Florida Whole Blood Coalition Inaugural Webinar (10/27/2022)

And you can see here that we have quite a number of incredible people. This is part of the stakeholder group that I spoke to you about. And you'll see in a little bit that this is really, I would say, almost everybody. We still have other people to bring onto the table, but the goal is, is to bring all the stakeholders on in your local region, if you want to make it statewide. But this is something that we've learned from people like Dr. C.J. winkler, who's one of our speakers today, about how to create just a really nice coalition. So our agenda today, you can see.

Before you go for it, I just want everybody to get clear. Just so everybody puts this perspective, not to bury the headline. This is really to orient you towards what we want to get done. It's going to be more of an overview and not a drill down. Eventually, what we're going to do is have additional sessions. We will drill down on several things. In the end, what we're going to be talking about are the things that are availability of the blood and sources of the blood, funding for the blood, and several other issues that pop up elsewhere. And we're going to drill down those in great detail later. But we just want to get the items on the table today. And we'll probably eventually say we're going to need to table this discussion to, to our subsequent talks, but that's where we're going to kind of go. So everybody gets that overview.

Okay.

I'm so happy you mentioned that, Paul. We have a lot to discuss in the coming months. We will be setting up regular meetings probably every two months, like Paul said. So we hope you join us for those as well. Okay. So we'll be going through an introduction, and we're very, very blessed today to be joined by some very special people. And I have Dr. Pepe now, if you wouldn't mind, introduce, really, the main man who's done so much work in this area, Dr. John Holcomb. Paul, please do the honors.

Yeah. It would take several hours to discuss all of the amazing accomplishments John's done. But what everyone needs to know, if they don't, if you don't, you need to know that he really led all the military research during a lot of the conflicts that we had in the Middle east over the early 2000s and, and in turn of the century here. And a lot of things we're doing today really got promulgated by him. While some of his folks did it, he was one that got it out, got it done, got it promulgated. Such as things like bringing tourniquets to the setting and this whole introduction of the concept of using blood products and eventually now really championing the use of blood across the United States. As he has been a research director and a professor both at the University of Texas and now University of Alabama. And I just, I could go on and on, but the main thing is if I want to know about what I should do and how I should treat my family member after they've had a serious injury, he would be the person I would be going to, to say prospectively, how do you get it done? So with that, John, please come on and join us. Thank you so much. And tell us a little bit back for the rest of the group that's joined us now. Tell us about the background you have there.

Well, Paul, that's like the nicest I've ever heard you.

No, maybe the shortest you ever heard me.

Yeah. Well, thank you very much. I appreciate that introduction. I, you know, as you, as everybody on this call knows, nothing happens by an individual. It's all by team effort. And, and I've been really blessed to have been work with great team members over the years, many who are actually on this call. And you know who you are. Randy, this is the second call you and I have been on today, so it's great to see you on.

Yeah. So that picture behind me is in Ukraine. We stopped on the highway and took this picture between leave and Kyiv. And I took it because it's the reason their flag is yellow and yellow and blue. I have no idea what those plants are, but they go on for miles and miles and miles and the beautiful blue sky and had the opportunity to work with an NGO and go over three times in the past couple months.

John, you should know one of the people that we use, who's our kind of eagle out of Krakow, has been over there quite a that she's on here. Kasha.

No, we communicate as well. So anyway, and just as an aside, but relevant to this discussion, whole blood transfusing whole blood was somewhat prohibited, maybe even illegal six months ago. And about two and a half months ago, their Ministry of Health published a law and a policy format allowing the use of pre hospital and hospital whole blood, largely based upon much of the data that we will talk about today and the experiences of today. So anyway, Peter, you want me just launch right into the agenda that you gave me?

Yes, yes, if you wouldn't mind. Thanks, John.

Absolutely. So I was asked to talk a little bit on background of mild sieve on whole blood Just many of us enjoy history. The first recorded use in the US military that I can find was from the Civil War with a small transfusion.

