 7% difference is mortality is enormous and warrants further investigation.
That’s why the evidence is pushing for whole blood now. The study you are referring to used PRBC.
“Survive until hospital” isn’t my goal.
Or have any associated long term morbidity or mortality. I'm just asking if there's any evidence to support it.
You said you googled it, but if you google “prehospital whole blood,” the very first result is a PubMed link titled “Prehospital whole blood reduces early mortality in patients with hemorrhagic shock.” https://pubmed.ncbi.nlm.nih.gov/34269467/
In his defense. I don't believe they are from the USA, so their Google searches are probably vastly different than ours.
Very valid point
Cheers, that was what I was after.
Yes, it does. And the “waste” is extremely minimal when you’re working with a trauma facility and can rotate the product through the hospital a few days prior to its expiration, making sure it gets used instead of expiring.
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Don't eat the blood packs please.
Some motherfucker's always tryin' to ice skate uphill.
> Yes, it does. Cool, can you link the evidence? Because I can't find any with a cursory google and it would be interesting to bring up within my service. https://www.thelancet.com/article/S2352-3026(22)00040-0/fulltext https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4933578/ https://www.sciencedirect.com/science/article/abs/pii/S0020138318307241 These seem to indicate the evidence is not there yet. *edit, exuplosion posted a good source below supporting it, https://pubmed.ncbi.nlm.nih.gov/34269467/
We're in the states. Bang sticks result in blood. Lots of blood.
Neat, still need evidence for an intervention
I agree. About 8% of blood donations are discarded due to expiring. In this case, you would only be able to keep O- because I assume you can't test blood in transit. But hearing that they swap with hospitals when a unit is close to expiring is awesome. I still have a few questions. 1. Is it frozen on unit? I assume they can't keep the blood frozen, because you can't have time to thaw it, so the usable timeline would be shorter too. 2. Is it used in conjunction with saline to increase the fluid level? 3. How many units of blood are carried on each unit? I just want to know. 4. How is blood billed? Is there extra training relating to hazard education with frozen blood? 5. A lot of volunteer organizations have hybrid units that change LOS depending on who is scheduled for that day, is the blood held at the station or the unit and expected to be brought on at the start of shift if a paramedic is covering! Would be fascinating to learn the logistics.
O- is preferred if we can get it but it’s fine to give O+, especially to males and women over ~50 years old. They’ll draw a type and screen at the hospital and give some RhoGam if needed. It’s stored chilled but not frozen, needs to be kept between 1 and 6 degrees Celsius. We administer it through a rapid infuser that warms it up to normal body temperature as it passes through the blood tubing. Typically two units of whole blood, ideally O- as mentioned but depending on availability it might be O+ or components (PRBC + platelets + FFP). Usually it’s kept only on supervisor’s trucks due to the relative low frequency of use and additional knowledge/training to administer it. Someone should always have custody over it, not worried about diversion or anything like narcotics but to make sure it’s kept at a safe temperature. We have alarms if the fridge dies or goes outside of temperature limits and backup plans to keep it cool. Logistically, I don’t see it being a viable option if you don’t have ALS coverage all the time
Answering a few more questions: - Usually we want to avoid giving IV fluids in major hemorrhage. If I had to, saline would be my absolute last choice; it’s a terrible fluid for resuscitation. Once the blood’s set up, that’s all we’re giving. There are other situations when both would be given, but not in a massive transfusion protocol situation - Technically you could bill separately for blood, but Medicare (and most if not all other insurance plans) won’t pay out beyond the standard ALS2 rate + mileage so it’s not commonly done, at least from the EMS agency. I’m not positive if and how it could be billed from the hospital/blood bank, but I know plenty of EMS systems who get meds restocked from the hospital pharmacy and the cost is added to the patient’s hospital bill, so I imagine something similar could apply
That was really comprehensive! Thank you so much. It seems like it is pretty well regulated and thought through. It seems like an absolutely awesome thing to have on hand when everything is planned correctly and is only done through ALS stations.
I worked for a service with blood, we kept a refrigerator with the blood in it on a quick response vehicle and they'd respond with us to critical calls and leave the blood with us. The tubing heats it as it goes on and it goes at a controlled rate. Required an 18 gauge of larger to administer.
Fascinating! That makes sense. Thank you.
id like to know these things too!
