Whole Blood in EMS: Life-Saving Science, Challenges & Implementation

Whole blood transfusions are gaining momentum in EMS, but how do they work in the field? In this episode of The Erik and Matt Show (EMS), Dr. Erik Axene and Matt Ball sit down with EMS medical directors Dr. Joshua Bobko, Dr. Mark Gamber, and Dr. Cynthia Simmons to break down the science, real-world applications, and the logistical challenges of whole blood programs. From trauma cases to medical emergencies, discover how prehospital transfusions are changing the game for paramedics and firefighters.

Transcript

Narrator: [00:00:00] Please be sure to like, share, and subscribe. 

Dr. Mark Gamber: Cause they're like, Oh my gosh, there's going to be a mismatch. You know, what if you give mom low titer OPAS whole blood? And I'm like, you know what? Mom's alive. 

Dr. Joshua Bobko: We really need to start thinking about our, our, our paramedics, you know, and our, our EMS providers as pre hospital clinicians.

Narrator: You are listening to EMS with your hosts, [00:00:30] Erik Axene and Matt Ball. 

Dr. Erik Axene: Well, it's an honor to be here today. We got a cool show. Very cool. We've had world record holders on the show. We've had some really interesting guests, but we haven't ever had three guests in one show. We've had two. Yep. Uh, but three in one show, a bunch of wonderfully talented medical directors.

Um, of course, uh, if you're joining us, you've been here before with, with Matt. Why don't you tell us a little bit about yourself? Man. 

Matt Ball, RN: Oh, nothing to tell. Firefighter, [00:01:00] paramedic, registered nurse here in the Dallas area. 

Dr. Erik Axene: Dr. Ball? 

Matt Ball, RN: Yeah. Ditch Dr. Ball. 

Dr. Erik Axene: Yeah. Okay. Uh, I'm Dr. Axene, medical director, uh, and, uh, ER physician.

Renaissance, man. Three friends with me here today. Uh, uh, really, we got a great discussion on whole blood today and we got really some unique perspectives. So, um, without further ado, I'm going to, uh, Dr. Bobko, uh, Dr. Gamber and Dr. Simmons. Um, and [00:01:30] we'll have each of you guys, if you can just introduce yourself briefly and then we'll get right into it.

Uh, let's start, uh, ladies first, Dr. Simmons, why don't you tell us a little bit about your history and your perspective on whole blood, a little bit about yourself. 

Dr. Cynthia Simmons: Hi there. Um, I'm Dr. Cynthia Simmons and I'm the medical director for the Arlington EMS system, which includes Arlington Fire Department and AmErikan Medical Response as a transporting agency.

Um, I've held that role for almost 18 years and also practice emergency medicine. I've been in the ER for almost [00:02:00] 30 years. Happy to be here. Awesome. 

Dr. Erik Axene: Thank you. Awesome. Glad you're here. Thank you for joining us. It's early. Not as early as Dr. Bobko. Dr. Bobko, why don't you tell us about yourself? 

Dr. Joshua Bobko: There's the awkward silence between me and Mark.

Uh, my name's Josh Bobko. I'm a, I'm an ER doc and a EMS physician out in a small place called Orange County, California. And, um, we have earthquakes and avocados. Um, but [00:02:30] occasionally we do see some fire. And, uh Right now in Orange County, we don't have blood, uh, but it is rapidly sort of expanding through the state through, um, different areas going to, to apply for local scope of optional practice.

And we can talk about some of that process and some of the regulatory things that are affecting who's doing it, who's not doing it. So look forward to [00:03:00] being part of that discussion. 

Dr. Erik Axene: Awesome. 

Dr. Mark Gamber: Hey, Dr. Mark Amber, I'm an emergency physician and the EMS medical director for, uh, Frisco Fire Department. And Frisco's had a blood program, uh, since December of 2019.

Uh, we started, uh, as an exchange program with a local hospital that's a level one trauma center and we've, we started with component therapy and then we evolved into carrying whole blood. So happy to discuss that program over the last five years.[00:03:30] 

Dr. Erik Axene: Awesome. Thank you guys. Great, great introductions. Now, in our last episode, we talked about, um, hemorrhagic shock. We just filmed a lecture in San Diego. I was swimming with great white sharks. And, uh, we had, uh, We interviewed a gentleman who was on Good Morning AmErika. It was bit by a shark and a really neat story.

Keane, Keane, who agreed to be on our, uh, our show with us and, uh, and on the lecture. Sorry. [00:04:00] And, uh, so we talked a lot about hemorrhagic shock and we wanted to be able to bring in whole blood. And so that's where this. That's the genesis of this podcast today that you're participating in. So we're grateful to have you here.

Matt Ball, RN: I think it's that and to that, that whole blood is starting to become more mainstream within EMS for the long time. It's been mainly critical care, flight medics, nurses that have been doing whole blood. And now it's like my department, like we talked about is, is gonna, we're starting a whole blood program within this year.[00:04:30] 

And so, you know, Dr. Gamber and other. Uh, facilities out in our departments out in California sound like they're doing that as well and then Arlington. So this is kind of becoming more and more mainstream and I know like anything, you know, what firemen love changing the way things are, right? So it's one of those new things that every firefighter is going to have and why do we got to do this?

And, but there's a lot of data that shows this is really good stuff that we're going to talk about. And it's very important, uh, that we know when to use this, how to use this and why to use this. 

Dr. Erik Axene: Yeah. [00:05:00] Nobody would argue. Uh, about a STEMI or an occlusive MI and how the time is heart, right? Kind of the adage, time is heart.

And, and with stroke, time is brain. And with hemorrhage management, uh, time is blood loss. You could bleed out very quickly. So getting blood as quickly as we can, that's really the whole pathophysiology of what's going on with this type of a patient. I was reading, uh, not to get too far ahead of ourselves, but it was interesting to me to read that, [00:05:30] um, exsanguination is the number one killer.

of, of trauma patients and half of them are in the pre hospital environment. And then if you added on the medical indications for a transfusion in the field, that number doubles. So there's a huge patient population that would, that would fall under this bucket of needing a, a transfusion in the field. Uh, Mark, you know, we talked a little bit, uh, a couple days ago about some of the [00:06:00] medical indications.

outside of trauma. Um, and, and as you've been actually on the front lines delivering blood, what types of patients have you seen? Uh, can you give us some specific examples, maybe a story uh, of a, 

Dr. Mark Gamber: a save? Yeah, I'd be happy to. You know, we're about 50 50 split between trauma and medical. Recent medical cases would include a dialysis shunt bleed.

Have you ever seen one of those take off? I mean, it. [00:06:30] It goes quick, and so we had a dialysis bleed and hemorrhagic shock that we transfused. Another recent case was a postpartum hemorrhage that was in hemorrhagic shock that we transfused. Uh, and then certainly GI bleeds are a pretty frequent medical cause.

Um, you know, there's been kind of a proliferation of anticoagulants out there. And, um, it doesn't take much for an upper GI bleed to take off and meet hemorrhagic shock criteria as well. So those [00:07:00] are just a few examples. 

Dr. Erik Axene: Go ahead, go ahead, Matt. 

Matt Ball, RN: I was just going to say, like, we had kind of talked about this science behind, um, hemorrhagic shock and blood administration in the field.