A couple ounces actually of whole blood from a healthy German to a southern casualty who had had an amputation. The patient lived. The surgeon who did the transfusion ended up being the chairman of surgery at the University of Arkansas and then the dean, which is where I went to medical school. How about that for loop closure?

And then of course World War I really exploded the use of whole blood. World War II even more so. Unfortunately, by the time middle of Vietnam came around, whole blood was falling out of favor to component use. Component use came into being without any what we would consider today high quality data suggesting that it was at least as good as or better than components. There was no data suggesting that it was more of a convenience factor. Ability to sell multiple components, and the need driven by chemotherapy, where patients needed platelets and no other components. So there were many reasons why that switch happened in the mid-70s, none of it data driven. If you kind of move forward a little bit, and some of us who have gray hair lived through the era of crystalloid, 10 to 20 liters, then red cells and then a little bit of plasma and hardly any platelets. Those patients didn't do well. They had multi organ failure, abdominal compartment syndrome, syndromes, compartment syndromes throughout their entire body actually, and on and on. And then now you move forward to several wars. My first experience with whole blood was in 1993 in Somalia where we, a third of the hospital donated whole blood. We gave it to really sick casualties and they did remarkably well. It was incredible. The resolution of coagulopathy and how well the patients did. And then you move forward. That didn't go over very well when we spoke to blood bankers around the country in the mid to late 90s. So we started working on ratios and that ended up being the balanced transfusion that you guys are familiar with in the hospital. But of course the ultimate balance transfusion is whole blood. And so if you kind of work your way through that logic, you end up with whole blood. Whole blood is. Now, these are data that just came out of TQIP just the other day. In 50% of the Level 1 and 2 trauma centers that submit data to TQIP, which is about 500 hospitals, I believe 50% now have whole blood available. And so really the, the real issue in my mind is to make whole blood available pre hospital. If you look at the data. I'll go to the second part of the discussion now, Peter if you look at the data that's been published, you know, in the New England Journal and in really high quality, the best journals around with high quality data, blood product resuscitation of patients in hemorrhagic shock is superior to crystalloid resuscitation. There's no question about that. Now if you translate what we've learned from the hospital to the pre hospital area, and I recognize what I'm saying here, then whole blood should be better than components as well. Should be better than components as well because it has, it is the ultimate balance transfusion. It's easier to do balance transfusion and it has platelets in it in addition to the course, the plasma proteins, which include fibrinogen and the red cells. So I think the data are highly suggestive that whole blood pre hospital is a superior product to red, to components. And I know that components are superior to crystalloid. Let me ask you a question for any questions.

Yeah. So the question I have for you is where are we right now in the cause? There's still people who are kind of watching and waiting, if you will. And you know, you had the refill trial that showed maybe not, not the best outcomes. Where, where do you think we are and where do you have to be? And I'm, I'm kind of, you know, I don't want to bury the headline here, but later we have Dr. Duchesne and Danielle Tatum. Dr. Tatum will talk about the data. But where do you think we are today and where do you think we have to go to prove this out?

Yeah. So, you know, changing practice is very interesting and is part of Paul mentioned before. We've kind of done that with tourniquets, we've done that with blood products in the hospital. It's now standard of care to give a balanced resuscitation.

You know, you have to have some data. I think you have to have some common sense and logistical, at least equivalence. The cost comes in there as well. There are, and then you have kind of people that are early adopters and then you have the Luddites on the, on the other end and kind of the curve in between. So.

There are whole blood studies around the country starting in the hospital, prospective and randomized multi center whole blood studies funded by the NIH. The DoD is funding a prospective randomized pre hospital whole blood study multi center. The French have a whole blood study that is starting and as well as in the uk so there are multiple well designed, I would call phase two B3 studies that we will have those New England Journal JAMA type data in three to five years. Until then, I will just until then. You know, I like to be data driven as much as possible, but I also, I try to be practical. If my son is 22, 21 years old, you know, he's kind of a bonehead. He does boneheaded 21 year old things. My daughter is much more careful. If my son gets in a, in a, in a car crash or, you know, hang gliding or jumping out of an airplane accident, I want him resuscitated with whole blood pre hospital. That's the way I think. I'm waiting on the randomized data, but until then, I would like for him to be resuscitated pre hospital with whole blood.