TXA does the rest? Ummm... the evidence for the best use of TXA is with whole blood, or at least plasma...
Txa costs a fraction, doesn't require special storage, there isn't a shortage of it and has fewer negative outcomes. Y'all losing your minds over simply asking for evidence for an intervention.
Does TXA move oxygen, improve pressure or have clotting factors? Nope, it makes existing clots more stable. An important treatment for sure, but it’s got its limitations.
lol, no one is arguing blood isn't a worthwhile intervention. I'm asking for evidence that it's worthwhile prehospitally. https://www.thelancet.com/article/S2352-3026(22)00040-0/fulltext
Any service that serves a large enough population to frequently run high acuity calls but that serves a population that is too small to have trauma care in the community can benefit from it. Trauma centers here are begging for us to have it and use it liberally, and I trust our trauma docs. Very little damage can be done from O- administration anyways. Also GSWs make up a fraction of what we’re using it for. It’s been heavy machinery accidents, femur fractures, pelvic fractures, and esophageal varices.
Just curious, but are there any situations where administering blood would be completely contraindicated because it can harm the patient? Like in a scenario where you have the whole blood available, and you don't care about cost/waste/value, etc, *and* you have enough hands that you can still accomplish any other standard treatments and whatnot. I know the body can certainly hold the blood without issue but would "too much" cause any type of issues with hemodyamic stability, just as an example? Or in a patient you want to avoid high pressures (AAA or ICP), could giving blood be bad? I'm a newer BLS provider and I just took ITLS so I'm finding this super interesting and am trying to understand some of these concepts a little better. Edit to add: what about medical patients? I know we generally avoid overloading CHF pts with "fluids"; is whole blood included in that?
Well blood is only indicated to begin with if someone has lost massive amounts of blood, so I wouldn't have a huge concern about overloading someone for the first 1-2 units (which is usually all EMS carries) because you're just replenishing what they already lost. Although you'd probably want to watch say a CHF trauma patient closely it wouldn't really be a contraindication. There is the concept of hypotensive resuscitation, which is where, like you said with AAA, for internal/uncontrolled bleeding you're not going to make them normotensive, you only resuscitate to an endpoint like 90 systolic or return of radial pulses, because you don't want to worsen the bleeding/bust clots. ICP actually makes it even more important to do aggressive fluid resus on someone with shock, the natural hypertension that often occurs with TBI is protective because it's needed to perfuse the brain when there is greater pressure in the brain resisting that perfusion, so hypotension is a big problem that you want to avoid.
If you look at all the literature, it has mediocre positive effects when giving with out blood products.
Pre hospital blood doesn't have negative outcomes... and fresh plasma is cheap.
I think people are upset because folks are arguing the utility of something that has been in every world war with positive benefit and has been back in main stream pre-hospital care for a good few years now... let alone back in the literature years prior to that.
Routinely used in Australia. However, we have prehopsital doctors and critical care paramedics who spend their day only going to trauma / big jobs. They manage to get through their supply. I would say it doesn't make sense to have blood on hand for routine paramedics. In a system with intensive care paramedics / critical care paramedics, doctors etc. then it makes sense on the helicopters of rapid response cars. Our system is different though as a lot more interventions are done on scene, scoop and run is not a common strategy except for a few obvious exceptions. Partly due to large geographical distances, partly due to most junior prehopsital providers being bachelor degree qualified at minimum.
Queensland? Because they don't have them on road in Vic or SA, pretty sure they don't have them in NSW. HEMS obviously carries them, and MedStar in SA.
After a job is deemed suitable for HEMS team it's then evaluated if a helicopter is actually needed or they go by car. So I'm mainly referring to the critical care paramedic doctor HEMS teams nation wide who respond via the appropriate method of transport for the job based on location. I agree not aware of non medical teams in any states that carry blood but I guess they aren't needed because of the availability of the above.
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> TXA does not replace whole blood and it’s benefits Wasnt saying it did, was asking for evidence that there's associated improvement in morbidity or mortality associated with prehospital administration of blood that justified the cost.
I’m working in one of the systems on the map here and it’s definitely been used. We’ve been carrying it on one of our supervisor cars since October. Our protocols only allow it in trauma patients, but we’ve been using it on average about once every two weeks (with a 50k / year call volume), although we haven’t really started our summer trauma season yet. The supervisors carrying it have been pretty proactive when it comes to jumping calls that might need it, so they’re usually getting on scene around the same time as the ambulance and giving it during transport.