I know Dr. Gamber, you said you did some, well, I'm sure all of you have done plenty of research on what is the data show as far as administering whole blood pre hospitally? What are the benefits? Like again, most EMS providers are going to want to know the why, why are we doing this? Is it really going to have an impact?

[00:07:30] Do we really have that many patients that this is going to affect? I know we've kind of touched on that, but what does the data tell us? 

Dr. Erik Axene: I can tell you, there, there are multiple trials that have been done and I know one of the big ones was the SWIFT trial and, and there was also another pre hospital blood transfusion initiation coalition where they studied 1, 500 patients and there was a 2 percent increase in mortality, um, with every minute of [00:08:00] delay of transfusion of blood based on that study.

So I know, and it, and it also, um, And, and you guys can connect, correct me if I'm wrong from a trauma perspective, it's really only penetrating trauma that showed the, the significant benefit. Really? Yeah. Just the penetrating trauma, blunt trauma. The evidence hasn't been there. And I'm not, I mean, um, the pathophysiology of a blunt chest trauma, as opposed to a stabbing.

I know 

Dr. Cynthia Simmons: ED [00:08:30] Thoracotomy. We used to teach this. We used to teach the golden hour, the old legacy golden hour. And, That, that mantra is really not holds true for hemorrhagic shock. And so it, utilizing blood in the field has really improved survivability, uh, and there's multiple studies that have shown that.

Dr. Joshua Bobko: Yeah. Yeah. And I think Erik, to your, to your point, you're probably referring to the refill trial, which is a UK [00:09:00] center study where they were. You know, it was about 80 percent blunt trauma. Um, and it didn't show, um, that there was any real survival benefit between standard care and, and transfusion. But I, I think before you kind of get into it, you kind of have to see how like these, these studies have evolved.

So just quick going back to that, you know, again, it is, it was majority blunt [00:09:30] and minority penetrating. But they also had some interesting time points where there was, you know, there was a bit of what we would, you know, call like remote medicine, where, you know, the on scene, like getting to the location was up to 30 minutes in some cases, and then they were on scene for an average of 20 something minutes.

So you're already at 50 minutes before you're getting blood plus transport. So, you know, I think what [00:10:00] what Dr Simmons is alluding to was that. As shock progresses, you, you start in, um, running into organ failure pretty quickly. And then you get into a point of irreversible shock where you essentially can't turn the process off.

And so with some of these studies, it's really important to see, you know, How it's being implemented and when it's being implemented because that drives the results and I think to [00:10:30] kind of go back to what I was saying originally is, you know, this all came out of a military, right? We've had the global war on terror for 25 years.

And fortunately. You know, those, those lessons that we've learned from the, from the blood of our, of our colleagues and our veteran friends have, have kind of driven this research, but there is a little bit of a difference because some of the early studies from like, um, Dr. Stacey [00:11:00] Shackelford and, you know, and, and John Holcomb, you know, they were looking at some of, um, some explosive type injuries as well, in addition to, um, Gunshots or blunt trauma.

And so that's, that's like a completely, you know, when you start including amputations, it's a little different than what we see in traditional EMS. It doesn't mean it's invalid. It just is a little different. And so then it started evolving into some of the civilian trials, like the pamper, [00:11:30] you know, which was the air medical trial.

And then, and then that 1, that 1 was given plasma, and then you had the combat trial, and then that 1 was looking at. Um, you know, after, after, you know, uh, trauma and, and, and they kind of disagreed, they were about, I don't know, Mark shaking his head, maybe 2018, 19, maybe when you were starting your, your, uh, process and, and, and you kind of the initial.

Impulse was good [00:12:00] and then the studies would disagree and then that's evolved and now you're starting to get really pretty good data coming out of like New Orleans and, um, and, and Houston and, and, and in the last year, even, you know, 2024 that has really kind of changed the tone of transfusion pre hospital.

Because I just don't think we didn't, we didn't know what we didn't know and, and the studies were [00:12:30] evolving and now we're at a point where people are actually doing it and you can look at your own system and your own, you know, your own processes and come up with data that's usable. So just wanted to throw that in there because I think there has been an evolution in these studies as it's become more broad spread.

Sorry to talk too much. 

Dr. Erik Axene: No, no, that was, that was, that was really keen. I wonder, have you come across like a minimum size department or demographic where the whole blood [00:13:00] programs, you know, based on the data actually have the benefit? A tiny little department wouldn't have the benefit necessarily. I think there's a probably a certain size and maybe more of the urban.

Matt Ball, RN: Yeah, I think it's, it's like you were saying when your department. There might be one patient a year, is that worth the hassle of implementing a whole blood program for one patient a year? That sounds terrible to say, but at the end of the day, that's reality. I know in my department, we looked at it, and last year they kind of looked at the numbers, and I think we were [00:13:30] looking at roughly 40 to 50 patients, probably, and that was just roughly looking at the indications would have received.

So that's a pretty significant number. How about you, Mark? How many do you have per year? Some 

Dr. Cynthia Simmons: of the smaller departments are rural. And those are the patients that are most likely to benefit from blood because they have longer transport times. So, if they can, uh, get a hospital to support their program and the finances that would support the program, those are the patients with extended transport times that could absolutely benefit from it.

And that's been [00:14:00] proven, actually, I believe the PROMET trial has proven it both in penetrating and blunt trauma.

Dr. Erik Axene: Mark, how many patients do you have a year with your blood program at Frisco? What's the data there? A 

Dr. Mark Gamber: little over one a month is the average for the last five years. So, you know, five years, 60 months, uh, about 75 transfusions. So that's, that's a city of 250, 000. Uh, you know, it's, it's a community that doesn't have a lot of penetrating trauma.

We're going to be, [00:14:30] you know, it's going to be more blunt than penetrating. And it's going to be, obviously, there's medical, uh, that's about 50 percent of the cases. And just to kind of, you know, be balanced, I think, I think it's appropriate to have the, is the juice worth the squeeze because there's an upfront cost, there's a lot of training.

Uh, so you've got to look to Dr. Simmons point geographically where you're at. Um, I also serve as Plano Fire's EMS medical director. They're about 300, 000 people and Plano has looked at this very deeply too and chosen to hold off from [00:15:00] carrying blood, whereas Frisco has moved forward. And when you look at the two cities.

Plano has a level one and a level two trauma center within the city that have whole blood in the ER. And this is, you know, whether it's component therapy or you're doing whole blood. There's just a lot of logistics that we'll talk through on this podcast about that. But there's just not a scenario in which, like, in Plano, I have 13 fire stations.

We can't put that at [00:15:30] 13 fire stations. This is a living tissue donation that we just don't have enough of to So, most cities put it on, like, one or two vehicles. And, um, you know, the question in Plano for all of us was can we get the blood to the scene before we can get the patient to the hospital? And in our equation when we ran the maps and the transport times and things we felt like the majority of the time we're going to get to the patient to the hospital faster than we get blood to the scene [00:16:00] due to short transport times level one and two trauma centers.

Frisco is a little more distant from those. We don't have a level one or a level two within the city. And so when we, uh, Uh, you know, when we looked at that, you know, we had a lot of construction, uh, we had a lot of significant injuries, but we didn't have a level one or a level two close by, transport time was going to be 20 plus minutes.

