Optimizing nonsurgical management of major hemorrhage

Major hemorrhage is life-threatening and can occur in a variety of clinical settings. A review paper in CMAJ, entitled "Nonsurgical management of major hemorrhage," advocates for the implementation of massive hemorrhage protocols across all types of hospitals to optimize patient care.

Dr. Jeannie Callum, the article's lead author and the Director of Transfusion Medicine at Kingston's Health Sciences Centre speaks with Drs. Blair Bigham and Mojola Omole about her work standardizing massive hemorrhage protocols throughout Ontario. Dr. Callum shares the transformative moment that inspired her to develop a province-wide protocol, starting from the point of roadside patient care.

She then details the critical need for precision in managing major hemorrhage, emphasizing a rapid response within the "golden hour." Dr. Callum outlines key components of care such as swift administration of tranexamic acid and the detection of coagulopathy. She then simplifies the main elements of a massive hemorrhage protocol into what she calls "the seven 'T’s."

In rural settings, Dr. Callum identifies the need for a simplified protocol due to constraints like smaller medical teams and a lack of comprehensive laboratory tests. Despite these challenges, she recommends innovative solutions like the immediate administration of tranexamic acid and encourages physicians to educate themselves about novel point-of-care testing technologies such as viscoelastic testing.

Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.

You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole

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The CMAJ Podcast is produced by PodCraft Productions

Transcript

Blair Bigham:

Hi, I'm Blair Bigham.

Dr. Mojola Omole:

And I'm Mojola Omole. This is the CMAJ podcast.

So today, Blair, we are talking about the non-surgical management of major hemorrhage. I'm sure you're very excited about this topic.

Blair Bigham:

I am so excited. I mean, I'm a non-surgeon. So there's not a lot I can do to stop bleeding, other than fix coagulopathy, which is this very mystical ideal that we talk about all the time. But in the emergency department, when you start bleeding quickly or you come in by ambulance, usually you're not that coagulopathic yet. And so all I can do is pour blood into you until I can get you to a surgeon.

Dr. Mojola Omole:

And for me, I never have bleeding. So this is all new things for me to learn.

Blair Bigham:

A non-issue for you. Yeah.

Dr. Mojola Omole:

Yes. But this is a great article that really streamlines the protocol for how we do massive hemorrhage. And what I love about it is that it takes into account that we have various protocols across the country, and it simplifies it by collecting the brightest minds who do this to come up with a great protocol that can be used not just in tertiary centers, but also in rural settings too.

Blair Bigham:

And also, Jola, there's a tension here, and maybe you can help navigate it because I'm a little biased. Because when people need a massive hemorrhage, they need it now, and it can take a long time to get blood products to the bedside. And it's not always just the rural hospitals that have trouble. I've had very fast responses in rural hospitals and very slow responses in some pretty big urban centers that already have a massive hemorrhage protocol, believe it or not. 

So I think the people who release blood always want to make sure they're releasing the right bag for the right patient. And so they're very, very deliberate and cautious, and I think that's exactly what they're trained to advocate for. At the same time, when a John Doe comes into the ER, we might not have them registered. We might know they're on their way in and not even have them in the building yet, but I can already be calling for blood, and sometimes it's tough to get that blood to the bedside. So these massive hemorrhage protocols are designed to really alleviate those delays and expedite getting blood into the patient.

Dr. Mojola Omole:

For sure. I think this is the tension that we're going to be able to tease out with Dr. Callum.

Blair Bigham:

Yeah, she is the source for this type of thing, and she's the one who at 4:00 AM has called me in the past to say, "Hey, why are you giving this blood product to somebody?" So she is so dedicated to making sure the right patient gets the right bag of product. I'm really excited to speak to her.

Dr. Mojola Omole:

As am I.

Blair Bigham:

Dr. Jeannie Callum is the lead author of the Review in CMAJ entitled “Nonsurgical management of major hemorrhage”. She's the Director of Transfusion Medicine at Kingston Health Sciences Centre. Thank you so much for joining us.

Dr. Jeannie Callum:

Oh, I'm delighted to be here and talking about my favorite topic, other than Alby men, of course.

Blair Bigham:

Well, you've got a surgeon and an emergency doctor here. So we are going to have a lot of fun chatting with you today.

Dr. Mojola Omole:

But I don't cause any bleeding.

Blair Bigham:

No, no.

Dr. Mojola Omole:

My blood loss is 0.0.