Yeah.

Coming from you, that, that says a lot. Yeah, go ahead, Paul.

Yes, the, the question is that there are different people that bring up the issues of are we going to, you know, the sourcing. And then the other issue comes down to also the make. I would like your opinion. They're always bringing up the issue about the pregnant, potential pregnant women, all those things, or they are pregnant. This one, you address that for a long time. And by the way, I just want you to know that those plants behind you are the RAP seed oil plant, according to Kasia. Just want you to know that the RAP seed oil.

Okay, all right, very good.

Yeah, so I'll take the last question first. We've actually spent a lot of time with this issue of RH negative women receiving Rh positive whole blood. Right. And you can't use, I mean, it'd be, it's extremely difficult to use lots of RH negative whole blood because that's anywhere from 4 to 8% of the population, depending upon the racial distribution of your donor center. 40% of the population is O positive. So that, that really is the product that is really spreading across the country, both pre hospital and in the hospital.

And largely because, what, 75% of that is usually very low titer. Opos.

Yeah. And different centers use different titers. But just for ignoring that issue for just a second, Paul.

On the RH issue.

What we were taught in school is that you cannot give RH positive blood to an RH negative woman because then her future pregnancies will all die. Well, that's actually incorrect.

And so those data are published.

If you had a choice, you would give RH negative to negative, but it's just not available.

We actually just have submitted for publication and presented at a national meeting. We did a Facebook survey of 7,000 women of childbearing age and asked them what they would want given the risk of hemorrhagic shock and dying. And the, the vast majority of the women said, please give me O positive blood even if I'm O negative and it puts my future babies at risk. And, and so, you know, the title, the reason we did that is typically, and this kind of goes to all this, you know, we should listen to our patients instead of a bunch of old white guys deciding what young women would get or not get. We asked them and they were very clear. And so that kind of messaging, plus the data that shows that the risk to the woman's potential future fetus is actually extraordinarily low and can be treated.

Most blood centers, most blood banks around the country now are stalking low, tight or whole blood, O positive, whole blood to deliver.

So we have to move on to the other speakers, John, but I hope you could stick around because we're going to engage, especially when we get down to C.J. winkler, that the ultimate thing for me here is we're going to have passed all the resistance is the funding and ultimate sustaining of funding for this and, you know, maybe getting reimbursed through cms and maybe all those things are things we're going to need to talk about later. We'll drill down on it in other sessions, but for today, we're going to try to talk about that later. So I want to move on, but can you stay with us for a while?

Yep.

Okay, good. All right then.

All right.

Want to do.

Sorry. Next Heroes.

Yes.

So.

So, Paul, you know, definitely I wanted you to, to make a couple. Dr. Holcomb, but I think you've already done that a few times there. But if you want to add in a few more comments and then if you wouldn't mind introducing our next speakers, which will be Dr. Jim Roach and Chief Heath Clark from BSO and Broward Health.

Yeah. So, yeah, and again, I don't want to take up a lot of time, but these are people I just absolutely admire their enthusiasm, their energy, their guts, and putting up against a lot of resistance for quite a long time. And their persistence has got blood here in South Florida. And thank you for the leadership. Other people, of course, started elsewhere, but I've never seen any two people who really worked hard to get it out here. And we're doing it. We're going to hear from them in a second. Jim Roach is actually, relatively speaking, kind of new to EMS per se in terms of being a medical director over the last six, seven years. But it's exemplary and just one of the people that I look up to, his energy gets it done. I mean, I just can't do it. And he has an incredible partner with, with, you know, Heath Clark. Chief Heath Clark, who is our division chief for the Broward Sheriff's office, which I'm very privileged to be part of. And especially for our. This, for the sake of our tactical folks as well, I want to make sure this thing continues to get forwarded out there. So with that, I wanted to bring on Dr. Jim Roach and Heath Clark. And Heath, by the way, I hope your fingers are healing pretty soon. I guess you can't dial the phone right, so just personally, I deserve that.