Uh, so I, it's, it's not rural, but it's not, you know, urban and right on top of a trauma center. It made more [00:16:30] sense to do that. And so we initially started out with blood on one asset, a squad program that could self dispatch anywhere in the city. We evolved and over the last two years, we actually have.

blood on a bat chief vehicle, one on each side of the city, so we kind of split it east and west. And, um, you know, we can get into it now or later, but I think there's an important conversation around not just, sort of, external advertising and talking about a blood program, but there needs to be constant internal [00:17:00] advertising to all your medics to talk about that first arriving engine.

You know, when you're looking at your call notes, what are you looking for? To get the bat chief on the way also with the blood because the dispatchers can't always pick that off It's it's got to be an internal sales job amongst all your firefighters to go. Okay. I believe I need to get the bat chief They're with blood or if you have a squad program I need to get the squad there with blood and then the folks who carry it.

They've got to be actively listening, too 

Dr. Erik Axene: That's a good point Dr. Bobkow or [00:17:30] Dr. Simmons, 

Dr. Joshua Bobko: I was just going to, I was just going to jump in there. I think what makes blood a little bit different in EMS versus some of the other things that we do, you know, like for example, sepsis, you know, trying to get people to recognize sepsis, um, looking at, you know, we're driven by quality indicators and how are we doing on these things, but at the, at the ground level operationally.

You know, my, my firefighter medics don't necessarily [00:18:00] see that they're helping recognize sepsis earlier in the hospital process is, uh, you know, they don't see the end reward of that. Other than at the end of the month, we say, Hey, good job, you know, our number is this or that. And, and that, and that's, that's pleasant, but you know, I think blood is a different thing where, you know, when we're asking about is a juice worse, but squeeze.

Well, it is a somebody, right? And when you've been on that case [00:18:30] and you don't have any other option and then somebody is gray and dying and then they're, they're, you know, better, um, you know, that that does have a significant impact. And I think that's maybe why it's resonated a bit with, you know, firing MS people because so many times they're put in that situation where They can't control a lot of things they, you know, there's a, there's a lot of, um, things working [00:19:00] against them.

And this is kind of something that gives them a solution that's achievable, attainable. Um, and I think that may be why it's kind of resonating. 

Matt Ball, RN: Yeah. One question I have for you guys as medical directors that I know a lot of medics, because I did, I wasn't introduced to, to whole blood or even a component therapy until nursing school and then critical care school.

So for the average run of the mill EMS paramedic for the average. [00:19:30] Fire department, paramedic explained to us the benefit when I went to paramedic school 20 years ago, it was, you got trauma. It was too large bore IVs and pour the fluid to him, right? Obviously we've learned that's a terrible idea now in trauma.

Why is whole blood explained to the average paramedic? Why whole blood is better than just volume with fluids? 

Dr. Erik Axene: Well, fused amount of words. I would say, uh, give them what they lost. Yeah, we've talked about the hemorrhage lecture. Yeah, 

Dr. Cynthia Simmons: it's not hard. It's not rocket science. It's just, you're losing blood. You need [00:20:00] blood.

Uh, that's exactly what you need. You don't need a lot of crystallide. You don't need a lot of saline or lactate ringers. You need blood. That's what you're losing and that's what you need. Um, and the idea is one to one. Uh, the most, a lot of studies out there have shown one to one is what, is what really improves survivability.

Um, yeah. And, uh, I will play off of what Dr. Bobko and Dr. Gamber said earlier in that bringing it home, we unfortunately in Arlington had a firefighter that [00:20:30] was shot in the chest. Um, and having lived through that experience, um, We did not have blood. We're still in the process of getting a blood program, but to use the, if we had had that, to use it to treat one of our own would have been, would have been prudent and, and wise.

And so I think to bring it home, even, even to take care of our own people, is, is just something that, that we need to [00:21:00] do. And blood is there. Blood, blood, blood can save lives. There's just, there's just 

Dr. Mark Gamber: Yeah, Dr. Simmons, I think your point is well taken. Um, it is just as important for patient care as it is for protecting our own.

And it's not, it's our firefighters, it's our police officers, it's our tactical teams. You know, you in Arlington have these incredibly high profile events, and, you know, we have to think about how we take care of our first responders when those things come up. And, Matt, to your point, [00:21:30] I think about things very simply, and I just think about the Kool Aid is on the concrete, right?

So we're spilling Kool Aid. And, um, you know, earlier, Dr. Axine, you talked about stroke and heart attack. That's ischemia of the heart, ischemia of the brain. Trauma is full body ischemia. And so with fluids, we just diluted the Kool Aid. You know, your oxygen carrying capacity is spilling all over the concrete.

And with just fluids, you've just diluted the Kool Aid and the oxygen carrying capacity. And your whole body is ischemic, so we need to replace that oxygen carrying capacity. [00:22:00] Otherwise, people die. Their whole body is ischemic. They go into multi organ failure from hemorrhagic shock. And so, we're just We're just bringing the medicine to the people by carrying blood.

It's just, as long as you can get through the logistics, it's not that big a deal. 

Dr. Erik Axene: Dr. Simmons, Dr. Bobko, have either of you looked into the number of people you would have, hypothetically, if you had a blood program? 

Dr. Cynthia Simmons: Um, we haven't done a full review of all of our charts, but we certainly have anecdotal reports, and we probably have two or three [00:22:30] a month that we think we could have given blood to, um, potentially.

So, but Certainly, I think two or three months is what we're looking at. 

Dr. Joshua Bobko: Yeah, I'll tell you, over the last three years, we're looking at about 275 people. Um, I, I put some of that information into some statistical stuff to try to create a map. And so, I know what cities that we would probably start in as well.

[00:23:00] And so, but I think the Maybe that's, maybe that's the next segment of, of the conversation is, you know, then why, why doesn't everybody have it? Right? Because, you know, you, you, there are some things and we're talking about protecting our own, you know, I, I use that example all the time with airway, right?

Like, we shouldn't be sticking eye gels and firefighters ever. Um, so the, the same goes to blood and, and I think, [00:23:30] you know, what you look at, right? Where that, where those two connect is, again, I think it was, um, out of New Orleans, the, the Tulane study actually showed decreased intubations, um, because one of the highest risks for trauma is obviously peri intubation and peri operative arrest, because we haven't properly resuscitated, so they were actually looking at the number of, um, cases that that had to be intubated that were, you know, traumas that [00:24:00] were, you know, had whatever their ISS score was.

Um, and, and I think it was, you know, the number intubated was about 10%. If you got blood, it was about 10 percent of the cases that did not get blood that got blood, meaning I think it was about 12 percent for people that were normal resuscitation, about 1 percent for the people that got blood. And that's a really big deal, going into an OR, and you find out that, you know, you're not even [00:24:30] having to intubate these people, and their hemodynamics just improve, you know, you kind of turn off that, that, um, that cascade.

And, and I think that's something else that is probably going to start coming out in the, in the literature as well. 

Dr. Erik Axene: Well, that's huge in health care. I know, uh, from a health care perspective, we can minimize complications. We decrease health care costs tremendously. Sure. In an [00:25:00] unrelated but very related topic.

I mean, you can, by preventing, uh, an OR stay or by preventing even a genetic disease that you could have screened for, the screening cost saves the healthcare system a ton of money. So even though these blood programs might be expensive, but by getting patients blood early, you've prevented that. the intubation.

