Prehospital Blood Transfusion Saves Lives in Florida
The Sarasota County Fire Department (SCFD) in Florida recently became the latest agency to implement a prehospital whole blood transfusion (PHWBT) program.
Currently, only 2% to 3% of all U.S. EMS agencies have a prehospital blood program in place, although there is an uptick on those numbers, said John Holcomb, M.D., FACS, a retired U.S. Army colonel, professor of surgery at the University of Alabama at Birmingham and the Uniformed Services University in Bethesda, Maryland, and a leading researcher in prehospital blood and military trauma systems.
Traditionally, normal saline has been used as a replacement fluid for patients experiencing significant blood loss. Whole blood has all blood components, such as plasma, intact, making it highly effective for treating patients with major blood loss and improving patient survival rates.
The National Highway Transportation Safety Administration (NHTSA) Office of EMS, noted numerous studies support the idea that prehospital blood transfusions with low-titer O+ whole blood can save the lives of those who would otherwise die.1
Exsanguination remains the leading cause of preventable death among trauma victims, with nearly half dying before they reach the hospital, the agency noted, adding 42% of those in a crash who later died were still alive when first responders arrived.1
Studies on mortality rates resulting from delays in patients getting needed blood transfusions range from 2% to 5%. A 2023 study published in the Journal of Trauma and Acute Care Surgery found a 2% increase in the odds of 30-day mortality for every minute of delay in prehospital resuscitation.2
SCFD Medical Director Marshall Frank, DO, MPH, FACEP, noted one research paper from 2017 indicated that for every minute delay of getting blood, there's a 5% increase in mortality.3
A 2024 paper noted that barriers to PHWBT program adoption include EMS clinicians' scope of practice limitations, program costs and reimbursement of blood products, no centralized data collection process for prehospital hemorrhagic shock and patient outcomes, and lack of collaboration between prehospital agencies, blood suppliers, and hospital clinicians and transfusion service activities.4
Inspiration and Implementation
Nadler said the idea to integrate a PHWBT program into the SCFD operations started after Fire Chief David Rathbun learned about the data at a Metropolitan Fire Chiefs Association conference in 2023 and asked the EMS division to research it. A driving factor for SCFD Assistant Chief of EMS Brian Nadler doing so was the 2005 death of his sister-in-law, Kerri Baker, after a horse-riding accident.
“If they had whole blood, she would be alive,” he said.
His wife and Baker’s sister, Kourtni Nadler—who is O positive—was one of the first donors for SCFD’s new program.
The capital for the program’s equipment came from a $119,000 state-funded EMS grant. Grants given to the department each year must be utilized for a new program and not used to sustain an existing program.
SCFD has partnered with SunCoast Blood Centers to implement its whole blood transfusion program. The agency has trained staff and installed the necessary equipment allowing SCFD EMS captains to administer whole blood transfusions to patients suffering from severe bleeding or traumatic injuries at an emergency scene or during transport before they arrive at the hospital. SCFD transports more than 100 patients a day to local hospitals.
Emily Myers, BSN, RN, CEN, EMS quality/clinical coordinator for emergency services, said, “A lot of people hear about the golden hour in trauma, and we're able to close the gap on that for patients experiencing hemorrhagic shock and bring the blood to them sooner, so we're giving them the best chance that they have to survive their injury.”
Nadler said past Sarasota County data shows that four to six patients a month would have met the criteria for its blood program, a number he calls “extremely conservative.”
“Our goal is to get off the scene of a trauma in 10 minutes,” said Frank, adding SCFD can respond in four minutes. “We have great scene times. We have no control over our transport time. Let’s just say it’s 15 minutes. For every minute that patient doesn't get the blood they need, that’s a 5% increase of mortality—that’s how the patient increases survival—by getting the blood sooner.”3
Blood Donation and Distribution
SunCoast Blood Bank has encouraged the local community to donate whole blood, which takes about 15 minutes and can be done every 56 days. SCFD stations host community open houses, which double as blood drives.
Scott Bush, CEO of SunCoast Blood Bank, said, “These transfusions have been instrumental in cardiac patients making full recoveries and kept hemorrhaging patients from bleeding out. However, supplies are limited, so we must reserve this procedure for the most critical of patients."
Nadler said if someone is O+, low titer, and they’re on the SunCoast Blood Centers’ watch list, a concierge service will send a vehicle to that person’s house to draw the blood. SCFD also has an internal donation system.
“As we donate blood, we say the blood is to be earmarked for the Sarasota County Fire Department,” said Frank, adding SCFD gets a credit for it. Nadler said the contract between SCFD and SunCoast Blood Centers stipulates the actual cost of the unit and what credit the blood center gives back.
SCFD’s contract with SunCoast Blood Centers stipulates the organization will give it blood at a specific cost per unit if it is used. If used, the patient is billed. As of Jan. 1, the Centers for Medicare & Medicaid Services will reimburse prehospital blood transfusions as Advanced Life Support Level 2 procedures.
SCFD orders the blood via a website and the SunCoast Blood Bank informs the agency when it is ready to pick up.
“As far as how long I can hold it, it basically leaves it up to our partnership to make that decision. They want it back within 14 days so they can do a turnaround,” Nadler said. “But if they don't have a unit to give me, then we just make a phone call, and they say keep it.”