All right, thanks a lot, Jim.

More time management skills.

Yeah. As I said, Here I go, Dr. Jim Roach. Here you go. Take it away, Jim. I'm very proud of what you've done here. Okay?

So thank you, Dr. Pepe, and thank you, Peter, for putting this together. And Dr. Holcomb, I'll tell you, this would never have happened in South Florida if It wasn't for Dr. Holcomb, Dr. Pepe, Dr. Entebbe, and you know, I also want to give a special shout out for Dr. Winkler. CJ, thank you, man, for everything you've done and allowing us to rip off and duplicate everything in your protocols, etc. So thank you. So the deal is, you know, we talk a lot of science and, and that's important, but I wanted to bring this personal because a lot of the things we do, they're affecting human beings and people's lives. And I want to introduce you to my niece. This is Taylor Brookley.

Taylor. This is her beautiful picture. And this is actually the school bus and her car. Taylor was 23 years old. She had finished, she graduated from college, she was working over in Naples. And middle of the afternoon, she was making a left hand turn and got T boned here by this school bus. And, you know, she was just an amazing young woman. She's 23, beautiful. She was actually. Her and her twin brother Tyler were born premature. They spent about three months in the nicu. And so they were special babies right from the beginning of their life. And her life was terminated early. And it was just a tragedy to our family. And when I saw this, you know, the firefighters, the hospital, everybody did everything what they, you know, what they were supposed to do. But as I thought about it, I said, I thought to myself, and especially listening to Dr. Holcomb's lecture, what do we give pre hospital folks? I mean, the best we offer them is Crystalloids we know that's not helpful and likely harmful. That put me on.

A mission to see what can be done for the people in Broward county that we impact. The question that we want to ask everybody is if you're involved in pre hospital medicine, what do you offer your firefighter? Paramedics to resuscitate, traumatic arrest? And that's just think about that as we go through these slides and people do these presentations. This is the BSO data. So I want to just talk about who is actually receiving whole blood from BSO. Most of us are giving MVAs and gunshot wounds take up the majority of our trauma. And then who's giving it? It's our Air Rescue 85 was the majority. But I'll tell you, we have a ground unit, EMS 17, which is our EMS captains, and they do a tremendous job and they're giving more and more whole blood and doing a phenomenal job. I do want to take a moment because our program would not be successful if it wasn't for Air Rescue 85. The EMS Captains and Lt. Kravanik, these folks are just incredible. I mean, what they do and the way they push this blood and just they become experts in this. So I am so honored just to be a part of their team. The next slide to talk about this is compelling data and I really want you to take a look at this. Let me define a couple of things before I get going. First is defining survivability. We use 24 hours. So if they survive to 24 hours in the hospital.

The shock index is heart rate over systolic blood pressure. For those that don't know that. And then the way we capture this is the actual first set of vital signs. So this isn't necessarily as they subsequently developed worsening vital signs, is the initial vital signs, as you can see. And one would expect, the patients that we give whole blood that are already in cardiac arrest, only one out of 21 survived. And we would expect that if you look at Class 1, so they came and they essentially had normal vital signs initially, 50% of those survived. Then if you look at class two, which is a shock index between 0.6 and 1, 18 out of 18, we had 100% of those patients survived, which is astonishing. Then the next category is class three shock. And here you can see 90% of those patients, nine out of ten survived to 24 hours. The most astonishing really is class four. These are the worst, the sickest of the sick in traumatic shock with a shock index above 1.4 and 100%. 23 out of 23 have survived at the 24 hour mark. So I find that to be really incredible and it really makes you see what the people that are on the ground, as I mentioned, air rescue, the captains, the tenant, they are so moved by what's happened here and you can see it here in the data, so it's really compelling. The next thing I want to talk about is another specific case. This is Diani. He's a, he's actually a pasture. This gentleman was out spearfishing one mile out with his friend and a boat ran him over. He had extensive damage, scalp injuries, he had thoracic injuries to his right ribs. He broke a rib, he had a pneumothorax. He actually was eviscerated with intestines that were external. Significant damage to his right leg with soft tissue injury and he was actively bleeding in the ocean. I first thing I thought of is how did this man make it back without getting bit by a shark? That would be the first thing. And then he explained to us his friend, who also has a spear, was swimming in the ocean behind him, protecting him and guarding him for sharks. So it's just an incredible story. He came on shore, EMS 17 arrived, they transfused him. The funny part of the story is that Diani tells it. He said, you know, I reached out and I thought I was going to die and when I reached out I grabbed somebody's hand. He said to them, I don't know what you are giving me, but don't stop giving it to me. Because he knew that whatever was happening was making his body feel better and he was getting resuscitated. So I put in the top left corner some numbers and I want to talk about what these numbers mean because a lot of times you hear people say, hey, we are like five minutes from the hospital.