You've prevented the need for the ICU potentially. You've prevented the need for the OR. I mean, there's a lot of very powerful things, Dr. Bobko, you've brought up that, that add a lot of value. In the healthcare world, we [00:25:30] call those soft savings. They're not direct savings, but they're soft savings. And, and by seeing the benefit of it from a healthcare perspective, you can save a tremendous amount of utilization of higher level of care, which is a, in our healthcare system, we need more thoughts like that.

It's, um, we have a very expensive healthcare system, and I think the pre hospital use of blood, I think we've established that. The science behind it. 

Matt Ball, RN: Yeah, the evidence is there. The evidence is there. to back 

Dr. Erik Axene: it 

Matt Ball, RN: up. Yeah. It's exciting for me as a, as a EMS guy [00:26:00] from the fire department, right, that gets, you know, all kinds of slack from the fire gods that, um, There's something I can actually do now for my trauma patients, where in the past, you know, you go on these major accidents, and maybe it's a prolonged extrication time, and I'm sitting there itching, like, my patient's dying right in front of me, and there's nothing I can do for them.

Like, giving them fluids isn't going to help. I can intubate them like you talked about. They need blood. They need a trauma surgeon, and there's nothing I can do for them here on the street, and it's extremely frustrating, uh, from [00:26:30] a guy that, like I said, is, is EMS minded, that This is something that's relatively simple in concept to do.

Obviously, the implementation sounds like it's a little bit more complicated, but it 100 percent saves lives, uh, out in the public, and I think, you know, every, any, any EMS agency needs to look at the benefits of doing this. I know, Dr. Simmons, you talked about rural departments. I know, like, funding is a big problem with a lot of smaller, rural, even volunteer departments.

And the [00:27:00] benefit there is that they can call for, you know, flight, you know, typically if they have a big trauma out in the county and they have an hour ground transport time, they're calling for a helicopter anyway. And those helicopters are bringing them blood. Typically I used to volunteer in a small department and that's, we would even fly a lot of patients from McKinney.

Now we don't because we've advanced our skill level. And I think we looked at doing a whole blood program about six, seven years ago in McKinney. And And from my perspective, I wasn't a fan of it [00:27:30] because I knew where we were at from a provider education and ability level. And we were not doing the basic things at that time correctly.

And there wasn't enough, um, there just wasn't enough people. I knew that people weren't going to do it, even if we had the ability to do it and we train them to do it. The majority of the department was not going to do it. Now, Dr. 

Dr. Erik Axene: Gamber said the internal advertising. Exactly. 

Matt Ball, RN: Yes, guys. If I mean, you can have all that, you know, they talk about a dose of diesel.

Well, a dose of [00:28:00] diesel doesn't again, like in a prolonged extrication, you don't have that option and the blood is the option there. So you have to have buy in from the folks that are going to be doing this for sure. Well, that's the perfect time. Go ahead. 

Dr. Cynthia Simmons: Yeah. This takes coordination. It takes communication.

It takes internal buy in. It takes protocols. It takes coordination with the hospitals. It takes logistics and equipment, refrigerators and temperature sticks and other things like that. It takes money. It takes coordination and communication with the hospital who's supplying the blood. Returning the blood before [00:28:30] it expires.

I mean, so to your point, there's a lot of preparatory work. I think that has to go into a program. Um, we are, we've been working on our program for over a year and we're still not. Um, in, in, we're still not in service yet, um, right now we're working through legal issues. So, there's a lot of different things and Mark can probably, since he, Dr.

Gamber can probably speak to that since he's been through those logistics, but, um, it, it, it takes, it's taken us a year and, and [00:29:00] we're, we're almost at the, at the end phase, but it, it takes some work. 

Matt Ball, RN: Let's take a quick break before we get into that. And we'll come back and talk about the next two parts of that, which is implementing the program and then the indications for the patient.

Dr. Erik Axene: Yep. And then pitfalls and challenges, 

Matt Ball, RN: pitfalls and challenges. Let's take a quick break.

Narrator: You are listening to EMS with your hosts, Erik Axe and Matt Ball. 

Dr. Erik Axene: We're back [00:29:30] already. I didn't see the countdown. Man. I'm glad you're here. Well, we had a great first segment. Uh, we're going to hit up, uh, part two here. Uh, we great discussion on some of the science and the, and the evidence, um, and some of it.

Pun intended, bled into this, but, uh, I think the indications and the, the challenges and pitfalls would be an interesting conversation with, with, uh, Dr. Gamber, Dr. Bobkin, Dr. Simmons. So, um, indications for it, identifying the right patient. [00:30:00] Yeah. You know, when we did our hemorrhage lecture recently, we were, we were trying to educate our, our students on the importance of early identification.

Uh, early identification and, and, and in this case, I think identifying the, the patient that really would have the benefit of, of a field transfusion. And, you know, we want to be a good steward with, with the blood that we have. Um, certainly if we're just throwing it around willy nilly, that's not gonna be a good thing.

Um, but, uh, as far as indications go, [00:30:30] we talked a little bit about penetrating trauma, uh, versus blunt trauma. Um, I, I know, um, you know, we, we don't need to talk about, uh, the specifics necessarily, but in identifying a patient in hemorrhagic shock, there's, there's a lot of education that has to happen to be able to identify the patient profile.

Um, Dr. Gamber and I, we talked a little bit about this a few days ago, um, you know, just looking at. Uh, the, the profile of a patient's, um, [00:31:00] vital signs. I mean, the, the, we don't want to treat numbers and just start throwing blood out there. It's more to it. There's a clinical context. Um, Mark, what are your indications?

Do you, can you just run through just at a high level of your protocols and what you use? I'll cover some of the indications and it's 

Dr. Mark Gamber: a lot about context too, right? So you gotta, cause some of it's based on vital signs and you know, if a teenager wrecks their parents car, they're going to be tachycardic and tachypneic.

And they might trigger some of these things, but they're not bleeding, and you're not, they're up [00:31:30] walking around. So you can't just be algorithmic and go, ah, they were in a wreck and they're tachycardic. You know, so you really, the, the top of the protocol reads, uh, in the setting of hemorrhagic shock with suspected need for mass transfusion due to marked internal or external blood loss.

Like, I need you to commit to you really think they're bleeding, not just that they're having an anxiety attack causing abnormal vitals. So once you're committed to thinking, man, I think there's a big time internal or, uh, external bleeding, then the indications for [00:32:00] us are, you know, anybody with a systolic of 70 or less is automatically a candidate.

Anybody with a shock index, um, that's, uh, over 1, you know, so ours is going to be like a heart rate greater than or over 100 with a systolic blood pressure at 100 or less. Um, that's another indication. 

Dr. Cynthia Simmons: Um, 

Dr. Mark Gamber: this is where we, you know, we started this early, but we, we chase Entitle CO2 as an indicator, and we think it's been pretty accurate, so big shout out, first of all, as Dr.

Bobko mentioned, to the military, and then this [00:32:30] went into, San Antonio's a big military area, and a very early adopter, so I consider C. J. Winkler and Dave Miramontes, and then some of the military trauma surgeons down there as kind of the, really, the forerunners into translating this into the civilian theater.