Blair Bigham:

Yeah, you just stop the pleading, right, Jola?

Dr. Mojola Omole:

Exactly. Never cause it.

Blair Bigham:

You've done a lot of work, Jeannie, not only locally, but for the province of Ontario in helping standardize a major hemorrhage protocol. What inspired you to do that work?

Dr. Jeannie Callum:

Well, I started when I was at Sunnybrook Health Sciences Centre just trying to build  the perfect massive hemorrhage protocol. And then I used to see patients coming in so far past any point of recovery because they had a long pre-hospital time, they had to go to a community hospital before, they could be transferred to Sunnybrook for definitive hemorrhage control, and then I realized some of these patients were coming to us, and they had a coagulopathy that was non-survivable. And there was one aha moment when I turned to one of the air  transport guys and said, "Oh, come on guys, you need to bring us patients that are better optimized and they're warm and they're not acidotic and they're not coagulopathic," and trying to say, "You guys need to do a better job."

And they said, "No, you need to start at the St. Elsewhere Hospital and you need to start at the roadside, and it has to be the whole patient journey rather than just focusing on when they arrive at the door of our own academic tertiary trauma center. You have to start at the roadside to ensure that these patients get better care." And that prompted us to develop a provincial massive hemorrhage protocol that we call code transfusion.

Blair Bigham:

Now, you had mentioned that you spent time creating a perfect massive hemorrhage protocol. Tell us why we need to have a protocol. Why the perfection? What happens when people don't get your perfect protocol, or when they have those delays in getting access to the right product?

Dr. Jeannie Callum:

Yeah. So Dr. Adams Cowley, he called that first hour of major hemorrhage the golden hour. And if care wasn't perfect within that first hour, patients were more likely to die. They weren't dying right then. They were dying three days later, two weeks later, but they had some irreparable physiologic damage. And so that's why I think it's really important that in that first hour, we provide faster, tighter, more protocolized care. Things like getting the TXA in within an hour of injury, things like getting the blood started faster, figuring out who's coagulopathic and getting it reversed.

Blair Bigham:

That's right because it's not just about blood, but there's tranexamic acid, there's calcium, there's other products or drugs that go along with that to ensure a good outcome. Now, this was four years ago. Your protocol's gone provincial. Most hospitals have a code something, whether code transfusion, code omega. I've heard it called a couple of different things. So why now? Why did you write your practice paper in 2023? What were you seeing that made you think this needed to come out?

Dr. Jeannie Callum:

Yeah. So perhaps about a year and a half ago, we decided we needed to collect quality metrics on every major hemorrhage across Ontario hospitals. So we created a REDCap database with collection of the quality metrics that we had pre-specified in that 2019 paper, and we started collecting them. And then we started to see where we were failing, and that's one of the failure points, was the knowledge mobilization and the knowledge translation, and getting that message out to people so that we just have this continuous quality improvement in trying to improve our outcomes for our patients.

Blair Bigham:

So define major hemorrhage for me. At what point does this protocol get triggered?

Dr. Jeannie Callum:

Yeah. So many, many researchers have published on the best criteria to trigger your massive hemorrhage protocol. Some people actually now call it a major hemorrhage protocol. And none of them outperform each other, none of them are probably better than the gestalt of the treating physician at the bedside, and none of them seem to outperform the shock index, which is a very simple measurement. So I think your massive hemorrhage protocol should be activated when you have the clinical scenario that can be associated with massive hemorrhage, whether that's a high speed car accident, a penetrating injury, a postpartum hemorrhage, something where you have somebody tha can have a massive hemorrhage, you've got a patient who's not responding to your frontline fluids, not responding to frontline uncrossmatched blood, and then you activate it with the expectation that your patient's going to need at least six units of red cells and they need other components other than just red cells. The massive hemorrhage protocol isn't for the patient that needs four units unmatched for a GI bleed. It's meant for somebody who's going to get coagulopathic, thrombocytopenic with a low fibrinogen level.

Blair Bigham:

I love that you mentioned the shock index, which is heart rate over systolic blood pressure. How much easier of a metric is that? It's in the triage note. It's on the monitor right in front of you. So easy to look at. And-

Dr. Mojola Omole:

I was today's year old when I learned this. I've never heard of this before. Well, a little bit smarter.

Blair Bigham:

And what do we use it? Is it 0.9 or one whenever you're... Basically, if your heart rate is higher than your systolic, you've got a problem.

