Two important studies (COMBAT and PAMPer) were just published that looked at plasma vs. normal saline for resucitation in hemorrhagic shock patients. Although the studies came to different conclusions (reflecting different trauma system environments)1, plasma does seem to confer more benefits when significant fluid resuscitation is required. TCCC guidelines have emphasized this for years, and point to whole blood as being the best choice, followed by platelets/plasma/packed red blood cells.
A growing number of EMS systems have begun looking at carrying blood products such as plasma for use in critical hemorrhagic shock patients. My agency has been at the forefront of this in the United States and is approaching two years now with blood products deployed for our ground 911 system. We’ve even got a pretty good article on it in EMS World magazine.
The clinical case for using plasma, blood products (such as packed red blood cells), or whole blood has been made and additional research keeps coming out validating its safety and efficacy in the prehospital environment. The key challenge for most agencies is the logistics.
Logistics Hurdle #1: Developing a Protocol
Our agency is fortunate to have a close working relationship with military and trauma physicians such as Dr. Holcombe and Dr. Love, who have extensive experience in deploying blood products outside of the hospital. Our medical director and senior leadership collaborated with these docs to take existing, validated guidelines and apply them to our system. The protocols are actually quite simple, and focus primarily on answering three questions:
- Who should get blood products? (Indications)
- How should it be given? (Procedure)
- Recognizing and handling transfusion reactions
The indications focus on signs and symptoms of hemorrhagic shock, and apply to trauma or medical patients. For medical patients, the inclusion of hemoglobin using a point-of-care hemoglobin testing device was an important step.
The procedural steps are very straightforward. We tag our blood using a standard “triage tag” which provides a wristband that can be attached to patient and tear-off barcodes that can be used to document which blood unit was provided. The blood type, tag, and expiration date are verified by two medics, then the blood is hung using a Blood-Y and a fluid warmer. Initially, we used the Belmont BuddyLite warmer but we are now using the QinFlow warmer, which has a number of advantages. That’s really it—as a procedure, transfusing blood is very simple.
Logistics Hurdle #2: Developing Processes for Handling Blood
Overall, the most important logistic step in our blood program was securing a positive relationship with our local blood bank. This has involved countless meetings between our senior leadership and blood bank leadership to ensure we meet their standards for storing and handling blood.
Our blood program workflow begins with receiving the blood. We store it in a central location in a lab-grade blood fridge and our Logistics Manager tags it with a triage tag, packages it in a plastic container with a “Blood Kit” number, and then takes a photo of the blood label which goes into a central shared folder.
We deploy with two field supervisors who respond to critical calls in Ford Explorers and are equipped with a range of extra treatment options (such as ventilators). Each supervisor carries a blood cooler which is stocked with two blood kits, one O-negative and one O-positive. The supervisors also carry the fluid warmer, hemoglobin meters, and additional supplies for administration.
The supervisors are dispatched to calls that might need blood products (shootings, stabbings, etc) and may also be requested to scene by crews. If blood is needed, the supervisor starts the blood and rides into the hospital with the patient and crew. After handing over patient care, the supervisor sends a very brief email indicating what run number, blood kit, and blood tag number was used, and then swaps out the now-empty blood kit with a full one from the central blood fridge.
We can then immediately order replacement blood (which quite often is delivered within a few hours). We also take the photo of the blood label (from the shared folder) and add it to the patient chart, so all of the codes, barcodes, and other information is now part of the patient’s permanent record.
Logistics Hurdle #3: CQI for Blood Products Program
Any high-acuity intervention needs to be carefully monitored in an EMS system. We have to review STEMIs, strokes, RSIs, cardiac arrests, and major trauma calls to ensure we are delivering high-quality, consistent service to our patients and community. Using blood products is no exception.
We monitor our blood program specifically looking for the following:
- Proper Usage: Did the patient meet the administration criteria? Was blood products indicated and appropriate? We’ve had very few issues with this—our supervisors are clinically saavy and appropriately cautious.
- Missed Opportunities: With an abundance of caution comes some risks. We’ve carefully monitored for calls that might have been benefited from receiving blood products and then looked to understand why they didn’t. In some cases, it has been a system issue, in others, it was an education issue and the crews who tended to the patient needed some additional clarification. This is monitored using an automated weekly report that looks at patients with abnormal vital signs who meet administration criteria and provides a list of charts to review.
- Unexpected Problems or Complications: Each blood administration call is reviewed individually to look for problems. As complications are encountered, leadership looks to identify the root causes of these, which in some cases has required tweaking processes or providing more education. Probably the most significant issue we’ve encountered was slow flow rates due to product separation. Working with the blood bank and fluid warmer manufacturer, we determined that gentle “mixing” of the cold blood was necessary prior to hooking it up to the blood-Y. We have not encountered any patient complications or reactions, although we do have procedures in place for this.
Other Important Considerations
- Education is key for implementing novel treatments or protocols in EMS. We conducted numerous in-person training sessions for our staff followed by frequent continuing education.
- Many people were concerned that receiving hospitals would react poorly to EMS bringing in patients with blood going. While we’ve had a few isolated complaints from ER nurses, our trauma surgeons, ER physicians, and hospital leadership have all been excited and supportive. To encourage this kind of support, we’ve made a point of reaching out to stakeholders at our hospitals to communicate about our blood program, provide updates, and share our protocols and logistics procedures.
- Many programs like this still focus exclusively on trauma patients. This is, in my opinion, a mistake. As our medical director put it—hemorrhagic shock is hemorrhagic shock, regardless of what caused the bleeding. And medical patients in serious hemorrhagic shock are a lot less likely to get mass transfusion at the hospital than trauma patients, so our ability to get them blood quickly does make a significant difference.
- Last: Blood products in EMS is one of those treatments that really seems like science fiction to me. Based on my experience, I kind of have a sense of how seriously injured trauma patients are going to deterioate during my transport to hospital. Blood changes that—these patients pink up, wake up, and mental status improves. Ultimately, blood doesn’t eliminate the need for definitive bleeding control (usually surgical) but it does buy time for the surgeon and reduce the complications usually seen in the Trauma Triad of Death.
If you’re EMS agency is interested in deploying blood products in the field, folks at my agency would be happy to help. Contact me and I’ll get you in touch with the right people.