And so I just begged, borrowed and stealed from those guys. And C. J. And I talked a lot about using entitled C. O. Two is an indication. So 56 years ago we started saying, look, if you're entitled, C. O. Two is 25 or less. Um, in the setting of what you think is [00:33:00] hemorrhage, then we're going to say yes to transfusion.

We find over the last five years for us, that's been very accurate and I think C. J. Would say the same thing. And then any witness cardiac arrest less than five minutes prior to arrival. Uh, in, in the setting of trauma, uh, or GI bleed we'll use as an indication as well. And I used to have some specifics around this, but I've learned to just trust the firefighter's spidey sense.

So basically, mechanism based, if you think you have significant penetrating trauma, you know, now if a kid in [00:33:30] school stabbed another one in the foot with a pencil, that is penetrating trauma, but that is probably not something that's going to cause hemorrhagic shock. But anything that looks significant to you.

You know, because I've seen people, you know, bleed out from an arm or a leg GSW, so looks significant, penetrating trauma, that's an indication for us to transfuse, irregardless of vitals, because some, Wayne Gretzky said, skate to where the puck's going to be. Sometimes we get there so fast, they haven't, they haven't knocked their vital signs to a point it would indicate it, but if [00:34:00] you see a bunch of holes in somebody, you know where they're going.

Go ahead and transfuse him. 

Matt Ball, RN: Two questions. It sounds, the criteria that you talked about, it sounds identical to the sepsis criteria, except without a presumed source of infection, you have a presumed, that your patient is bleeding. Everything else sounds the same. Yeah, I mean, it's 

Dr. Mark Gamber: different forms of shock, right?

You've got septic shock, your body's falling apart. You've got hemorrhagic shock, your body's falling apart. 

Matt Ball, RN: Do you automatically, do your guys automatically transfuse blood in a traumatic arrest or only [00:34:30] because hemorrhage is the number one cause of death and trauma as we know, do they automatically do it?

If we can get it there, 

Dr. Mark Gamber: we do if we can get it there. Okay. 

Matt Ball, RN: Okay. Just 

Dr. Erik Axene: curious how 

Matt Ball, RN: that worked. 

Dr. Erik Axene: Mm-hmm . You mentioned identifying hemorrhagic shock and I, I, I wish I, I can only have so many studies up here with me, but there was a study done on folks, you know, guessing how much blood was lost and we're really, really bad at it.

We're really bad at it, you know, it wasn't a, was it, you know, a hundred [00:35:00] ccs of blood or was it two liters of blood? We, it's, uh, there's a wide range of guesses. So, I like what you said, that spidey sense, Dr. Gamber, and, and trust, trusting our paramedics, which I think has a lot to do with training, which we'll get to with challenges, but um, I think as far as indications go, uh, identifying that patient population is, is key.

Any, any other thoughts, Dr. Bobko, Dr. Simmons? 

Dr. Joshua Bobko: If, if I may, I just wanted to, I think that trust is a [00:35:30] really big, it's a really big deal. And I don't know, Dr. Simmons, your experience, um, but one of the issues that I, that I definitely have noticed, at least in our local areas, I think there's a little bit of a hospital based misunderstanding of pre hospital transfusion.

Um, and in fact, there's, you know, I've had conversations with, with, uh, some of our Some of our trauma docs and, uh, and not necessarily the university setting, but [00:36:00] some of the community trauma centers that perceive some, you know, because there is a scarcity for resources, they perceive some competition with EMS for blood.

Right? And the argument kind of goes, you know, if there's only so much blood or well, first off, the argument may be, I can't even get whole blood in my, in my, in my trauma bay. Right. That's number one. And then, and then within the systems, you'll have a hospital that has whole blood and another [00:36:30] hospital that has just blood components.

Uh, the second is if I can't even get whole blood in my trauma bay, then why should, why should it be on the ambulances? Um, you know, wouldn't it be better at the trauma center since I'm trauma surgeon, we have all the bells and whistles. Um, but I, but I think it, You know, there's sort of a fundamental misunderstanding from a hospital based perspective of what we are trying to do.

I'm sure, as my colleagues will [00:37:00] attest, and yourself as well, we, we just want to find the people that need the blood and they give them the blood as soon as possible. Like, like, I don't really care who's got it or how it happens. I just want them, I want us to get really good at identifying it. And I think that's where, you know, sort of the Uh, like the minutes matter trial kind of starts to show where, you know, for your, your odds, mortality, your odds ratio for mortality goes up 11 [00:37:30] percent per minute, you know, I mean, that's, we need to start looking at, at, can we really do what we, what we say we can do, because sometimes, you know, when you get to the hospital, things don't, things don't always just happen instantaneously, there's, there's always got to be, You know, there's a dispatch and then there's, I mean, there's a call and there's a dispatch and then there's on scene and then there's treatment and there's transport, then you get to the ER and then there's another assessment and then there's got to be an order and then it's got to come up.

Somebody's got to [00:38:00] run to grab it from the blood bank and then bring it up and then by the time it's in somebody's arm, it's, you know, I mean, again, I think it was the minutes matter was showed that it's like 26 minutes, right? So yeah, yeah. So we, we, we just have to do better, but we have to bridge that, that, or we got to crest that trust mountain of, we're going to do this as a system and, and we're going to trust our people to do it sooner rather than later.[00:38:30] 

Dr. Erik Axene: I'm glad you brought up trust. That's, that's, that's huge. And, and we can't be in all these places. Our, our hands are working through the hands of, of our medics. And, and that's enormous. 

Matt Ball, RN: That's a perfect thing for the providers to know, the paramedics out there. So, I, I teach outside. And one of the departments that I taught at recently went.

to sequence inhibition or basically brought on paralytics, right? And it was a new thing for that fire department and a lot of the [00:39:00] questions I got when teaching the medics was, well, why do we need to do this? They're going to do it at the ER. And that was Dr. Bobko, that same thing that you just said was what I told them was, you know, they would say, well, our transport times are only five minutes.

Okay. But. You're on scene, you're not immediately going to load your patient and leave the minute you get on scene, you're going to be on scene for a few minutes, then you have a five minute drive, then once you get to the hospital there's a delay before the doctor comes in or [00:39:30] whoever comes in, so you're looking at 15 to 20 minutes of that patient is hypoxic, and as we all know in trauma that's a really bad thing, or in anything that's a really bad thing, so we can do that in the field, And, you know, help those patients.

It's the same thing here. If we can give blood in the field, we're dramatically increasing our patient's chance of survival. And so, like you said, it's, it's, uh, it doesn't really matter who gives it. If we, if we don't get the patient to the trauma surgeon at the hospital, he's alive, he's got nothing to work with.

[00:40:00] But 

Dr. Erik Axene: That's good. So we have the indications here, and I think you've kind of Brought up a challenge. This is this developing that trust with the with our whole health care community. This isn't a one a one person job. I mean, this requires a group of people. It's like a link. We're just a link in this chain.

Um, Dr. Simmons, you you. talked a little bit about some of the legal challenges. I guess we could jump into that now. Some of the challenges of this, [00:40:30] what legal challenges are you having and what can you share with us? 

Dr. Cynthia Simmons: Well, so again, I think it's the combine. We have a combined entity where I'm at, where we have a private vendor that's doing transporting and a fire based first responder organization.

