EMS1: 4 Considerations for Adopting a Prehospital Blood Administration Protocol

No longer just for hospitals and helicopters, blood products can benefit medical and trauma patients in the field

By Tim Nowak

Have you considered adopting a blood administration protocol in your EMS agency? What once seemed like only an option for hospitals, helicopters and critical care is – in all reality – an option for 911 ground ambulances, as well. For one agency, “it’s now become the standard of care … and expectation,” noted Eric Bank, chief of EMS at Harris County (Texas) Emergency Services District Number 48 Fire Department.

Blood and blood product administration is growing in both popularity and usefulness in the prehospital setting. Since this isn’t typically part of your standard scope of practice and medical formulary, carrying blood on your ambulance comes with its own set of specialized needs.

1. INDICATIONS FOR PREHOSPITAL BLOOD ADMINISTRATION

Blood and blood products can be administered to patients in both medical and traumatic settings. Wren Nealy, assistant executive director with Cypress Creek (Texas) EMS, noted for his agency, “60 percent of our use is for medical-related hemorrhagic shock, not just trauma.”

The obvious external hemorrhage stands out, but leading the top of the list in both Harris County and Cypress Creek is hemorrhage due to post-childbirth and gastrointestinal bleeding complications.

Bank reported a 4-to-1 ratio of administration for medical complaints, compared to traumatic injuries. Both Texas agencies, in fact, have experienced great success stories where an initially pale, cool and diaphoretic patient arrived at the emergency department with seemingly normal skin due to blood administered in the field.

2. SUPPLY AND DEMAND

EMS, compared to Level-I trauma centers, uses markedly less blood units just by the nature of our call volumes. Because of this, it’s important to work with local hospitals and blood banks to develop a reliable and cost-effective supply chain.

As the blood stock rounds a week in-service, the local blood bank exchanges its stock in order to keep this precious resource available for appropriate use and to avoid its waste. This timeline has not only proven to be a wise use of available blood units, but it also allows both agencies to defray some of their costs because of a timely exchange process.

3. RESPONDING WITH BLOOD

While responding with blood on a critical care unit or a supervisor’s vehicle seems like a logical first step, both agencies have learned that in order to have an effective system in place, blood needs to be carried on all of their ambulances.

After all, when your patient is bleeding, exsanguinating, they need blood 10 minutes ago … not 10 minutes from now!

Training all paramedics has been a huge logistical task for both of these agencies, but it has proven to be a beneficial one. Added classroom hours, time with equipment and experience utilizing physical blood products for patient care have allowed these agencies to create somewhat of their own specialty-level of paramedic provider; one where added oversight and continued education is highly warranted.

4. PREHOSPITAL BLOOD ADMINISTRATION EQUIPMENT NEEDS

In order to keep an adequate blood stock at an appropriate temperature, specialized refrigerators or coolers are often needed in the prehospital setting. Simply storing the blood at a station, and then adding it to the rig once a call drops, is not a viable option.

As the blood is hung and its tubing is primed, it needs to be warmed before its actual infusion into the patient. Specialized warmers become invaluable in this process in order to promote a normothermic infusion of this life-saving product (and to avoid the trauma triad of death phenomenon).

WHAT DOES THE FUTURE HOLD FOR BLOOD ADMINISTRATION?

This expanded-scope option may not yet be on the radar for all ALS ambulances. “This program wouldn’t be a success if it wasn’t for the support of our board, medical director and community,” Nealy noted.

Freeze-dried plasma seems to be a promising option for the future for hemorrhage control, as well as advances and cost-saving measures regarding storage equipment.

We hear more and more about how simply attacking hemorrhage patients with more fluid, like normal saline, is harmful because it turns the blood into Kool-Aid. Why not give them what they really need?