Dr. Jeannie Callum:

Yeah. Definitely at 1.4, you probably need your massive hemorrhage protocol if you're faced with a bleeding patient.

Blair Bigham:

Got it.

Dr. Jeannie Callum:

And in children and in obstetrics, there's some suggestion that perhaps one. So between one and 1.4 is a bit of a gray zone. You probably don't need it below one, and you should be calling for unmatched red cells.

Blair Bigham:

Got it. So I'm going to ask for the Coles Notes version of a massive hemorrhage protocol. Walk us through just some of the major components because it's not just packed red blood cells.

Dr. Jeannie Callum:

Okay, so we actually call this the seven Ts. So we have seven things that begin with T that you have to remember. So the first is you need to trigger it appropriately. You need to give your tranexamic acid within one hour of the bleed or one hour of injury in a trauma patient, which doesn't give the trauma docs a lot of time. If it takes 35 minutes for that patient to get to the emergency department, it doesn't leave you a lot of time to get that TXA in within that golden hour. We want you to start transfusing. We want transfusion to target. We don't want just a blind ratio with no thought put into your transfusions.

We want testing done on the patient to make sure that we're keeping on top of their coagulopathy. We want the temperature to be monitored and aggressive preventative strategies put in place to prevent hypothermia, and then when it happens, to treat it. And then at the end of it, when you get control, source control, hemodynamics are improving, coagulation is improving, the speed of transfusion is slowed, then you terminate so that the blood bank can go back to every other patient that's in the emerge or in the operating room and so that other patients can have care.

Blair Bigham:

I remember from my Royal College exam having to memorize what comes in various buckets or what various trials said about the ratios of transfusion. If somebody's bleeding out quickly, why can't we just transfuse whole blood?

Dr. Jeannie Callum:

You mean an actual unit of whole blood, or just a ratio of certain amount of blood?

Blair Bigham:

An actual unit. Instead of having to fuss about ratios and thaw frozen plasma, which in community hospitals, I've never seen done in less than an hour, why can't we just have whole blood in the emergency department in a fridge or in the back of an ambulance or channeling those flight paramedics? Why can't we have TXA and everything out in the field?

Dr. Jeannie Callum:

So let's start with just whole blood question. Why not whole blood?

Blair Bigham:

Sure, I got excited there. I asked you everything all at once.

Dr. Jeannie Callum:

So whole blood seems like a great idea, but when you think about it, okay, you can only keep whole blood for 21 days. Okay, so now, we have a short half-life. Whole blood, you have to obviously match for the red cells. So we have to give group O whole blood. Group O people have anti-A and anti-B. They don't like people that aren't group O. And so if you put a lot of whole blood into somebody, you're giving lots of anti-A and anti-B that could potentially impact your recipient.

Blair Bigham:

Oh.

Dr. Jeannie Callum:

So now, the whole blood has to be low-titer group O whole blood. So you can't take it from a donor that has higher than average titers. And it has to be from a man. Not that we have any problem against women, but women have antibodies against tissue types that can cause transfusion reactions. So now, we're looking at a very niche donor. And considering many of our patients are women, now you're looking at O neg, low-titer group O blood from a guy.

Blair Bigham:

Got it.

Dr. Jeannie Callum:

So now, we're talking about the rare donor, and we can only keep the unit for 21 days. So not very practical.

Blair Bigham:

Right. So let's go to my second question there. What about getting some sort of product or drug out there into the field so that 35-minute transport time or longer, if they have to go to community hospital first, how can we tighten this up so that they're not coagulopathic by the time they get to you?

Dr. Jeannie Callum:

Okay. One of the best ways to prevent, treat the coagulopathy of trauma is tranexamic acid. So in clinical studies where patients got tranexamic acid on the way to the hospital, they were less coagulopathic on arrival. So it preserves their fibrinogen, it preserves their INR. And so that is super important. One of the most recent publications that come out just in trauma in general, when you look at their Table 1, 80% of patients in the United Kingdom are getting tranexamic acid in the pre-hospital phase. And so that's a worldwide movement to get that done. And we can do that in Canada. There is nothing to stop us from making that happen. We know that it's safe, it's effective, and it can be done without delaying transport. The second thing you might want to give in the ambulance is blood, whether it's plasma or red cells. So we now have three randomized controlled trials randomizing patients to getting normal saline versus getting plasma and red cells or just plasma. And in those individual patient randomized trials, there doesn't appear to be a benefit to pre-hospital blood over normal saline.

