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Medicine has improved a lot, especially pre-hospital. However, hemorrhagic shock still accounts for about 40% of preventable deaths due to trauma each year [1]. Much of our current knowledge of how to treat hemorrhagic shock was gained during the past 20 years of the War on Terror. We have learned that addressing massive hemorrhage takes precedence over airway as evident by MARCH and HABC treatment algorithms. So apart from stopping the bleed, we need to replace what was lost. By now we should all know that crystalloids and colloids aren’t going to cut it. If blood is what is coming out, blood is what needs to go back in. It’s that simple.
As with all new protocols there are people in opposition. Whole Blood is either fresh (from a walking blood bank) or stored by refrigeration. Since it’s impossible to say for certain a patient’s blood type in the field, whole blood is Type O positive for emergency use. Opponents of whole blood treatments in the field say it’s too risky to give to patients when you don’t know their blood type and that there are too many logistics issues. Well, I’m here to tell you today that putting whole blood out in the field is possible and is in our patients’ best interest.
Here are my top 10 reasons why you should start a whole blood program.
1. Research supports whole blood treatment for hemorrhagic shock
Both military and civilian entities have proven that whole blood works. They didn’t always know this though and this lack of knowledge had devastating consequences, especially on the battlefield. The Army Rangers ran into this problem when they tried to perform fluid resuscitation for hemorrhagic shock using only crystalloids. The results turned what little blood soldiers had left into diluted Kool-Aid. Civilian trauma centers also saw this in the 1980s-90s when drug related violence caused large numbers of gunshot wounds. Volume resuscitation using crystalloids led to worse patient outcomes.
In the early 90s, military trauma surgeons started using fresh whole blood as a result of shortages of stored components. Using whole blood showed great improvement in patient outcomes. Since then, there have been several case studies and retrospective studies showing that whole blood works for patients with severe hemorrhage.
2. A whole blood program is better than components
Whole blood contains much more than what components do. Whole blood contains all the necessary clotting factors and plasma ratio that components lack. Components are usually given in a 1:1:1 ratio of red blood cells, plasma and platelets. This all sounds good in theory but actually delivers less than whole blood. Components deliver a hematocrit of only 29% as compared to 38% with whole blood [2]. There is also a lower platelet concentration in components compared to whole blood as well as clotting factors. And if there’s one thing that a patient needs when they suffer severe hemorrhage, it’s their clotting factors and platelets.
3. Larger organizations have helped lay the groundwork for whole blood programs
Programs like STRAC and agencies like Memorial Hermann’s LifeFlight, Cypress Creek EMS, and Harris County ESD #48 have really shown us that implementing a program isn’t hard, but the logistics need to be in place beforehand. States like Texas have led the way and you can follow the template they use for your own and modify as necessary to fit your agency’s needs.
4. It’s easy to train paramedics on whole blood transfusions
Nurses are allowed to start blood products in most states and paramedics are allowed to continue those same blood products. Whole blood would be just another blood product that RNs and paramedics could use to treat their patients.
In pre-hospital medicine, simplicity is key. It’s hard to calculate fluid resuscitation for pediatrics when using components. Whole blood makes it much easier. Give the patient the volume based on their weight from one bag of whole blood instead of divided between three different components.
5. There is minimal equipment associated with whole blood programs
EMS agencies including HEMS all carry the necessary tubing to administer blood products. Whole blood can be given through the same IV tubing, so no new oradditional equipment is needed. Compared to components, whole blood only requires refrigeration. Whole blood is more compact, delivering all the components in one bag instead of three. This reduces the amount of IV tubing needed.
Blood needs to be warmed before being delivered to the patient. A blood/fluid warmer is an essential piece of equipment that you must carry. Make sure that your blood/fluid warmer can handle high flow rates (150-200 mL/min even at 4-degrees Celsius input temperature) while warming the blood to body temperature. Equally important, make sure that your warmer has the capacity to handle intense bolus flows (aka intermittent flows). Both requirements are not trivial to accomplish; therefore, make sure you have the right equipment. A recent study by Lehavi A, Yitzhak A, Jarassy R, et al., tested several brands and found that the Warrior by QinFlow was the best performing blood/fluid warmer on the market [3]. The study was later referenced by the Committee on Tactical Combat Casualty Care (CoTCCC) Advanced Resuscitative Care Guidelines and Management of Hypothermia Guidelines [4] [5].
6. Partner with local healthcare entities to reduce whole blood waste
Opponents of whole blood in the field say that EMS won’t use it in time before it expires, thus increasing waste. However, programs such as STRAC and others have shown that partnering with a local hospital reduces waste. When a unit of whole blood gets close to its expiration date, that unit is then rotated into the hospital’s inventory where it is more likely to be used before it expires.
