鈥淚t has been said that the three most regulated things in medicine are nuclear medicine radioisotopes, chemotherapy drugs and blood products,鈥� says Assistant Chief Tim Burns, at Montgomery County (Md.) Fire and Rescue Service (MCFRS). That鈥檚 because whole blood, along with its component parts, is almost always in short supply and require complex storage mechanisms and tight storage controls. But recent medical experience has established that prehospital blood transfusion is feasible and saves lives 鈥� and to a much greater degree than had been understood.
How does a public safety agency obtain and maintain the critical resource that is whole blood while getting it into the field to save lives? As Montgomery County shows, it can be done, and to great effect with some forethought and cooperation.
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A brief history of whole blood transfusion
Whole-blood transfusions aren鈥檛 new. They date back to British medical experiments of the 1600s and were increasingly common by the 1800s. The efficacy of whole-blood and plasma transfusions became clear during the World War II. Those who received this care saw mortality .
While prehospital blood transfusions were common during the First World War, they were mostly relegated to hospitals by the Second. Challenges of blood collection, distribution, monitoring, and maintenance were complex in the field. Concerns about bloodborne illness, such as hepatitis and HIV, would further complicate matters.
That changed in 1993. During the Battle for Mogadishu in Somalia three American Black Hawk helicopters were shot down and a protracted battle took place to save the survivors. Military doctors worked in place for 48 hours straight to save who they could. This included use of whole blood transfusion on the battleground, credited with saving many of those who survived. One of those doctors, brought that experience back to first responders, first in Texas and now nation-wide.
The results of prehospital blood transfusion in American public safety have been remarkable. One study finds patients who received whole blood in the field saw a
鈥淏lood is the most powerful intervention in the past 50 years,鈥� says Jon Krohmer, MD, FACEP-FAEMS, steering committee chair at the . To be effective, this coveted resource needs to get there fast and ready.
How Montgomery County embraced whole blood by learning from others
MCFRS rolled out its whole blood program in 2024. In the first four months of the program鈥檚 trial, 24 people received blood transfusions in the field; of those, 16 survived. What they discovered almost immediately was that whole blood鈥檚 utility is more important than they had initially thought.
鈥淲e鈥檙e seeing cases where people survive acute trauma that would have until very recently been assumed fatal,鈥� says Krohmer. 鈥淪urgeons are seeing patients they鈥檝e never seen before because until now there was no way to save them. That person lying on the pavement is now a witness, not a victim.鈥�
Whole blood benefits not only trauma patients, MCFRS has found utility in medical scenarios as well.
鈥淚t鈥檚 not just the hair, teeth and eyeballs calls,鈥� says MCFRS鈥檚 Captain Nicholas Wagner. 鈥淚t鈥檚 the nursing home calls where internal bleeding is common. You don鈥檛 want to overestimate your need, but there鈥檚 a tendency to underestimate.鈥�
Regional partners are key
MCFRS had the advantage of regional partners who went before them. Maryland State Police Aviation Command, which spearheaded the state-wide blood protocol, put nearly 4 years into that effort. 鈥淲e were able to learn from not just , but from and as well,鈥� says Burns.
As a result of working with these partners, MCFRS was able to calibrate their blood supply. 鈥淒.C. Fire Department had to almost double the amount of blood they had available initially. Our neighbors in Howard County had a similar experience, so we knew this was a possibility,鈥� says Wagner.
The type of blood used for many whole blood programs is low-titer O positive whole blood, meaning it has fewer antibodies, and Type O+, because it is most prevalent in the donor population. Approximately 38% of the US population has the blood type O positive.