And so for us, it's a matter of coordinating and communicating with Those two entities along with multiple receiving facilities all from different hospital systems. So we have two level twos and one level three trauma [00:41:00] center really two level three trauma centers that are in close proximity of our Of our transporting radius, and so communicating and coordinating, um, and like was mentioned previously, I think some of the biggest pushback that we've actually had was initially from the blood bank and them not wanting to give up their precious resource through the EMS systems, and so we've had some sit down communication and meetings With the blood banks, we had to [00:41:30] prove and sort of show our temperature regulation.

So we've done several months of freezer temperature regulation monitoring to show that we have responsibility and communication and have training to be able to return the blood before it's expired. And so all of the logistics of the, of the, of the program. To be able to work with our colleagues and with the attorneys from each of those respective agencies.

Um, so it's involved a lot of coordination and communication at [00:42:00] many different levels. Um, but there's an absolute benefit in it, an absolute, uh, Absolute, uh, life saving potential. It's just a matter that the logistics and the meetings have to occur, whether it's from blood bank or hospitals or different agencies, EMS agencies, um, and the attorneys for all of them.

Dr. Erik Axene: Now, we here in Texas, we're in a more of a progressive environment. Um, Dr. Bobko, you and I talked yesterday a little bit about some of [00:42:30] your challenges, um, with the way that your medical direction, I think you have a county medical director who functions under the state medical director. Is that kind of how it works?

Is that right, Dr. Bobko? Yeah, so, 

Dr. Joshua Bobko: again, I, trust me, the last thing Texans want to hear about is California. Um, I, I respect that tremendously, so I won't bore everyone, uh, but yeah, basically California cedes the authority to what are called local EMS authorities, uh, throughout the state. [00:43:00] And then those local EMS authorities kind of set the tone.

There is, there are things that are, um, you know, agreed upon at the state with sort of common scope of practice, this kind of thing. Um, yeah. Medicines, um, you know, but and you can apply for local optional scope of practice and those have to go through the state process with the, uh, okay of the local EMS authority.[00:43:30] 

Um, so, so again, I'm totally the wrong person to have. You should probably have Steve Patterson on here from Corona Fire, um, who has the first running blood program in the state. Um, I know Ventura, Los Angeles, um, city and county, um, Sacramento, and I believe, and I know, uh, Riverside, San Bernardino, everyone, everyone has gone through that process.

So they're in varying [00:44:00] stages of, of, uh, implementation, but Steve and Corona is number one. So I got to give him his props. I think former Loma Linda colleague of yours. 

Dr. Erik Axene: Oh, I didn't realize that. What's his name again? Steve Patterson. Steve Patterson. Very cool. Was he in attending out there? Yeah. Oh, okay.

Dr. Joshua Bobko: Yeah. So, um, he, he is, he, he's been attending. I think he works a lot out at, out at Riverside. Uh, Okay. [00:44:30] But he's been, I know he's the, uh, medical director for San Bernardino Sheriff's Air Rescue as well. Um, so, uh, and just an all around great guy. Like, if you, if you need anything in California, he probably knows how, how it works.

Dr. Erik Axene: Ah, very cool. Well, those are interesting challenges in California, and you know, actually, from my perspective, this is one of the coolest things of this, this collaboration right now is to hear [00:45:00] Dr. Simmons and Dr. Gamber and I communicate with you and Dr. Bobko in California to see how some of the struggles are the same, but they're different.

Uh, the, the, uh, we have more in common than we have different. I know Texas is a whole lot different than California. We kind of joke around about that, but, uh, it is really cool. Say it again. Austin. Except for Austin. Keep it weird, right? Something like that. Yeah, that's right. But I think to 

Dr. Joshua Bobko: the point, and then I'll just, I'll end the California [00:45:30] part of this.

At least for us, again, the way that it has to work, we don't have sort of the delegated authority. So for us, um, depending on your local authority, you may be able to do some of these local applications or trial studies. Um, or you may not, and that's, that's kind of how it works. And if you are in a, in a place where, um, that it is, um, a little bit more [00:46:00] progressive, then generally that, that kind of filters through the system.

And then in other places, you know, we've talked about some of the, the rural, I know, I know Dr. Simmons was talking about some of the rural areas and not having money. I'm again, I'm in Orange County. We have all the resources in the world and we have, we have long time transport times for people that like to live in the canyons or down by the beach.

And, but the system has to be willing to make this change. [00:46:30] Um, and sometimes it takes, you know, it takes quite a bit of pushing, um, because everybody likes to stay in the little comfort bubble. And, and that's really, I think, getting this, these messages out and talking about the new studies and the places that are doing blood, like Dr.

Gamber, like creating their own research that other agencies can pull from. It's going to be super important for some of the people that are on the sideline waiting to see what happens. You know, there's, there's, everybody's always waiting for the mythical [00:47:00] study that says here's exactly how we should do it and why.

Dr. Erik Axene: Yeah. Well, you know, Mark, you're Working right now with the Whole Blood Program, now we can talk about a ton of different challenges and pitfalls. You've experienced a lot of them, um, and, and Dr. Bobko and Dr. Simmons are experiencing them currently. But as you move through and have been in a program now since 2019, maybe you could talk a little bit to some of the challenges and pitfalls you've experienced, [00:47:30] whether it's storage, transportation, blood handling, supply chain issues, uh, training.

All that. Maybe just to tell us a little bit about your experience. 

Dr. Mark Gamber: You know, I think the first thing was sourcing. So we were inspired by a case. We had a, a really interesting field amputation case. Uh, the guy was in hemorrhagic shock and um, uh, air ambulance brought blood to the scene. And we were inspired by that and thought, you know, maybe we could do [00:48:00] that too.

Uh, in San Antonio, the, the regional blood bank is, is really good about working directly with EMS, but that's probably not true in most of the United States. There's just not, there's not necessarily a mechanism to give back. One of the primary tenants of our program is we don't want to waste the precious resource that's given to us.

So how do you do that? Because these, it, the, the expense is something, you know, 500 for a unit or so. That's what I got. So that's potentially a [00:48:30] cost. And so we needed somebody that was willing to give us blood and take it back if we didn't use it. Because we knew we weren't going to be an incredibly high utilizer.

We knew we'd use it sometimes. Local blood banks in Dallas Fort Worth weren't ready for that yet. So we went to a hospital. And I would say you probably want to go to a place that's a level one trauma center because They're, they use a large volume of blood. When we started in 2019, that was mostly component [00:49:00] therapy, packed red cells and platelets.

And you think about all the surgeries that go on at Level 1 trauma centers, much less all of the anemic patients like cancer patients that get transfused. And they're using, you know, a hundred plus units a week easily. So if we weren't using the asset, we could bring it back. And it would get put in the pool and used immediately and there's no wastage.

And as long as there's no wastage, there's no charge then to the fire department, which makes it a budget neutral program for our taxpayers, other than [00:49:30] some of the upfront costs. So that, that's how we got started. We, uh, we developed a contract with a Level 1 trauma center that was kind enough to sit down.

And like Dr. Simmons mentioned, they wanted to look at our processes, which is totally appropriate because if we're bringing the asset back to them, they need to know it's safe to put into their patients and that we've been a good steward with that. So, that's where there's, you know, there's roughly a 10, 000 upfront expense when you're looking at getting temperature monitoring systems.