Blair Bigham:

Oh.

Dr. Jeannie Callum:

There was a fourth study that was done. It was published in the New England Journal of Medicine. It was a cluster trial. So they randomized the site rather than randomizing the patient. It showed a mortality benefit, but that could not be replicated when they went and did individual patient randomized trials in the US, the UK and France. So I think it's really early days on the pre-hospital transfusion. And I think we need a lot more basic science research, we need a lot more research on the product, and a lot more clinical trials to flush out, well, who might benefit.

Dr. Mojola Omole:

There was a question that looked at patients receiving tranexamic acid, and that there was no advantage for patients with intra-abdominal or GI hemorrhage getting tranexamic acid. Why do you think that is?

Dr. Jeannie Callum:

Yeah, so the study you're referring to is the HALT-IT trial, patients having severe GI bleeding, including a good proportion of the patients had cirrhosis with a variceal bleed, which I know you know these are brisk bleeds. So if there's one patient population we'd like to slow down the bleeding, that would be a group of patients. In that study, there was no benefit, patient important outcomes, bleeding outcomes, transfusion outcomes, nothing. And there were more thromboembolic complications. So not only was there no benefit, there was harm.

I wonder whether or not there was harm in that study because when you see a GI bleed, they didn't start in the... You're not seeing them in the first hour of the GI bleed. They take time to become symptomatic, time to get to the hospital. And so you're probably seeing them many hours into it, and you're beyond the TXA point. We know there's no benefit after three hours. So it's not surprising that maybe in GI bleed, we didn't see a benefit. The other thing is they gave four grams in that study. That's a lot more TXA that was given, say, in the trauma trials at two grams. And so maybe it was too much for too long a period of time.

Blair Bigham:

On the other end of the curve, kind of.

Dr. Jeannie Callum:

Yep. Really, if someone calls me and says, "Oh, this patient's at three and a half hours post-injury. They're still bleeding. Should we would give TXA?" And my answer is always no. You're past the three-hour mark.

Dr. Mojola Omole:

Do you think there's any advantage... This is directly related to what I do because sometimes when we are doing a gallbladder or a bowel case and there's just a lot of bleeding, especially in the laparoscopic cases, and so we do sometimes give TXA just because we're like, "Well, let's see if it works," because it works in orthopedics. So we're like, "Well, let's see if it works in general surgery." Is that going to be causing harm, or are there any studies that support the use of that in not necessarily a massive hemorrhage, but in a situation where you already are calling for blood and you're just trying to slow things down?

Dr. Jeannie Callum:

Yeah. So recently completed was the POISE-3 randomized trial in surgical patients, and their dose was a gram on entry to the operating room and a gram at exit. It was such an easy thing to translate or to teach or it just seems to be so intuitive. And so in major surgery, it reduces the major hemorrhage rate. So that's for prevention. What you're talking about is a case perhaps you go in and you're not expecting a lot of bleeding, but that there is a lot of bleeding. You know it started in the last hour, because you actually saw it.

Dr. Mojola Omole:

Actually caused it.

Dr. Jeannie Callum:

Yeah, I was trying to be polite.

Dr. Mojola Omole:

I know. It's all right.

Dr. Jeannie Callum:

In those cases, there's no problem. I think you should be giving TXA that already hasn't been given as part of that POISE-3 trial.

Dr. Mojola Omole:

Great, thank you.

Blair Bigham:

Jeannie, a common pain point for emergency doctors is about reversal of anticoagulants, and there's always a question on the Royal College exam for emergency docs about what to do if there's antiplatelets involved. And I know there's a lot of trials around this. There's some new novel drugs that we can't always access, but what's the bottom line for an emerg doc who gets this undifferentiated Jane Doe, John Doe trauma patient, we don't know anything about them? Should we be considering some sort of empiric reversal, or should we just be following the massive hemorrhage and stay away from anything like Octaplex or vitamin K? These types of things just get thrown around sometimes. Or for people who are on, let's say an antiplatelet, maybe something other than just aspirin or an anticoagulant. Where does that fit into the massive hemorrhage protocol?

Dr. Jeannie Callum:

I think we should be targeting reversal of anticoagulants in a massive hemorrhage protocol patient within that first hour. I think you want to target and get it done. I think it's really important to reduce the cognitive burden on the emergency physicians and have a very clear protocol on how to do this. So I think that protocolizing is really important. We came up with a great way to do this when I got to Kingston. So I have an order set. It's called anticoagulant reversal. You click off what drug you want to reverse, and then it asks you a couple questions that the blood bank needs to be able to dose it, like the weight of the patient or the INR or whatever, and you just click sign.