鈥淧art of our agreement,鈥� says Wagner, 鈥渨as to set up two blood drives to support the blood bank before our launch. We also reached out to the area hospitals and let them know we were using blood so that they could expect it.鈥�
鈥淭he biggest part is a relationship with that blood bank,鈥� says Krohmer. 鈥淚t鈥檚 a totally different culture. O-positive whole blood is like gold to them. You don鈥檛 want a medic just coming in without addressing their concerns 鈥� to maintain the integrity of their supply, zero waste, robust logistics.鈥�
鈥淲e set up a good relationship with our trauma center,鈥� says Burns. 鈥淲e set up an intermediary, which has a good relationship with the Northern Virginia Blood Bank. The local blood bank acts as an intermediary for the blood we鈥檒l use.鈥�
A process for deployment
In Montgomery County, 4 EMS supervisors maintain a supply of 6 units of whole blood under normal circumstances. Each of the 30 employees trained to function as EMS supervisors 鈥� go through 4 hours of classroom training, followed by 4 hours of hands-on training,鈥� says Burns. 鈥淎ll of our ALS providers are trained to an awareness level as well.鈥�
鈥淵ou want to make sure that your people are following the process,鈥� says Burns. 鈥淭he process is almost important than the outcome, because blood is a precious commodity. Our goal is zero wasted units of blood鈥�
The storage equipment and temperature monitoring equipment are low-maintenance and passively monitored via cloud services and real-time alerts. 鈥淥nce a day we do an accounting and then we don鈥檛 really need to think about it too much,鈥� he says. 鈥淥ur field providers understand that we have this capability and are able to request it to the scene if an EMS supervisor was not initially dispatched on their call.鈥�
Ensuring the integrity of whole blood in the field
Part of the zero-waste strategy involves whole blood only being deployed for a maximum of two weeks in the field before it needs to be brought back to the blood bank for component recycling. 鈥淚n order to do that,鈥� says Burns, 鈥渨e need to have all the documentation about how it鈥檚 been stored and its temperature range. 鈥� We only pay for blood that is used.鈥�
To prevent waste, MCFRS keeps whole blood in coolers in vehicles. Each bag is stored with a cooling insert that will keep the blood cold for 48 hours, but which is replaced every 24. And every bag has an integrated, cloud-connected thermometer on it that will alert several people if the bag approaches or is outside of temperature range and log these values
To administer blood, it is run through a warmer to body temperature. 鈥淚t鈥檚 not a regular IV infusion set,鈥� says Burns. 鈥淚t鈥檚 a hand pump that gets the blood into the patient quickly.鈥�
Using FirstWatch to monitor the program鈥檚 quality
MCFRS works with FirstWatch to monitor its whole blood program. 鈥淧rocess managers are integral to our work here in Montgomery County,鈥� says Wagner. 鈥淲e monitor the processes and see where we can make improvement through training or system changes. When blood is deployed by one of our EMS duty officers, we get a trigger alert from FirstWatch.鈥�
Wagner and his team use FirstWatch鈥檚 to then evaluate the incident. 鈥淲e can monitor the clinical outcomes and how it was deployed,鈥� says Wagner. 鈥淚n FirstPass we can also see if there were any missed opportunities. Are there gastrointestinal bleeds, for example, that we might have missed? We can trace the call back to dispatch and see if maybe the EMS supervisor was on the call.鈥�
鈥淭hey get an alert in my pocket when blood is used,鈥� says Burns. 鈥淭hat lets administrators know they need to replace that bag of blood. FirstPass also let鈥檚 them know when they could have used blood but didn鈥檛. It opens our eyes to opportunities we might be missing.鈥�
Minutes matter
The opportunity presented by whole blood transfusion in the field is predicated on timeliness. The sooner blood is administered to the patient, the better their chances of avoiding further injury or death. 鈥淔or every minute of delay, ,鈥� says Krohmer.
Having a whole blood program gets blood to people faster. Even in the hospital or trauma center, says Wagner, there is a delay. 鈥淭here needs to be a series of requests to the pharmacy or blood bank, and so forth,鈥� he says. 鈥淚t can take upwards of 30 minutes in some cases.鈥�
And that鈥檚 if the hospital even has blood available. 鈥淭here are plenty of hospitals in the U.S. that don鈥檛 have any blood product in the emergency department emergency department,鈥� says Kromer. 鈥淪ome smaller hospitals don鈥檛 have any blood components at all.鈥�
Additional whole blood resources
Chief Burns notes that there鈥檚 a powerful movement afoot to spread whole blood to first responder agencies nationwide. 鈥淭he benefits of getting blood started faster have spread like wildfire,鈥� he says.
鈥淵ou see pockets of programs around the country,鈥� says Burns. 鈥淚n Texas, where it all started, of course, but now also South Florida and the National Capital Region, where we are. The benefits are undeniable, so it鈥檚 taking off.鈥�
- For more information on how to start a prehospital transfusion program at your agency or to learn more, visit . Or ask around. Chances are there鈥檚 an agency near you willing to lend a hand.
- Tracking the whole blood landscape as updated guidelines allow EMS to carry and administer whole blood
- Stop the bleed, fill the tank 鈥� The New Orleans EMS blood program
- Insider analysis: Delaware鈥檚 statewide whole blood rollout sets a new EMS standard
馃└ Where EMS is using whole blood
ABOUT THE AUTHOR
Crawford Coates is head of marketing at , author of , and co-founder of . He has worked with public safety for 20 years.