Uh, you're looking at getting, you know, fancier [00:50:00] coolers. We even went to the point of getting one of those Hemler blood fridges, just like, you know, the blood banks have at our main fire station. So, you know, just ballpark, think about 10, 000 for upfront cost to get this going. Um, and then you gotta think about blood warmers, too.

And you just put that on the one resource, you know, the unit that's got, in our case, the Bat Chief vehicles. We actually, after a while, put the blood warmers on all of our first line [00:50:30] apparatus because we wanted the patient with a line in blood warmer primed and ready to go so that as our bat chief showed up, everything was ready to go to just hang the blood because we were trying to reduce the time to get blood in humans.

We can't get blood on every asset, but on every apparatus, but we can get a blood warmer on every apparatus. So we've evolved to that over the last couple of years. So, we, we circulate blood back through the hospital about every, uh, [00:51:00] 10 days to 2 weeks. And so, there's a lot of people, you know, power that goes with that.

Our, shout out to Jack Sides, our EMS captain. He's been doing this for 5 years and he runs a lap to the hospital roughly every 10 days to 2 weeks, uh, to, you know, to, to drop off blood before it expires so it can be used in the surgical pool and to pick up a fresher batch for our patients. And he's got a tight relationship with the folks in the blood bank.

We keep logs, so we show them that we're being good. And here's the great news. Five [00:51:30] years, no wasted blood. That's good. If we use it, then we pay, pay for it. But if we don't use it, it's, it's an even trade for the new stuff. Now going to whole blood has been something of the last couple years. And you have to have a place that has whole blood, right?

So your average community hospital is not going to have whole blood. They don't really have mass transfusion protocols at non trauma centers or level 4 or level 3 trauma centers, typically. It's typically going to be a level 1 or 2. And in order for them [00:52:00] to have an exchange plan, plan with whole blood, They have to use a lot of whole blood, because they can't give it out if they don't use enough themselves.

So, the hospital that we have the exchange program with, it's a level one trauma center, they kind of had to hit a critical mass of whole blood usage, probably about a unit a day, in order for us to be able to borrow some, put it on the field, and then bring it back if we don't use it, and they would still use it in time not to waste it.

And that's, that's the critical mass we've hit the last couple years. We're now exchanging whole [00:52:30] blood. Now, every once in a while they get short. So, our protocol allows for either one, whether we've got whole blood or component therapy. Our protocol covers either one. So, if we've got whole blood, we use that first.

If we've got component therapy, we give them a unit of plasma and then we give them a unit of PRBCs. We'll give, if we've got two lines, we'll give both at the same time. If we've got one line, we'll do the plasma first and then the PRBCs. Just talk about internal and external advertising real quick.

There's, there's a fun conversation around how you, you [00:53:00] educate yourself as an EMS medical director, EMS officer, and then how you lead everybody else through that education process. Right. You know, it starts with just doing military history. It's totally fascinating to look at World War II, the Vietnam War, the Korean War, and see what we did as we've evolved.

Uh, and then you get into the operational. You got to get out the blood warmers. You got to get out. everything and play with it as an entire department. This is not just a couple people. This is a program where your guy on [00:53:30] the engine in the periphery of the city has to know the indications for the protocol and has to know how to get the line and get everything working.

But just as important as talking to your local hospitals. because they got to understand what you're thinking about doing. And the trauma centers are going to be hip to the whole thing because they've already been doing it. But, you know, what about a postpartum hemorrhage? What about a dialysis bleed?

They don't necessarily need to go to a trauma center. And so now you're talking about taking somebody getting whole blood to a community hospital and [00:54:00] that blows some of their minds. Right? And I mean, I'll give you a great example of it. You know, we took a, um, a patient who was post, significant postpartum hemorrhage, hemorrhagic shock.

Uh, we started transfusing her. We arrived to a local non trauma center, and the doc said, I don't know why you're giving her blood, and threw it in the trash can. And she continued into hemorrhagic shock and the doc had to then order multiple units of blood for her. And she ended up a few [00:54:30] days in the ICU.

She had a good outcome or I wouldn't be bringing it up right now. But it's just, it's sort of an education point that you really have to go on the talk track at all your hospitals. And, and, and you know who gets really wound up about this is the pathologist of all people. Cause they're like, Oh my gosh, there's going to be a mismatch.

You know, what if you give mom low titer, OPAS, old blood? And I'm like, you know what? Mom's alive. Mom is alive. So baby's alive. So we'll worry about the next pregnancy. Now that she's 

Dr. Joshua Bobko: alive on that note, it's an interesting [00:55:00] dilemma because, you know, that's the thing that they are most concerned about in the world.

And you're kind of telling them, you know, yeah, that's, we have bigger problems, so that must've been a fun conversation. 

Dr. Mark Gamber: They're like, but, but, but you don't have checking and you're not. I'm like, they're gonna die, you know, let's get them alive to the hospital because all these, all these indications we just went over there.

There are indications for dying rapidly 

Dr. Joshua Bobko: to show that that's what's happening. 

Dr. Mark Gamber: So [00:55:30] sorry, a lot of that is just that's just sort of the anecdotes of life. Like you're saying that some of the research is catching up to what we're doing, but it takes people like us just leading on it. 

Dr. Cynthia Simmons: Yeah, there's this recent study that just came out that shows that with low titer Uh, whole blood that the risk of all of allotransfusion with a pregnant mom was at max 7 percent and much less than that in most cases.

And so again, yes, for a mother that's [00:56:00] hemorrhaging, uh, it can be life saving, absolutely life saving. In fact, 

Dr. Joshua Bobko: there's, I know there was a military study that I had, that I had read and I I'll have to find it. I'll send it to you, Erik, so you can, you can add it. But I think there are incidents in the military.

Was, was less than 1%. So, I mean, these are, these are very large, much larger numbers than any one trauma system that, or any one EMS system. 

Dr. Erik Axene: It kind of, it reminds me of a time I was, [00:56:30] go ahead. 

Dr. Cynthia Simmons: One of the things we did too was, uh, offer to have, uh, blood, uh, drives with our pathology and blood bank. And that was proceed, was received very well, especially if we offered to have like our recruit classes, our fire recruit and police recruit classes.

A lot of young healthy people donate a lot of blood and they, they absolutely love that idea. So it's a negotiating tool. 

Dr. Erik Axene: It reminds me of a time I was talking to a nephrologist and he was so concerned that I was going to cause kidney failure in this [00:57:00] patient who was dying. Uh, And listen, if this patient survives to the ICU on dialysis, that's a miracle.

We're given the contrast. Um, this is a good place for us. I think, uh, we'll just get ready for a summary here. I, I wanted to give each of you a time just to say something, final words. Dr. Simmons, any final words here before we, uh, finish up? 

Dr. Cynthia Simmons: Um, we've been teaching March algorithm, and we've been teaching, which is [00:57:30] different than we originally taught, um, and we've been teaching Golden Hour, but I think we've come to a place now where the science shows that we can do more than just stop external hemorrhage, but we can actually treat and replace.

Um, hemorrhage and prevent, um, severe hemorrhagic shock, um, from causing lethal, uh, complications. And it doesn't take a lot of blood loss. It takes about 40 percent, 30 to 40 percent, and somebody's in severe shock. And that's [00:58:00] not a lot. Um, and so we can really treat through the use of whole, um, blood cells, um, And whole blood, uh, the complications associated with that.

