By Sean Krofssik
Hartford Courant
HARTFORD, Conn. — Use of whole blood products to save egregiously injured U.S. military combatants became a practice during wars in Iraq and Afghanistan and even before those conflicts, according to experts.
In Connecticut, Saint Francis Hospital is using such a Whole Blood Program and expanded it to a third EMS program earlier this year and has a fourth in the works. The program has already performed more than 250 successful blood transfusion in the field, and the hospital said it has saved lives.
| MORE: On demand: Bringing whole blood to the front lines of EMS
Whole blood contains platelets, plasma and white and red blood cells in a correct ratio, an “advantage is its component balance,” the “goal of massive transfusion,” particularly in trauma cases, according to the Mayo Clinic. Further, in bringing whole blood to the point of injury, such as a car crash, EMS “teams can act faster to stabilize critical patients and ultimately save more lives,” according to ems.gov, which is part of the National Highway Traffic Safety Administration.
How it works
Enfield Emergency Medical Services is the latest state EMS program to join forces with Saint Francis Hospital for the program that allows the whole blood to be administered to a trauma patient while still at the scene of an emergency or while in transport to the hospital.
Using the program allows the first responders to treat patients suffering life threatening blood loss in the field. According to Saint Francis Hospital, less than 1 percent of ground EMS agencies in the have this capability.
Saint Francis, a Level I Trauma Center, established the first Whole Blood Program in New England in August 2020 with a partnership with American Medical Response ( Hartford ) and then added Granby Ambulance Association in March 2021.
John Pettini, a doctor of osteopathic medicine, and fellow of the American College of Emergency Physicians and Emergency Medical Services at Saint Francis, has headed this program from the beginning, and said when the hospital first started this program in 2020, the nearest hospital that provided a Whole Blood Program was in Onslow County North Carolina.
Medical and traumatic blood loss patients are eligible to receive the care. It is similar to technology used in military operations and it follows the same principles used in the hospital.
The whole blood can be brought into the the field, according to hospital officials citing one example, because “the low titer type O-whole blood is stored between 2-6 degrees Celsius in a specialty cooler in the Enfield EMS station. A compact, portable, battery-operated blood warming system, including state-of-the-art blood tubing, warms the blood to 100 degrees Fahrenheit for administration to patients.”
The Saint Francis Blood Bank manages the distribution, tracking, and rotation of whole blood product in coordination with the EMS programs.
Pettini said it’s been a game-changer for patients in the field who experience blood loss.
“On the national level of trauma care now it’s considered the most meaningful thing we have done in prehospital care for trauma care since the beginning of hospital care,” Pettini said.
“That’s why now all of the national oversights like the American College of Surgeons Committee and Trauma, American College of Emergency physicians, Pre-Hospital Physicians Association and others said this should be the standard for trauma care in the United States,” Pettini said.
Pettini said since 2020, the program has reduced mortality in trauma, shootings, and stabbings, as well as medical cases such as gastrointestinal bleeds and postpartum hemorrhage.
He added that Trinity has been ahead of the curve and was one of the first 50 hospital systems in the country to carry whole blood.
“We’ve put in a lot of work behind the scenes, and we’ve helped keep it going across the state. We look at this as kind of a global thing. We are epicenter of it in this region. We have helped our colleagues in New Britain and Bridgeport get going even though they are outside of our system,” Pettini said.
Preserving lives
Pettini said time is of the essence when helping reverse the shock of traumatic blood loss.
“If we don’t do it early, shock becomes irreversible. Across the United States and other countries, the No. 1 cause of death for those age 44 and under is trauma,” Pettini said.
Pettini said this idea of this type of blood transfusion in the field was done in the military during the Iraq and Afghanistan conflicts.
“Then they started getting blood out instead of the clear fluids and from 2006 over the next 10 years they started putting blood in and pushing it forward and then some landmark studies came out looking at if they got this blood out in the first 15-30 minutes and who is living and dying, it showed the blood was a huge benefit,” Pettini said.
“We had special operation soldiers carrying refrigerated cold blood in packs out in the field, on missions or having them in helicopters,” he said. “As the war was winding down, we thought we could save a lot of American lives if we pushed this out into the field. It’s just never been done.”
Pettini spent six years as a researcher for the Department of Defense as a funded researcher from 2014 to 2020. He did his residency at Parkland Hospital in Dallas, which he said is one of the busiest trauma centers in the country.
Evolving practices
A study published in the Canadian Journal of Surgery, titled “Fresh whole blood transfusion capability for Special Operations Forces,” confirmed “retrospective data from recent conflicts in Iraq and Afghanistan show an association between the use of FWB and survival.”
Pettini said since the 1970s emergency workers have used clear IV fluids, lactated ringers or normal saline to resuscitate trauma patients. He said those fluids have no meaningful benefits for these patients but “kind of just stuck around.”
