Emergency medicine has always been a collaborative practice, where teamwork and communication are paramount as first responders, nurses and physicians work together knowing that every second counts. While much has been written about collaboration during the clinical handover of care when paramedics bring a patient to the emergency department, there has been far less focus on the opportunity to collaboratively empower paramedics to save more lives in the prehospital setting.
Working together, we have a significant opportunity to help paramedics save lives of many trauma patients. Trauma remains the leading cause of death for people under 45 in the US, according to the American Association for the Surgery of Trauma. Furthermore, among trauma patients, uncontrolled hemorrhage is the number one cause of preventable death.
After my 23-year-old niece, Taylor, died in a tragic car accident, I thought a lot about Taylor, who had recently graduated college and had a beautiful life ahead of her. As an emergency physician, who has witnessed these heartbreaking outcomes for more than two decades, I thought deeply about what we do–and more importantly what we don’t do–for trauma patients.
Over the past 50 years, there has been very little innovation in prehospital care for trauma patients facing hemorrhagic shock. Paramedics can use permissive hypotension to keep the patient hypotensive until they arrive at the hospital, and they can give saline, but saline has many negative effects, from diluting coagulation to making the body colder.
Saving Hemorrhaging Patients at Accident Scenes
As the District Chief of Emergency Medicine, I have heard paramedics describe how horrible it is to be stuck watching a hemorrhaging patient die while waiting to be extricated after a car crash – and not be able to do anything to help.
Putting myself in their shoes, I realize their experience is a lot different than mine working in a hospital having access to every possible resource. I can empathize with our paramedics and how their work inevitably takes a toll on their wellbeing.
I had read about how some cities had launched whole blood programs to allow paramedics to provide a whole blood transfusion – before patients arrive at the hospital.
I set out to create a whole blood program in Broward County, and it became the first in Florida. I worked with the Broward County Sheriff’s Office to help equip and train paramedics to administer whole blood transfusions to hemorrhaging patients.
Whole blood is natural blood from donors that is unseparated, so it contains all the components of blood (red blood cells, white blood cells, platelets, and plasma). As it must be kept at four degrees Celsius, we keep it in a small portable cooler. Paramedics use a small device towarm the blood, and another device to manually pump the blood as it is transfused via Y tubing. This entire setup is relatively simple and costs about $10,000.
“Another One for Taylor”
Our program launched in early 2020 but faced significant delays, not surprisingly, due to the pandemic. We are pleased with the outcomes so far, as about 75 of the 115 trauma patients who received whole blood transfusions have survived past the 24-hour mark.
One of these patients was a local pastor who has two young children. He was hit by a boat propeller while far from shore and nearly died from massive blood loss, but paramedics gave him a whole blood transfusion on the scene that saved his life.
Another case involved a young woman whose legs became trapped under a collapsed dashboard in a car crash. She was only five minutes away from one of our trauma centers, but she was going into hemorrhagic shock from internal bleeding. Paramedics called me to discuss whether she needed an emergency amputation to save her life. Instead, paramedics gave her a whole blood transfusion while working to extricate her, and she survived and recovered fully.
Soon after the program launched, I learned that when our paramedics save a life with whole blood, they say, “here’s another one for Taylor” in honor of my niece.
Captain Dean Meadows, who has worked in fire rescue and paramedicine for 28 years, told me that whole blood protocol has renewed his love for the profession. He vividly describes “watching the life come back into” the man in the boat propeller accident.
The efforts of our paramedics are inspiring, but so is their incredible collaboration. As word got out about our program, we started getting calls from EMS in nearby cities when they had a hemorrhaging trauma patient. Boundaries became secondary to saving lives. When possible, our paramedics (equipped with a whole blood kit) jump into another city’s ambulance to provide a transfusion.
Lessons Learned from Battlefield Medicine
While whole blood transfusions given by EMS are relatively new, the US Armed Forces have been using whole blood transfusions since World War I. Successful outcomes on the battlefield have been well documented, and there is growing evidence in peer-reviewed medical journals showing that whole blood can be a much better option than IV fluids for trauma patients in the prehospital setting.
San Antonio, Texas, which is the pioneer in EMS whole blood protocol, launched its program in 2018 and has provided more than 1,000 transfusions. . Other cities, such as Houston, Minneapolis, New Orleans, Pittsburgh and Seattle, have since adopted whole blood protocol, as did our neighboring county, Palm Beach, after we shared our program with them.
I hope to expand the program by adding several more units. I also hope that other municipalities will adopt this collaborative model and work together to give trauma patients, like Taylor, a fighting chance.
Dr. James Roach is the system chief of emergency services at Broward Health and the District Chief of Emergency Medicine. Broward Health, which is one of the 10 largest public health systems in the US, serves the northern half of Broward County in South Florida. It has both a Level I trauma center and a Level II trauma center.