We don't really need whole blood.

So I want to give you some numbers. 6 plus 12 plus 5. What does that mean? The average time it takes to get on scene for fire Rescue is about 6 minutes. Our goal for off scene times is 10 minutes. The best we're doing right now. And we're really doing everything we can to get off scene. We're running at about 12 minutes. And then if you take that five minute transport time. Now remember, this isn't accounting for when you arrive at a gun shooting, the police will oftentimes not let you on scene because of scene safety. Motor vehicle accidents. You also have to establish scene safety so many times it's hard to even get on the scene, even when you arrive, you can't get to the patient. So despite all that, we know from the shackelford data that 30 minutes, the golden 30 minutes, it's not the golden hour. So under the best conditions, you've eaten up at least two thirds of your golden half hour following the, you know, the best of the best and what we can do in the pre hospital. So there's an absolute need for whole blood resuscitation no matter where you are and no matter where you are in proximity to the trauma center. Logistically, I want to hand this over to Chief Clark now because you know, he's been fantastic in talking about logistics and intercepting, having the EMS captains intercept en route to the, to the hospital. So and again, before I even hand over to Chief Clark, I want to say again, he's another member of this team, that this would definitely have not gone forward if he didn't grind through this and you know, fight every fight to make it happen. So thank you, Chief Clark, for everything you've done.

I couldn't do without you, Jim. So yeah, it starts with you, my friend. So just to tag along with the original, that story that Dr. Roche closed out with that individual that actually delivered blood to our patient there, he confided me at one point that he was actually considering leaving the career and retiring. He'd been on, you know, for a full career, but this was the first instance in his career he felt like he truly was making an impact in trauma patients lives and outcomes and that's reinvigorated his career. And we determined on the podcast, podcast last week EMS World with Chief Coyle, that this is actually a paramedic retention tool for anybody out there who's looking to retain paramedics.

So when you're looking at the county, we have three trauma facilities. Currently we're the only providers of whole blood in the county. I can technically reach anywhere with Air Rescue 85, barring weather, so on and so forth. And if it's practical and if it makes sense to actually fly beyond that, I have one EMS supervisory unit in service that is available to anybody within the county. It is a regional unit. It generally speaking ends up serving my, my territories just because that's where they're going around doing training and coaching and so on and so forth. But perfect instance with Davy Fire Rescue. Six to eight weeks ago we ran a, a joint call together where my air, my EMS captain rode in in a Davy rescue with a very positive outcome. The I don't know if Chief Brand is on, but he was actually first in the scene, recognized the need for blood, called for EMS 17. It worked seamlessly. So when people talk about, ah, we have a short transport time, because in a lot of cases, when you look at three different trauma facilities throughout the county, many people will say, I can't, I'm not driving that far. It's not that big of a deal. All information and all data that we have so far indicates that the sooner we get blood on, the better and the more effective it is. And in fact, the less blood you need in the long term. So regardless of how close you might be, you're not close enough to not need blood. And that would be my argument. So because of the disparity of resources compared to the overall size of the county, we're looking at 400 square populated miles.

