EMTs and paramedics from the District of Columbia Fire and EMS Department (Fire and EMS) perform dozens of life-saving interventions every day and night throughout Washington, DC. Soon they will be adding a new tool to their EMS toolkit.
When a patient suffers a traumatic injury or experiences major bleeding (hemorrhage), doctors typically give blood to a patient when they arrive at the hospital (transfusion). Without rapid blood transfusion, patients with life-threatening hemorrhage can die.
Thanks to the American Red Cross and generous blood donors, Fire and EMS is bringing the same blood from the hospitals to paramedics in the field.
Transfusion of patients by EMS will increase the chance of surviving a devastating blood loss injury- more than doubling the odds of surviving and making it home from the hospital.
What types of injuries can whole blood be good for?
Patients injured in motor vehicle crashes (high-force blunt trauma), crush injuries, victims of violence, and those who sustain traumatic amputations all experience major blood loss.
Patients may also experience life-threatening hemorrhage due to medical conditions like profuse gastrointestinal bleeding, a ruptured aorta or bleeding during or after giving birth (peripartum hemorrhage).
All these patients may derive benefit from our program of prehospital blood transfusion.
Where does whole blood come from?
Blood is collected from volunteer donors, screened for diseases, and verified to have non-significant levels (low titers) of antibodies against Type A or B blood. White blood cells are filtered out, but the blood is left whole, with plasma and platelets to promote clotting and red blood cells to carry oxygen.
The blood will come from the American Red Cross and be stored at George Washington University Hospital’s blood bank.
When Fire and EMS units require units of blood, they will be picked up from GWUH and placed in temperature controlled and monitored medical storage devices throughout firehouses and EMS units across Washington DC.
What type of blood will DC Fire and EMS be transfusing?
Fire and EMS will be using “universal: low-titer type-O whole blood when it transfuses eligible patients suffering from hemorrhagic shock. You may see this blood product abbreviated as ‘LTOWB’.
“Low-titer” means the units of blood which we transfuse will be screened to ensure they have low levels of antibodies. This makes it safer to transfuse the blood we carry into patients with any blood type.
“Type-O blood” is known as the “universal donor”, meaning it can be safely transfused into any patient with any blood type. Depending on the regional donor blood supply, our patients may receive either “O-positive” or “O-negative” blood. O-positive blood is much more commonly available. Only seven percent of the US population has O-negative blood type compared to 37% with O-positive.
The “positive” and “negative” labels refer to the Rh status of the blood. Rh factor is a protein that can be found on the surface of red blood cells. If blood cells have this protein, they are referred to as “Rh positive”. If the protein is not present, the blood is referred to as “Rh negative”.
“Whole blood” contains all blood components – including red blood cells, plasma, and platelets. In the hospital, patients often receive “component therapy” consisting of only one of these three blood components at a time. When a patient is bleeding profusely, they lose all of these components – and all three of these components can be replaced by transfusing whole blood.
Are whole blood transfusions safe?
Yes, and we’re not doing anything different than in the hospital- just bringing it to the ambulance and to the patient sooner.
Whole blood transfusions have been used as far back as 1917.
All whole blood that is administered is low in titer level of anti-A and anti-B antibodies, making it safer for administration and less likely for a transfusion reaction to occur.
Prehospital administration of whole blood is being utilized safely in hundreds of EMS systems across the country and in many trauma centers. Adverse severe reactions are extremely rare.
Who is eligible to receive prehospital transfusion?
Prehospital whole blood may be administered to patients over one year old with significant bleeding (traumatic, obstetric, gastrointestinal, etc.) and signs of hemorrhagic shock.
Fire and EMS advanced life support Paramedics follow our system-wide prehospital care treatment protocols to determine when a patient should receive transfusion.
The treatment protocols also provide clinical guide of how the transfusion procedure should occur.
Can whole blood be transfused into children?
Yes. Our blood transfusion protocols were developed in close collaboration with Children’s National Medical Center.
Our pediatric blood transfusion protocol allows our Paramedics to transfuse children over the age of one.
As a layer of clinical safety, our paramedics must consult the expert pediatric Emergency Department staff at Children’s National Medical Center prior to initiating a transfusion in any patient between the ages of one and 15 years of age.
Can a patient refuse transfusion or opt out of whole blood transfusion program?
Yes. Our paramedics are required to obtain verbal consent from any adult patient prior to initiation of transfusion – provided the patient can communicate with our providers. If parents are present, they must provide consent prior to transfusion of children.
When patients cannot provide consent because of the nature of their injuries, or when a parent is not readily available and a child is at risk of dying, our paramedics will do everything possible to save lives, including transfusion of blood when clinically appropriate.
As part of our whole blood transfusion training program, our paramedics are trained to look for medical alert tags, wallet cards, or any patient-specific treatment directives prior to initiating a transfusion. Conscious patients with decision-making capacity can refuse blood transfusion at any time. For unconscious patients our providers will quickly search for any of these medical alert items before initiating transfusion.
Will every fire station and ambulance carry blood?
Not yet - but eventually we hope to. The blood supply is extremely limited, and the skill of prehospital transfusion requires specialized training.
Based on an in-depth analysis of our clinical data, our department will deploy units of whole blood with our more highly trained EMS supervisors in areas of the District most likely to use those units of blood, that is, in regions of the District that have historically had the highest levels of patients suffering from hemorrhagic shock.
These EMS supervisors are spread across the District.
Crews in any of our six battalions can request one of the EMS supervisors to respond within minutes to help care for a patient suffering from hemorrhagic shock.
Are DC hospitals already transfusing blood?
It is already in use in the ER and trauma bays at MedStar Washington Hospital Center, George Washington University Hospital, and in hundreds of emergency departments and trauma centers across the US.
Will this really make a difference? If so, how?
Yes! A growing body of evidence demonstrates improved outcomes for patients who receive blood in the field prior to arriving at the hospital. Evidence suggests early whole blood administration (defined as less than 35 minutes from time of injury) in severely injured trauma patients can increase survivability.
A 2022 study in the Journal of the American College of Surgeons determined that whole blood increased 30-day survival 60% and reduced the need for blood product transfusion during the first 24-hours of hospitalization by 7%.
In the first five months of 2023, we identified that 222 patients would have benefited from prehospital whole blood transfusions. We anticipate needing to give blood to approximately 400 patients per year.
What if a patient develops a transfusion reaction during transfusion or after arrival to the hospital?
Prehospital transfusion reactions are rare but are a possibility. Recognition of and treatment for transfusion reactions is covered in our full-day blood transfusion training program.
Paramedics will treat any actual or suspected adverse reactions accordingly, including the administration of emergency medications.