So, I think there's a lot of, um, logistics that have to go into any program. Uh, and kudos to the, the organizations and, and medical directors and, and, um, and departments that have, have gone through this. We're in the process of that currently. [00:58:30] And, and have gained and earned a healthy respect for the logistics that are required.

But, um, I think that. At the end of the day, we're here to provide the best patient care that we can, um, for ourselves, for our providers, for our tactical officers, and for our citizens. And so, um, I think that whole blood is one way that we can do that. 

Dr. Joshua Bobko: Dr. Bob? Um, sure. I, you know, again, I, I just, I'm following on Dr.

[00:59:00] Gamber, Dr. Simmons, Coattails, you know, all of the, all of the people that are, are kind of making this happen. Um, I think, I think what I would Issue may be a challenge to anybody that's, uh, that's listening or watching that, you know, that I think the trust component is a really, a really big part of E. M. S.

Um, and, and I think that there is this [00:59:30] some places have an overwhelming, overriding sort of dogma of, uh, considering our, you know, Pre hospital men and women as technicians, and I, I think we really, and, and as a result, you know, when, when you limit some, the amount of tools somebody has, when you, when you kind of put them in that box, then the amount of output and the amount of, um, sort of thought that goes in, you're, you're limiting as well.

And I think we really need to start thinking [01:00:00] about our, our, our paramedics, you know, and our, our EMS providers as. Pre hospital clinicians, um, they're going to recognize the same criteria that I'm going to recognize. And so we have to put a little bit of faith in them to make that decision for the benefit of the patient and then give them the tools to do something about it.

Um, but, but it's very hard for hospital based and office based system administrators to do that without [01:00:30] having those relationships with the men and women that are doing the job that, that we're asking them to do. Um, so I really, I really would ask that for my colleagues that are listening and for the, for the chiefs that maybe are listening and you're thinking about doing it for your medics, you know, our medics see more trauma and more codes than pretty much anybody in the world.

So to think that they're just technicians, I think is dramatically underselling the capability that is out there and we need to [01:01:00] put some trust into that capability. 

Dr. Erik Axene: Wow. Well said. That's. That's awesome. Couldn't agree more. Dr. Gamber. 

Dr. Mark Gamber: Yeah. You know, this is one of those mid career shifts when, um, Some of us were doing residency, me included.

We were still back in the days of let's give a lot of fluids and maybe we'll get around to giving a little bit of blood. And we were diluting the Kool Aid. And as we learned and changed our practices and evolved, um, as a trauma center, you know, we moved. to, um, different ratios of component therapy and eventually to [01:01:30] whole blood.

And it's incumbent on EMS medical directors like us and EMS chiefs to take the medicine that's in the hospital and immediately ask ourselves, how can we push that outside? And to Dr Bobko's point, we have incredibly skilled clinicians that can deliver this stuff. I think the medicine is now irrefutable.

That whether you've got access to component therapy or even better whole blood, get what you can and figure out how to get it in your system if it makes sense for you and you can afford the time and the training to do it. I think the juice is absolutely worth the squeeze to. [01:02:00] to do it. Um, and the other thing I'll just say is, you know, from a morale perspective, this is a really cool thing.

Um, you know, our job is to practice great medicine as EMS medical directors and also to serve as motivators and educators about how cool what we do is every day. And when we got together as a fire department and said, we're going to do this and we looked, got into the committees of going, you know, where are we going to put the blood warmers and where are we going to carry the blood and.[01:02:30] 

How quickly are we going to cycle it through? It was a ton of fun, and it was just a team building experience. And I find that the medics I work with in Frisco are that much more fired up about being medics because we have this program. I think it's very empowering, and when you do things like this, you're saying, I trust you, you're doing some awesome stuff.

And it's not just showmanship. Like, the medicine is great, the medicine is sound, but it's very much a morale building program, too. [01:03:00] 

Dr. Erik Axene: Totally agree. It's exciting. Dr. Ball. Yeah. Do you have any thoughts? Not even 

Matt Ball, RN: close. Yeah. Just off the heels of what they said that to the firefighter EMS, uh, private EMS providers, I, I find it very exciting that we're able to do this.

You know, we've talked about this a lot and I preach this a lot and I get a lot of kickback for this, but for 20 years I've been a firefighter. I have never once pulled somebody out of a building and saved their life by pulling them out of a fire. And [01:03:30] not only have I not done that. It's only happened maybe once or twice in my department in 20 years.

That is kind of what people think saving lives is when you join the fire department. And that's not reality. If you're in Houston or New York or a big city, it happens obviously more often, but for most of us, the most of the firefighters in the country, that is not. What you're going to be saving lives doing.

That's just not the reality. And this is something we train extensively. We go out to the training field and we drill on [01:04:00] all these different techniques to save somebody out of a building, which I'm not negating. That's super important. And a lot of times it's a firefighter that goes down and we need to get out our own.

It's extremely important. That same level of importance needs to be placed on EMS and programs like whole blood programs because like Dr. Simmons said, whether it's a police officer or a firefighter that has, you know, an, an injury or an incident on duty that we need to respond to a tactical medic, a car [01:04:30] wreck, whatever the case may be, um, we have to be just as prepared for a critically ill, Medical patient as we do a fire victim.

We have to do that. And so as I would speak to the paramedics out there that we have that responsibility that if whatever your protocols are, if you're implementing a whole blood program or R. S. I. Or whatever the skill is, you need to be proficient at that skill. You need to know the indications. You need to know when and how to give [01:05:00] this life saving therapy to your patients.

Um, like I said, I find it's, it's super exciting to me. It is the future of mainstream EMS. I think it's coming, uh, more and more. And so we need to be prepared for it. 

Dr. Erik Axene: You guys haven't left anything for me to say. I agree with all of y'all. Um, uh, but I will say this, though, is that more and more people are starting to recognize the importance of what we do in the pre hospital environment to the whole healthcare system, the whole continuum of care for our patients.[01:05:30] 

It used to be, and, and, you know, Mark and I, we talked about, sorry, Dr. Gamber, and I've talked about this multiple times, is that it's been a long time. For coming now for people to recognize the health care journey doesn't start at the ambulance bay doors. It starts in the pre hospital environment with dispatch and bystander CPR and all this.

And I think what's exciting for me, to Dr. Gamber's point, um, is that what we do is so exciting. And I don't think a lot of our colleagues really [01:06:00] appreciate how, how much of an impact we can have on the whole healthcare system. That, to me, is super exciting. And I think what I've To me, what kind of surprised me today was, was how excited I got to even talk about how much trust is involved here.

And I'm glad Dr. Bobko brought that up because I think that, that trust, that relationship that we have between the healthcare system, the hospital, and the pre hospital environment, the link between the two is us, guys. I mean, the, the, our medical [01:06:30] directors are linking the two environments together. Um, and that makes me very, very excited.

So I've enjoyed our podcast today. I think, uh, you guys have been amazing. Thank you for your time and sacrificing your morning to join us on this podcast. Um, this has been amazing. Thank you so much. We'd like to end our podcast. Yeah, I'll see you guys on the next one. Be safe out there.

Narrator: Thank you for listening to EMS, [01:07:00] the Erik and Matt Show.