What we'll do is if we have a very astute lieutenant that realizes the type of patient they have, they'll ask for the whereabouts EMS 17 if they're available, and if they're within reason, they'll actually try to make an intercept. This is something we copied off of San Antonio? I believe so another shout out to the guys out in Texas and Dr. Winkler, it's another thing we ripped off and copied. It works really well. Picture a F150 pulling up with lights and sirens to an intersection, hopping out with a Q and flow and a cooler with blood products in it, throwing their thumb out, waiting for the rescue to pull up, coming to just about a stop, hopping in the back and taking back off. We're talking maybe a total of 20 to 30 seconds of loss of forward velocity. It's a pretty smooth transition. We've done it a number of times right now and it's very effective. We've been able to continue to evangelize on this and it's continuing to catch on with the possibility of expanding the program. We should see a lot more of that behavior happening. So where a lot of this comes from is this right here is Taylor. So when our guys are delivering blood, it's another one for Taylor. That's really what it is. This is a personal thing for us. This is family. And the people we take care of out in the field, we treat them like their family. That's what this is for us. That's where it comes from. That's where. That's how Jim brought this to us and why we championed it. I was fortunate enough to inherit this program, and it's an inception from Chief Nugent after she retired. We've made some big changes to it and continue to grow and improve upon it.

And with everybody's help in the county, we continue, we continue to push forward, whether it be Dr. Anteby, whether it be the folks over at Memorial, at Candice and Dr. Katz, Broward Health with Dr. Roach and Dr. Puente. There's a lot of good things cooking here. The hope here in the long term is we want to use this group to determine the best way to increase supply and drive down the cost in order to make it so other entities, whether it be within our county or region or across the nation, can get into this game and make dynamic impacts into their patients lives. We've kind of identified that somewhere between four and eight units, depending on how we place them throughout the county, would probably be ideal in order to make sure that we can reach the most amount of people at the least amount of wastage. I've been asked a lot about wastage. As soon as we realized we were operating entirely off of late signs and we augmented our protocol to allow for a little bit more, a little bit more, a little bit more of a liberal interpretation of whether or not we thought our patients may or may not need blood products. We, to the best of my knowledge, in the last 18 or 19 months, I think the only instance of wastage was one time and it was human error. So we've gone from using, from not using our blood and eating the cost and disposing of it to using it every single time we have it. We miss more cases than we can actually treat because of lack of resources and a lack of blood supply. And that's the other thing we're hoping to help collectively solve through all the wonderful and impressive minds that are on this call with us today. So that's where we want to go with this going forward. Have I used up all my time, Peter? I know I can talk a lot.

Yeah, you guys are perfect. Jim. Jim and Heath, you guys are incredible. I remember when we were at the first watch on the back of a napkin and we all agreed we're going to do this for Taylor and where this has come and what you guys have done. The data you just showed was incredible.

Yes. There was one slide where you showed the map just in case. Some of the other chiefs are from Broward county are on. Currently it's EMS 17 and then your helicopter. We're hoping to get other EMS systems in Broward county like Coral Springs, Lauder Hill, perhaps Sunrise, and we're going to really put those units around the county so that everyone can get blood either by ground or by air. So we're going to need all hands on deck. And I know that we have the right team to do it here in Broward County. So thank you guys so much for doing that.

I now want to. Awesome. Thank you, guys. I now want to move on to our next set of speakers, who I also have the pleasure of working with, which is Chief Charlie Coyle, division Chief of Medical services for Palm Beach County Fire Rescue. We call him Boy Wonder. We call him Kevin Costner. We call him a lot of things. They're all good things. And then another incredible person is Madonna Zotzenberg, and she's the director of Trauma services and Emergency management at Tennant Health. So she works at two different hospitals, both St. Mary's and Delray. And I wanted to bring them in to talk about the Palm beach county experience into the hospital. And then we're going to be joined by one of the trauma surgeons, who's a good friend of mine, Dr. Neerhas, to talk about a particular case. So Charlie and Madonna, take it away. And if you want to share some slides, that'd be great.

