It’s a rare issue in EMS where everyone agrees. But these days, offering whole blood and the ability to administer it in the field has support that’s broad and enthusiastic.
Among the EMS and medical organizations that have endorsed adding whole blood to the EMS arsenal include the National Association of EMS Physicians (NAEMSP), International Association of EMS Chiefs (IAEMSC), American College of Surgeons Committee on Trauma (ACS-COT), American College of Emergency Physicians (ACEP) and U.S. Department of Defense/Joint Trauma System. A new cross-sectional advocacy organization, the Prehospital Blood Transfusion Coalition (PHBTC), was created in 2023 to help accomplish needed legwork in areas like developing reimbursement frameworks and scope-of-practice adjustments to allow field transfusions.
The movement is still young, and the number of ground services carrying whole blood is still fairly small. A 2024 review found as of September 2023, more than 121 EMS systems in the United States were carrying blood products. In most cases (70%-plus) this was low‐titer O‐positive whole blood, preferred because type O-positive blood is widely available and “low-titer” means it has reduced antibodies, making it safer to transfuse without cross-matching. However, some agencies also just carry components such as packed red blood cells and plasma.
Other sources cite different numbers, but a consensus is that perhaps 150 ground EMS agencies in the U.S. may carry whole blood. But that number is thought to be growing.
It certainly is in California, where the Ventura County Fire Department rolled out the state’s first prehospital blood program with a pilot earlier this year, and a new group, the California Development and Rapid Operationalization of Prehospital Blood (CAL-DROP) coalition, has come together to help drive further adoption through partnerships, data collection and building a donor network.
Its members include the fire departments from Los Angeles, San Bernardino and Ventura counties, Sacramento, and several smaller cities; EMS agencies from Los Angeles, Riverside and Ventura counties, Sacramento, and more; Harbor-UCLA and other top medical centers; and several blood banks.
“Until now, our only answer to hemorrhagic shock in the prehospital environment, if it can’t be controlled with direct pressure or a tourniquet, has been saline and a lot of diesel fuel,” said Kevin Mackey, M.D., NRP, FAEMS, medical director for the Sacramento Fire Department and president-elect of the NAEMSP. “With truncal wounds in particular, we don’t really have an answer other than TXA. And normal saline doesn’t carry oxygen and doesn’t do anything for clotting, and some literature suggests it’s actually a disaster for clotting downstream. So, replacing blood that’s lost with blood is the logical best answer to improve patient outcomes.”
‘Like narcotics tracking-plus’
In California that’s being accomplished under a local optional scope of practice provision approved by the state for Sacramento County and other participants. Ventura Fire got started in the spring; Sacramento leaders expect to have blood available for transfusion in the field by mid-October.
It’s required several components, including forging new relationships with blood banks; obtaining field refrigerators that can reliably keep the blood within its allowed temperature range; and honing the ability to closely track supplies and monitor their usage.
In Sacramento, the refrigerators came from Delta Development Team, and the tracking and monitoring ability came from LogRx, which has updated its popular narcotic/medication tracking and management system to support the EMS use of whole blood.
“We started hearing from customers about a year ago with requests to be able to track blood like they do every other drug,” said Clive Savacool, the company’s founder and CEO and a longtime firefighter, paramedic and fire chief in California. “Seeing what a difference it’s made on the battlefield, we thought it would be a perfect fit.”
While adding new fields to the company’s software wasn’t super difficult, the key to the expansion has been temperature monitoring within the refrigerators. LogRx had recently partnered with Knox in its first direct integration with another company; that allows LogRx users to know in real time when their Knox MedVault doors are opened or closed and by whom. Now they’ll get valuable information from the blood refrigerators. LogRx is also putting the finishing touches on real-time temperature tracking that can send alerts if temperatures get out of range (there may still be opportunity to help beta-test this; reach out to the company if you’re interested).
The key advantages of LogRx’s medication tracking and management approach carry over as well, including operation on mobile devices, easy QR/barcode labeling of units, biometric/user authentication, GPS and timestamp logging, tamper-resistance and support for administration and oversight.