“Those clear IV fluids just don’t have any clotting factors and no ability to carry oxygen,” Pettini said. “When you have rapid blood loss, hemorrhagic shock, you need to replace in the body what is lost which is whole blood and all of its components. Blood itself is a complex organ system. It has a few major components including the red blood cells and they carry oxygen to the tissue and keep the machinery of life going.”
“The clear plasma part of it that carries the red blood cells is filled with the clotting factors. When someone loses blood quickly and go into shock, the definition it is there is not enough oxygen getting to the tissues. The cells change their whole state of metabolism into a safety net that you can’t last too long in, but you have a little bit of time,” Pettini continued. “The earlier we can get blood back into the patient we can restore that homeostasis and their cells will go back to their normal function and deliver oxygen to the tissues.”
The whole blood used by Saint Francis comes out of state from Dedham, Massachusetts from the Red Cross.
While donated blood is called whole blood, stewards of the blood supply will split and spin blood into separate bags with just red blood cells or with the plasma. Plasma can be separated into 13 other products, according to Pettini.
“Whole blood across the United States went away in the 1970s,” Pettini said. “If we have an oncology patient in chemotherapy, they may only need red blood cells or platelets. That became standard in the ’70s. Most of us in civilian life never used whole blood, we would give red blood cells in one bag and plasma in others. After a certain ratio we give platelets. The military would say whole blood is everything the patient bled out and that’s everything they need back. The military brought back the system of whole blood in the last 20 years.”
“The bleeding patient in hemorrhagic shock needs to be replaced with what they just lost on the street or internally in their body,” he said. “That’s what whole blood is. Not the separated components. When separate components, we have to put in an altoqualine in. One bag gives you back exactly what you had and its super easy for the medics to carry on the street.”
Blood has a 21-day shelf life and the blood in the field is cycled out every 7-to-10 days, to the hospital for the blood to be used before it expires.
“There are a lot of checks and balances that go into the program,” Pettini said. “That was only pioneered in 2018 in the San Antonio, Texas region. That left the blueprint for us to follow. But it was hard for us to implement because you are doing something new.”
‘We don’t want to be behind’
Pettini said the transfusion while transporting to the hospital is “a bridge” to get to the trauma center for surgery.
Erin Riggott, chief paramedic for Enfield EMS, said Enfield was approached by Pettini about adding the Whole Blood Program.
Pettini said Enfield was selected because it’s a “good regional resource” and has also provided this service to neighboring towns. AMR Hartford and Granby also serve their surrounding towns.
Enfield EMS has gone through the training and purchased the coolers and specialty heating equipment.
“We had 14 cases where we have administered blood and all with good results,” Riggott said. “When you have a whole lot of blood loss, the quicker you can replace that blood loss, the quicker the person is going to do better. That’s what we were seeing. The last one was a gunshot wound. We’ve had a handful of traumas including car accidents and medical cases with GI bleeds as the most common of those that we see.”
Riggott said the blood is stored in one of the intercept paramedic vehicles that can meet EMS or neighboring ambulance crews.
Nine of the 14 calls by Enfield EMS were in Enfield . There were also two in Suffield, East Windsor one in Windsor Locks.
“You have to guess at the time of call if you need it so you can get it started quickly. Our neighbors have been great about that. When the dispatch comes in, they use their ‘Spidey sense’ to say this could be a situation where we use it. They give us the heads up to get it going. We don’t want to be behind,” Riggott said.
Riggott said a couple of the 14 calls would not have made it to the hospital without the blood.
“You can see and immediate improvement once we give the unit of whole blood. People tend to perk back up or pink up. Their blood pressure and heart rate seem to settle out pretty quick. Not having it before and having it now, it’s like amazing. You are like ‘wow’ after you administer it.”
Pettini said the program has been a success in Enfield.
“It’s gone really well there with no logistical issues,” Pettini said. “I oversee and review every case within 24 hours, and we’ve had no issue with patient selection, and the trainings have worked well.”
Saint Francis will add St. Mary’s Hospital ( Waterbury ) as the fourth location. The hospital’s EMS system is run by Trinity Health. The whole blood program will be available in Waterbury and the surrounding communities like the Naugatuck Valley by late January. Training was to begin on Jan. 6 and the service will be available about three weeks later.
The blood type used is Type O blood is safe to give to anyone.
“After 70 years of research and billions of dollars from the federal government, we’ve all defaulted to the department of defense and civilian life, the best thing to use in 2025 is whole blood. We still rely on the volunteer donor system in the U.S. Please give blood for the public health,” Pettini said.
Riggott said she feels lucky that Enfield was selected for the program.
“We hope to be the keeper of the program for a long time,” Riggott said.
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