Well, first and foremost, I'm extremely honored to be on this webinar today with so many brilliant minds, and I'm extremely thankful. I'm thankful for my whole team at Palm Beach County Fire Rescue because this is an undertaking. I would love to tell you that this is easy to conquer and take over, but it's not. I would like to thank all of our medical directors, of course, I would like to thank all of our trauma centers. And then I want to speak specifically about some of the agencies that were doing this before us. The first picture that you see next to the thank you slide is strac. We did get the opportunity to go out and meet Dr. Winkler and his whole, entire team. We did get to meet with Lieutenant Brian, or no, Bill Bullock from San Antonio Fire Rescue. And I can tell you that the way they welcomed us out there, they give us all the specifics, the protocols, the validation studies for the equipment, they gave us specifics on how to monitor the, you know, the temperature in the coolers and, you know, how to make it a web based portal. And I mean, they were, they were amazing and they still continue to be amazing. Dr. Winkler and I were talking before the webinar started today, and I'm just eternally grateful for that entire team. The next picture, I know, not a great one, but if you look to the far right corner, you'll see the mat down there that says BSO. You know Chief Heath Clark as well as Dr. Jim Roach. These are amazing people. I want to say that they were way ahead of us, but really we went through the process at the same time. But I'm going to tell you where we stumbled a little bit through the legal perspective. But they have, I mean, welcomed us down there. We've probably been down there probably about 10 times. Before we got started with our program, they gave us all their protocols. You know, Keith Clark and I speak probably two or three times a week. They're just amazing people. And then New Orleans, you know, New Orleans Fire Rescue, New Orleans ems, specifically Captain Thomas Drainsfield and Chief Cedric.

I'm not sure if I'm saying it right, Palmezzano, I believe is his name. But he has been fantastic as well. You know, they again shared all their protocols with us and shared all their equipment and how they're using, you know, blood products. Not currently whole blood, but they should be working towards that. And I'll leave that to the New Orleans folks to speak about. But the first thing that I want to talk about our program specifically is when we started on July 6, the reason why it says July 6, 2022. I just want to be clear. We started working on a contract to be able to carry whole blood on 2018. Now Covid didn't help with any of that. But I will tell you, after being put into a new position, taking over where the previous management left off, I found out that there was like kind of like a, you know, pretty much a disputing factor that no one was getting past. So our attorneys were stuck on indemnification, OneBlood's attorneys were stuck on indemnification. And we were at a stalemate. We weren't moving forward. So what I learned is, you know, I ended up having to contact our risk management team. Our fire rescue administration staff was amazing. Chief Durham was the chief at that time. He put me in front of the mayor as well as the county commissioners and we were able to go around the word indemnification. But I guess the take home point here is don't get stuck. When you start to build out a contract with being in an email chain. You need to go and see people, you need to talk to people, you need to put people in the same room together because otherwise this will take you four years like it did us. We've only had nine administrations, as you know, up until this point today from July 6th. But we have a very restrictive protocol. As a matter of fact, it's a lot more restrictive than New Orleans, or it's similar to New Orleans. It's a lot more restrictive than the folks that are out in STRAC in San Antonio as well as bso. But I know over time we'll work through that. You know, our trauma surgeons were extremely concerned that we were going to overuse the product and transfuse the wrong patient. So we wanted to work with the trauma surgeons to build a protocol that everyone felt good about. And I know in time we will push past where we're at and we will increase our opportunity to give the blood. But currently I don't really have too many impressive slides with the data, but I did find some notable things when just looking at those nine cases. Number one. Eight males and one female. Of course, like Dr. Holcomb said, boys and men just tend to do things that are a little bit more risky than the girls. Although I have a girl and I would dispute that. But I will tell you that it appears that we're giving most of these administrations close near the weekend and mostly to males. We do have two helicopters, one that's upstaffed for 12 hours a day and the other one's upstaffed for 24 hours a day. Five administrations have come from our tramahawk personnel, which is our helicopter. And then we had four administrations by EMS, 23, which is much like Chief Clark was describing that pickup truck that has it on the. That on their vehicle at all times. Our average age was 30, although we did have an outlier that was a 70 year old. We did give it to somebody that was below the age of 16, which I thought was interesting because I didn't think we would get there that quickly. Survival approximately 44%. That's at the 24 hour mark. Like Chief or like Dr. Roach said, survival to discharge though, 33%. So we still have one patient that's a pretty significant TBI that's still in the hospital. He definitely lived past the 24 hours, but I don't know what that outcome is going to look like. Then we did have a inter facility code that we did administer it, but the patient was coming from a non trauma center and the patient was already in traumatic arrest. We did give the blood. I think we did everything perfectly per protocol, but this poor young man was in a lot of trouble when we got to him. The maps that I'm showing here, just so everyone can kind of get a brief overview of what Palm beach county looks like, we do have two excellent level one trauma centers. I do have them circled on the map here, which is St. Mary's on the north end, and then we have Delray down in the south end. And the EMS captain that we selected is kind of right south of St. Mary's Hospital. And how we got to that EMS captain, because I'm fortunate enough to have 49 fire stations, we have eight EMS captains on daily. We're going to have a ninth one on here soon. But how we got to that data was if you look at the map on the right hand side, you'll see the little circle around station 23. 23 goes down as far as the bottom circle, which is Station 32. It kind of runs a little bit north of that, but they cover pretty much the central part of the county. But the interesting part is when I looked at our protocol that we had drawn up and I looked at mechanism of injury, and we pulled all of our information out of our electronic patient care reporting system, and essentially what we found was this group of patients that would have. I think we were. We. We looked at a couple of different ways. I think we looked at probably 30 administrations that were a potential for round units last year. But the interesting part was, is when you dig down deep in the data, you do not have the conclusive evidence that patient actually was going to get transfused at the hospital. So this is where I'm going to turn it over to Madonna Stossenberg. I will tell you that if you're going to do something with whole blood in your city or county, you need to work with your trauma team. She is the absolute glue. I worked with her, Dr. Lautenberg, many other people from our trauma teams, but she was amazing. And she still is. Well, not she was amazing. She is amazing. And basically what she did was she took some of our data that we were looking at for a year, and then she cross referenced it in the trauma registry to see if the patients we thought would have got blood last year actually did get blood. So I'm going to go ahead and turn it over to Madonna to walk us through what the process looks like for her.