Blair Bigham:

Wow.

Dr. Jeannie Callum:

And if you have patient on two anticoagulants, you just thrombolyze somebody. And now, they're bleeding into their head, but they're also on heparin. Both of them can get reversed on the same order set. You don't have to remember dosages, you don't have to remember it's Pradaxa for your dabigatran bleeds, you don't really need to remember the dose. You just hit the order set, click submit. And so I think figuring out how to operationalize it. In our trauma bays, we have big signs that just have the poster with the list of the drugs. So I think that helps, but I think it's even better to have an electronic order set to make it super, super easy. In terms of prophylactically though, getting everybody PCC that's coming in. Actually, a study was just published where they randomized patients to getting plasma with your regular ratio-based resuscitation versus plasma with PCC on top of that. And there was no benefit on top of the plasma, but they did not do a study of randomizing people to plasma versus PCC.

Blair Bigham:

Got it.

Dr. Jeannie Callum:

Do you need plasma that has all 13 clotting factors, or can you just get away with 2, 7, 9 and 10? So that's a big "we don't know". Needs more research.

Blair Bigham:

All right. And PCC being prothrombin complex concentrate, all the really good stuff within FFP.

Dr. Jeannie Callum:

Correct.

Blair Bigham:

Awesome. And then just to put it to rest, if you're on an antiplatelet, do I need to care? I'm not talking about intracerebral bleeding. I'm just talking about your massive trauma patient.

Dr. Jeannie Callum:

Yeah. I think that decision has to be highly personalized. There was one prospective randomized trial of people with intracranial bleeding on aspirin or Plavix or both, randomized to platelets or no platelets. And the patients getting the platelets had worse outcomes. A similar analysis was done for GI bleeding patients presenting to the emergency department, comparing patients who their emerg doc had given them platelets, compared to the emerg doc that elected not to give platelets, and you were better off without platelets. Not in a randomized trial, but in a cohort-matching study, which is making us super nervous about anti-platelets in that setting. So I think it's not the routine. You need to personalize it until we have more trials so we actually know what we're doing. So definitely, don't make it a spinal cord reflex where someone's on aspirin, they're bleeding, you give them platelets. Think.

Blair Bigham:

Right.

Dr. Mojola Omole:

It all seems very manageable when you're in a major clinical setting, but what are the challenges for smaller and rural settings? And what should the takeaway be for physicians who are working in those environments?

Dr. Jeannie Callum:

I think there are a lot more challenges, or you could say some opportunities to be a little bit more innovative in those regions. I think the first limitation is you've got less people in the emergency bay where you're trying to manage them. And so there's one emerg doc managing everything compared to a team of about 15, say, at St. Michael's Hospital in Toronto. You don't have a full laundry list of coagulation testing that you can do. You probably don't have a fibrinogen level. You might not have an entire recipe list of coagulation factor replacement. You might not have plasma. You definitely aren't going to have platelets at lots of community hospitals.

And so your protocol has to be somehow simplified so that you can hit those key things and get them in within that golden hour while you wait for your patient to be picked up to go to a major trauma hospital to get definitive hemorrhage control. And so the protocol, you still have to have a protocol. It's just got to be different, and it's got to be simpler. Some of the things that we've done is things like suggest just give two grams all at one time. Don't try and give a gram and then a slow one-gram infusion. Just give your two grams, get it done, and go on to the next task that you have to do for massive hemorrhage patients.

Blair Bigham:

I love this question, Jola, because a massive hemorrhage protocol is fairly blood work heavy because we're trying to do this with metrics and not just throwing buckets into people. And at some hospitals, when I work in a cardiac transplant hospital, I have bedside coagulopathy testing. I get my INR back in minutes. Everything's very, very fast. When I work in a community hospital, I might not even have more than two bags of red cells in the building, and my FFP is coming in a police car from Ottawa, for example. Where does the future lead us in terms of getting faster and better blood work to make these decisions and be maybe more patient specific with our MTPs? And I guess I'm getting at things like thromboelastography and other bedside tests that are, I'm sure expensive, but give us that real-time information to titrate our transfusion products to that patient right in front of us.