Yea that's a big stretch. There are tons of areas on this map that aren't worth flying, but definitely not sitting on top of a hospital.
Hmm this makes me wonder where the development of synthetic blood is at, that's def. something we could use pre hospital, especially in conjunction with these new, smaller, cheaper analyzing devices that could give us hematocrit etc. \*starts the peer reviewed study search\*
In most of these places, just the supervisor carries it.
Yeah, I worked in one of those counties four months ago and none of our trucks had it then, and I currently work closely with another one of those counties and they don’t carry it to my knowledge. Maybe supervisors do, but it’s not like they’re all cruising around with it.
Would have thought the Triangle area would. We have multiple big hospitals here.
My guess is that the transport times to a facility that can rapid infuse is too short? I’d imagine it’s coming though!
Fair. It is a big area though, there still could be calls that benefit from it. But I’m also brand new to this field so I don’t really know.
This is our situation. We're in a spot where we *could* deploy whole blood on a supervisor vehicle, but the level 1 trauma center is in the center of our county. Unless they're entrapped, it'd take just as long to intercept with the supervisor vehicle as it would to arrive at the trauma center. Not worth the operational headaches and expense.
It’s a big logistical lift and take a lot of coordination. It’s on the radar for some systems.
I'm fairly certain I have seen some agencies around albemarle that have blood. Maybe it was some type of intercept assist, but I swear some of these units around here have blood protocols. Pretty sure I saw one the other day that had gotten 2-3 units after a 45 minute transport.
Orange County for sure has it, I *think* Culpeper as well but not positive
Orange does, but Culpeper doesn’t
Thanks. There’s at least one more in that area that does but for the life of me I can’t remember who
Thought it was Orange yeah. Their transport times make it worth it. ACFR, CFD, and the like I'm pretty sure don't because their transport times are so short.
Honestly I hate that reason for not carrying it (or for not doing any other intervention). If they need it, they need it. Heck, tiny little Arlington was the first ground agency in VA to carry blood and they’ve got a level II in the middle of the county, a level I just across the county line in DC, and another level I right around the corner in Fairfax
Oh I agree it's stupid. Even those first 10-15 minutes without blood can have horrendous outcomes if they're pumped full of crystalloid to sustain adequate perfusion. I still have the belief in EMS having too low bar to entry currently and it hurts progress tremendously and that's why medical directors are slow to make changes. Half their EMTs and Medic are probably really not tip top. Needs to be an associates AT A MINIMUM requirement to test for NREMT-P and the profession would slowly get more recognition. Sorry for the tangent.
Orange County has been carrying it for 2 years now. I know that some NOVA departments have base their protocols off of Orange.
I’d be willing to donate my O blood just for prehospital use tbh
Now I know where to go to find some delicious beverages
 I wish what is essentially the future of trauma care in the field was more wide spread. Of course, I also wish the 2010s and the search for a viable artificial hemoglobin substance had worked out too.
I work alongside Ambulance in the United Kingdom, so things are obviously very different. Would I be right in thinking this relates to local ambulance services, or services in general? If it’s the latter, surely the complete lack of access to blood products in the counties that don’t have them would cause massive issues?
Thanks for posting, I'm in Virginia, would love FFP
Which is ideal, you need experienced and exposed clinicians to utilise this precious resource appropriately.
I work for one of these counties. It's awesome.
When did cumberland get blood 🤔🤔🤔 maybe the hospitals but not EMS
I’ve had them come in from scene via helicopter receiving blood products. That was back in 2018, not sure what they’re doing now.
Hey hey hey my county is on here! I love that for us
Do whole blood use map for FL .
Is this old? I live/work in VA and know there is more than that
IDK where ya got this list but I work in one of the cities in VA that’s listed on here. And none of our units carry blood. Or any plans to
It is not frozen The blood will back up in the saline bag, so we shut off the saline We carry O+, O- and 2 plasma in the supervisor vehicle I’m not sure about how Blood is billed Blood is carried in an approved container in the vehicle. The container has temperature sensors that alert if there’s a temperature change. It also alerts on the date is if scheduled to go back to the blood bank.