Frank said that while SCFD sends the blood back 14 days before it expires “You have 37 days to give it once it's drawn. It depends on how fast they give it to us. If the patient's drawn on Friday, we might not get it until Tuesday. … It could be we have it for 20 days, we could have it for 14 days, we could have it for 9 days. It all depends on where we're at in that lifespan.”
In balancing between not having enough and having too much, Frank pointed out while SCFD carries two units per EMS captain for a total of six units, they're also alternating so not all units expire at the same time, and to know that when a unit is used, it will be replaced.
Dispatchers at Work
Dispatchers play a key role in the program’s success. Frank said that in stroke calls, “dispatchers can identify stroke almost 80% of the time. We need to push to train the dispatchers or have a system where the dispatchers can identify somebody who's going to need the blood, because like Chief Nadler said, that's a delay in time for the paramedics to get on the scene, identify the need, and have the captain dispatched. If the dispatchers can identify that early, then they can dispatch them sooner. Our dispatch protocols are very broad in terms of what the captains get dispatched to, but the earlier they get there, the better.”
Frank said SCFD uses ProQA software, which provides an intuitive, adaptive panel interface offering emergency dispatchers specific, scripted caller interrogations to quickly identify the chief complaint and dispatch a response, often in less than a minute.
“The questions they ask is, ‘Do you see active external hemorrhage? What does the skin look like? Is the skin pale, sweaty? Is the mental status abnormal?’ Those can be triggers that somebody fell and their skin’s pale,” he said. “That gets an automatic dispatch.”
Captains are dispatched with blood units depending on the determinants or if they're requested based on the update by the paramedic and then they will rendezvous, Nadler said.
“The captain stays with them the entire time. They are the only ones able to transfuse the blood,” he added. “They can do it without calling the doc for orders if it’s a medical hemorrhagic shock. For now, they're going to call and consult with medical direction. If you have a patient that's esophageal varices, we can give it. If you have a patient that's got a massive GI bleed that's a medical related or post hemorrhage from postpartum hemorrhage—whatever it is that causes hemorrhagic shock—they’ll be able to give [the blood].”
The blood can be transfused in two minutes using LifeFlow infusers, Nadler said.
Transfusion Tool Kit
The blood collected and supplied by the SunCoast Blood Centers is stored in temperature-controlled, monitored medical storage devices made available to SCFD EMS captains. Nadler noted each military-grade cooler has a 72-hour backup battery and can stay cold for up to 96 hours. The coolers are equipped with Wi-Fi, offering the ability for captains to receive alerts on their phones regarding temperature variations, for example. SCFD has four coolers—one for each EMS captain’s vehicle and a spare cooler.
Also in the tool kit are LifeFlow Plus Blood and Fluid Infusers enabling the rapid delivery of blood to patients needing it as well as warming equipment.
Updated Response Plan
SCFD changed its response plan and the determinants for its EMS captains located throughout the north, central, and south part of the county where the whole blood is carried.
“We have a very unique medical direction here,” Nadler said. “We have advanced practitioners, who act as medical control between the paramedic and the medical director. Our medics don’t call the medical director first. They call our captains first, and they have advanced protocols. Currently, their advanced protocols is blood, but one we're getting ready to roll out in the next six months is ultrasounds on the captains’ vehicles so we’ll add a fast exam to their inclusion protocol for the blood program.”
Partnerships Matter
It’s important to establish a partnership with a blood bank, Nadler advised other EMS agencies in looking to start a PHWBT program.
“You have to have the same mission,” he said. “They can't be on their mission to make money, and we can't be on our mission to save money. The mission has to be who the end user is going to be.”
Frank said a PHWBT program’s success is “wholly dependent on the crews responding to the call calling for the blood early, instead of worrying about if it's protocol. You would think their captains are dispatched to these certain type of calls. It might come in as a fall, but the patient is severely bleeding from esophageal varices on the update. It’s up to the paramedics, lieutenants, and firefighters responding to the call to look at the update from dispatch and say, ‘We might need the blood. Let's go ahead and call for it now.’ They're finding that's making the biggest difference.”
As the program evolves, SCFD will continue to analyze the data and make adjustments accordingly, said Frank.
References
1. National Highway Traffic Safety Administration. The untapped lifesaving potential of prehospital blood transfusion. EMS Update Newsletter. December 2024. Accessed February 19, 2025. https://www.ems.gov/resources/newsletters/december-2024/prehospital-blood-transfusion-101/
2. Deeb A-P, Guyette FX, Daley BJ, et al. Time to early resuscitative intervention association with mortality in trauma patients at risk for hemorrhage. J Trauma Acute Care Surg. 2023;94(4):504-512. doi:10.1097/TA.0000000000003820.
3. Meyer DE, Vincent LE, Fox EE, O'Keeffe T, Inaba K, Bulger E, Holcomb JB, Cotton BA. Every minute counts: Time to delivery of initial massive transfusion cooler and its impact on mortality. J Trauma Acute Care Surg. 2017;83(1):19-24. doi:10.1097/TA.00000000000015.
4. Schaefer RM, Bank EA, Krohmer JR, et al. Removing the barriers to prehospital blood: A roadmap to success. J Trauma Acute Care Surg. 2024;97(2S Suppl 1):S138-S144. doi:10.1097/TA.0000000000004378