Dr. Jeannie Callum:

Yeah. And I think that those more aggressive testing is really important to prevent over-transfusion. We see people finishing a massive hemorrhage protocol with hemoglobins of 180, 200, and they've been clearly over-transfused.

Blair Bigham:

Certainly. I'm probably responsible for one or two of those. I'm sorry.

Dr. Jeannie Callum:

Well, it's turning out to be about more than 50% of the massive hemorrhage protocols in the province finish 24 hours post-resuscitation with a hemoglobin above 120.

Blair Bigham:

Gotcha.

Dr. Jeannie Callum:

Where you put your threshold for over-transfusion, I'm not sure where you put that, but a good proportion are getting more products than they actually need. And on the other side, we see people who have a fibrinogen of zero, and it's two hours before it is addressed. And that's a problem.

Blair Bigham:

Gotcha.

Dr. Jeannie Callum:

Because that patient is never going to stop bleeding unless we get on top of the coagulopathy. So I think fiscal elastic testing, whether it's ROTEM or TEG, it's coming. So everybody needs to start educating themselves. These multiple companies make these different machines. They're getting smaller, they're getting easier to use. You basically just put... It looks like a little cartridge. And a little drop of blood in the top, and it just starts running. You don't have to pipettes. Even a surgeon could do this at the bedside.

Dr. Mojola Omole:

Imagine.

Dr. Jeannie Callum:

Imagine that.

Blair Bigham:

So it sounds like the future, lots of excitement as we try to make sure that no one's being transfused too late, but that no one's being over-transfused, walking that line and hitting the sweet spot.

Dr. Jeannie Callum:

Yeah. And people have done retrospective analyses to look at what is the sweet spot in trauma, and it looks like it's tight. It looks like it's that 80 to 120. If you go under 80, you go above 120, you start to see mortality rates going up. And so I think it's really important that we're being quite tight. The British guidelines are recommending every 30 to 60 minutes, you should be doing blood work on your massive hemorrhage protocol activation. I think if you can get it in at least hourly, you're doing a great job. If you can get it to every half hour, fantastic. But minimum, every 60 minutes.

Blair Bigham:

Lots to aspire to. Jeannie, thank you so much for joining us today. This is awesome.

Dr. Mojola Omole:

Thank you so much.

Dr. Jeannie Callum:

Oh, that was a great conversation. I had so much fun. Thank you.

Blair Bigham:

Dr. Jeannie Callum is the Director of Transfusion Medicine at Kingston Health Sciences Centre.

Dr. Mojola Omole:

So Blair, what were your takeaways from this really exciting conversation with Dr. Callum?

Blair Bigham:

Well, I'm excited to know that these protocols continue to be refined and I guess disseminated, and really trying to get hospitals to not just have them on paper, but have them ready to implement in practice. Because again, it's like responding to a code blue. There can't be delays. Everything has to go smoothly. It also makes it really easy for clinicians who don't do a massive transfusion monthly or weekly like a lot of people in maybe a busy trauma center or a busy GI center. When it's a rare occasion, it's so helpful to have it protocolized. And Jeannie really gave us a sense of how easy those protocols can be when they're implemented to perfection.

Dr. Mojola Omole:

Well, I think she makes it look easy, but I'm sure that this is very challenging to coordinate. And I look forward to how when they... Because I'm sure they're going to be collecting the data of how does this work in different settings because part of our geography in Canada is that it's very vast, and we have different accesses to services. So I'm looking forward to seeing in the future if there's ways to modify this for settings that are low resource.

Blair Bigham:

And it doesn't always happen where you think it's going to happen like in the emergency department or in the operating room. And so this type of thing, it can happen anywhere where people have these massive bleeds. Sometimes it can be a little bit difficult to recognize, for example, if it's luminal bleeding, but you got to be ready to pull the trigger, and the massive transfusion protocol just allows the whole hospital to know that there's a situation going on and it's all hands on deck.

Dr. Mojola Omole:

Wonderful.

Blair Bigham:

That's it for this week's episode. Just a big shout-out to all of our listeners. We just hit a quarter million downloads. Thank you so much for listening, and please continue to like and share our podcast so that we can get the message out there and spread all this amazing expertise that we get from our guests. And a huge shout-out to our producer Neil Morrison from PodCraft Productions who keeps us on track and keeps our audio sounding pure. I'm Blair Bigham.

Dr. Mojola Omole:

And I'm Mojola Omole on my way to become a podcast superstar. Until next time, be well.