7. Whole blood programs allow paramedics to use best-practice protocols
Get any group of paramedics together who work for different agencies and eventually they’ll start talking protocols. It usually ends up being a competition about who has the best protocols. We like having the free-range to treat patients to the best of our knowledge. Medics will go on and on about RSI, field amputation, chest tube insertion. Now medics have heard about whole blood and they want to be able to say it’s within their protocols. Apart from pay, EMS agencies really only have what protocols they allow their medics to follow that separate them from other agencies. It can be a great recruiting/retention tool to say you have the most up-to-date protocols.
8. Whole blood programs save lives
When it comes right down to it, saving lives is why we got into this field. There is so much evidence on this treatment from case studies that it should really be a no-brainer at this point. Whole blood is the answer to a patient suffering from hemorrhagic shock. Old habits die hard, however, and that’s no more evident than in EMS. While most people agree that “we’ve always done it this way” is the most deadly saying, not much changes. Whole blood isn’t something to be scared of, nor is it too complicated to get the logistics in place. Whole blood is a simple solution to a very real problem. Patients are dying before they can get to an OR. Whole blood given in the field can give them a fighting chance.
9. Whole blood transfusions offer minimal risk to patients
One major concern people have with whole blood is the risk it poses to females who are Rh negative and have childbearing potential. Whole Blood is O pos due to the emergent setting it’s given in. The risk people are worried about is an Rh-negative female receiving a blood transfusion containing Rh antigen and producing antibodies that could later harm a fetus that is Rh-positive in the future. One thing to consider is that a woman can’t get pregnant if she died from massive hemorrhage. Also, there’s only about a 20% chance she will make the antibodies once exposed. Overall, there is only about a 6 percent chance she will develop a life-threatening condition to her baby. These disorders can be treated via intrauterine transfusions so the overall risk of infant mortality due to a blood transfusion is extremely low. We have to treat the hemorrhage before we start worrying about the risk it might pose to an infant years down the line. The woman’s life is at risk now; give her blood.
10. Offering a whole blood program is the right thing to do
We as healthcare professionals have vowed an oath to help others in need. In order to do that, we must keep up with the latest tested and proven treatments for our patients. We are our patient’s advocates. We must speak up for them when they cannot. It is our job to stay up to date on research and know the best practices for our patients. Doing something because “that’s the way we’ve always done it” is wrong. Our patients deserve better. There are a lot of advances in medicine and all may not be practical to push out to the field of EMS, but the use of whole blood is.. Whole blood is more compact, easier to use, and all around better for our patients. It’s time to push whole blood out to the field where it is needed.
Learn more about QinFlow and the Warrior blood/fluid warmer.
Resources:
- Curry N, Hopewell S, Dorée C, Hyde C, Brohi K, Stanworth S. The acute management of trauma hemorrhage: a systematic review of randomized controlled trials. Crit Care. 2011;15(2):R92. doi:10.1186/cc10096
- Ponschab M, Schochl H, Gabriel C, et al. Haemostatic profile of reconstituted blood in a proposed 1:1:1 ratio of packed red blood cells, platelet concentrate and four different plasma preparations. Anaesthesia 2015; 70: 528–36.
- Lehavi A, Yitzhak A, Jarassy R, et al. Comparison of the performance of battery-operated fluid warmers. Emerg Med J. 2018;35: 564–570.
- Frank Butler, John B. Holcomb, Stacy Shackelford, et al. Advanced Resuscitative Care in Tactical Combat Casualty Care: TCCC Guidelines Change 18-01 (14 October 2018). JSOM Volume 18, Edition 4 / Winter 2018.
- Bennett, B. L., Giesbrect, G, et al. Management of Hypothermia in Tactical Combat Casualty Care: TCCC Guideline Proposed Change 20-01 (June 2020). Journal of special operations medicine : a peer reviewed journal for SOF medical professionals, 20(3), 21–35.
About the author
Stephen Alexander is a Critical Care Paramedic residing in Little Rock Arkansas. He enjoys writing informative and educational articles about pre-hospital medicine. Stephen started his career in EMS by enlisting in the Army as a 68W Combat Medic. He then attended the U.S Army Flight Medic program through UTHSCSA and received his paramedic license through NREMT. He then went to RUSH Advanced Trauma Training Program in Chicago and attained his CCEMTP. He currently flies for the Arkansas Army National Guard MEDEVAC unit.