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Should ground ambulances carry blood for transfusion?

by Laurie J Sutor, MD, VP of Medical Services and Chief Medical Officer

Many in our community read a series of articles recently published by the Dallas Morning News regarding the dangers of trauma with serious hemorrhage and the benefits of having blood available in the field for the use of emergency responders prior to reaching the emergency room (ER).  This sentiment echoes what many emergency physicians have been urging for a few years now, with some support in the civilian scientific literature.  Having blood available on the pre-hospital transport especially makes sense in rural areas or other situations where transport times to the ER will be lengthy.  With this in mind, Carter BloodCare has been supplying blood to air ambulances, who typically are traveling further distances than ground ambulances.  We have worked with the air ambulances since our participation in the PAMPer trial, a randomized, multi-center trial to evaluate the efficacy of plasma in the pre-hospital setting (see reading below).

Our supply of blood to these air ambulances is a tremendous logistical operation.  Blood of course is of limited shelf life and must be kept within a narrow and rigorous temperature range (1-10 degrees C for transport).  The air ambulance base co-operates with us in monitoring the temperature and integrity of each blood unit at all times while in their possession.  Not every ambulance trip will require the use of blood, so the blood goes out and back many times without being transfused.  Eventually, nearing the end of its shelf life, it may get rotated to a hospital for use there before it gets expired and wasted.  Only occasionally does a unit actually get transfused on an air trip. It is then replaced by the blood center with a new unit or two when the ambulance returns to base.  Arrangements must also be made for documentation of the transfusions, work up of any adverse effects, and notification for any subsequent blood unit recalls or lookbacks.  Finally, the blood for pre-hospital transport must be group O to be the “universal donor” type for all recipients.

So, what about putting blood on ground ambulances as well?  Sounds like a great idea.  So why are so few ground ambulances in the Dallas-Fort Worth area (or beyond) carrying blood currently? 1) We are fortunate that a lot of the trips in the Metroplex are relatively short, and reach an ER relatively quickly.  2) The 911 dispatcher in each city is using their own choice of ambulance provider (often from their own munipality) for transport in emergencies, so that adds up to a lot of agencies to supply, and 3) probably most challenging, there is a shortage of blood.

Why is there a blood shortage?  The shortage is most acute for the universal red cell blood type, group O, especially group O Rh negative.  We just seem to use this type as quickly as we draw it and cannot stock any excess on the shelf or afford any growth in use.  Despite robust efforts by the blood center, we are barely supplying the current demand for hospital and outpatient needs. This blood is used for not only trauma, but treatment of other acute anemias, such as bleeding at childbirth or during surgery, gastrointestinal bleeding, cancer treatments, bone marrow transplants, and so forth.  Our current group O donors are beset with calls from us at the blood center, asking for them to come back and donate again.  But they can only do so much. The numbers show that our most reliable donors are our older donors, and they are “aging out” of the donor pool and not being replaced adequately by younger donors.  Although 62% of the U.S. population are eligible to donate, only 3% of these individuals actually donate each year, and only about 45-50% of those are group O blood type.  For those who do donate, the average person donates 1.8 times a year (of a possible 5 times a year for whole blood).

So, if we opt to put blood on ground ambulances, and it is out there being carried around and not necessarily transfused very often, we may have to cut back on what blood is stocked at hospitals and other facilities (surgery centers, long term care facilities, emergency rooms etc).  Alternatively, we need more individuals to step up and donate blood regularly to support this initiative for our community.

Suggested reading:

Dallas Morning News series “Bleeding Out” parts 1-6 by Lauren Caruba, published online Nov 30, 2023

Dallas Morning News editorial “EMS crews should carry blood”.  Dec 6, 2023.

Prehospital plasma during air medical transport in trauma patients at risk for hemorrhagic shock (the PAMPer trial). Sperry JL, Guyette FX, Brown JB et al.  NEJM 2018, 379(4):315-26

Morgan KM, Abou-Khalil E, Strotmeyer S et al. Association of prehospital transfusion with mortality in pediatric trauma.  JAMA Pediatr.  Published online May 22, 2023.

Braverman MA, Smith A, Pokorny D et al.  Prehospital whole blood reduces early mortality in patients with hemorrhagic shock.  Transfusion 2021, 61:S15-S21.

Gruen DS, Guyette FX, Brown JB et al.  Association of prehospital plasma with survival in patients with traumatic brain injury.  A secondary analysis of the PAMPer cluster randomized clinical trial.  JAMA Network Open 2020, 3(10):1-15   Online October 15, 2020.

Association of prehospital plasma transfusion with survival in trauma patients with hemorrhagic shock when transport times are longer than 20 minutes. A post hoc analysis of the PAMPer and COMBAT trials. Pusateri AE, Moore EE, Moore HB et al.  JAMA Surg  Feb 2020, 155(2):1-10.  (Statistics guide from America’s Blood Centers on blood donation)