“I can run reports and see on my dashboard when the blood was checked, and we check it every morning,” said Mackey. “It’s like narcotics tracking-plus, because LogRx added features to enter the actual temperature at the time of the check, and because it’s also GPS-tagged, I can see exactly where it was checked, including a picture of it.”
Close tracking helps make the case
The degree of oversight possible with LogRx’s tracking and management helped Sacramento leaders convince blood bank partners that had some initial reservations about extending their valuable supplies to fire and EMS.
“That was by far the highest mountain and hardest hurdle,” said Mackey. “It’s not like putting a bag of saline in your ambulance and carrying it around; blood is considered a tissue, and tissue has to be maintained at a very specific temperature. You’ll hear folks talk about the cost of the equipment and the operational challenges, but you can overcome those. But the blood banking world is still pretty new to this and still warming up to it, especially in California.”
EMS systems working with blood suppliers must both understand their regulations and educate them about EMS’ operations and capabilities. Sacramento Fire’s partner had initial reservations about taking back unused blood until they could be assured it had stayed within temperature range. LogRx helped reassure them.
“I can pull up our dashboard right now and know exactly what the temperature is in our blood refrigerators, how much time they have left at that temperature and what the battery strength is,” Mackey added. “It will also alarm before it goes out of temperature. Sharing that with your blood bank is really important. Then LogRx let us build in an additional layer where we actually have photographs of the blood that verify it’s still in temperature and good to be used.”
Sacramento Fire will be using the “blood medic” model pioneered by systems like New Orleans EMS, where select crews, in this case four, will be equipped and trained for the field transfusions. They’ll follow strict protocols and work closely with their trauma centers and blood provider to rotate stock and prevent waste.
The department prepared using a stepwise training approach that started in August with two EMS captains taking refrigerators into the field with bags of dextrose solution. That helped them get familiar with the equipment and start building muscle memory. Two more units will join them once the blood is ready.
They’ll serve areas of California’s capital that have historically been most likely to need the new capabilities. Qualifying patients will be victims of hemorrhagic shock, commonly through shootings, stabbings and blunt trauma; those with systolic blood pressures under 70 or shock indexes greater than 1.2; and witnessed traumatic arrests.
The blood refrigerators are standalone devices that don’t require connection to vehicle batteries and communicate wirelessly with the cloud. Internal PCM packs require daily changing, but that’s about all the maintenance needed. The blood will be administered with handheld infusers from LifeFlow.
What will determine success?
Success will rest on improvements in patient outcomes.
“My first lens is always the patient, and that they experience a better outcome than they would have had we been just carrying saline and TXA,” said Mackey. “The second one is that the equipment performs as expected. If we have very few problems with the equipment, that’ll be success. And then the third one will be that the field personnel adapt and accept giving blood, and it becomes part of our daily operation like anything else.”
Systems wishing to add or trial whole blood should consider funding first. Sacramento Fire used an Urban Areas Security Initiative (UASI) grant obtained with local law enforcement. “It’s actually not that expensive to stand a unit up,” Mackey noted. Then identify a blood supplier and initiate dialogue. Big players like the American Red Cross and Vitalant are increasingly engaged with prehospital efforts but may require outreach. The Prehospital Blood Transfusion Coalition can also be a source of experience, expertise and troubleshooting.
Whether or not you encounter reluctance among partners, it can add security and efficiency to the handling of whole blood, along with the other valuable therapeutics you carry, to have an easy, comprehensive, tamper-resistant system for overseeing its use. That’s good reassurance for suppliers and everyone else in your community.
“As firefighters, we can have a reputation of being a little like bulls in a china shop, which is not totally inaccurate,” said Savacool. “So, for a pharmacist or doctor to decide, ‘I’m going to trust these guys to carry this extremely valuable product,’ they have to know we’re not going to be careless with it, that we can keep it at the right temperature, keep it safe to give to patients and keep it safe for them to take back. It’s a big step for them, but LogRx can help demonstrate that.”
For more information, visit LogRx.