Madonna. Before you go on, I want to ask Charlie, you made a mention of someone else that you work with called Oneblood. Can you tell us just real quickly who that is for the purpose of people in other parts of the state and around the country as well? Okay.

Yeah. And basically, myself and Chief Clark, we work directly with OneBlood. I'm pretty much sure I know Chief Clark says it. Well, Anyone south of I4, if you're getting blood products, you're getting them from Oneblood. So yes, we work closely with OneBlood. I believe a lot of the blood that we order, when we use it, it's usually like a 24 to 48 hour turnaround. So the blood. The blood person that we deal with is in Broward county, but essentially where the whole blood's coming from is Orlando down here. So there's a little delay when we order it.

In essence, it's your blood product source, it's your blood banking source, so to speak, right?

Yes, sir.

Yeah.

Okay. Okay, good. Hey, Madonna, Come on up. Thank you very much for being here. It's fantastic to see you.

Hi, Dr. Pepe. Thank you. And thank you, Chief Coyle. This has been a really great experience. And I want to concur with Chief Coyle in saying that the collaboration between pre hospital and the trauma centers is essential to the success, at least, that we've had here in Palm Beach County. So when Chief Coyle showed those maps, one of the things that we did was we started working on this about a little bit over three years ago. We brought it to our Palm Beach Health Care District trauma agency and a group of us trauma surgeons, leadership from the trauma centers, and then Palm Beach County Fire Rescue, put our heads together and started having conversations. So the data collection component that he's talking about is we, for the trauma program managers, directors on the phone and the trauma medical directors, you have a trauma registry within your hospital system that we collect data, and Dr. Holcomb kind of pointed towards that as far as the TQIP data. So what I did was I took all the patients that Chief Coyle pulled, and then I cross referenced them and ran a report in our registry with patients that would meet the criteria, the EMS prehospital whole blood criteria. Then we took a look and we dove into each patient individually and determined whether they would be candidates for whole blood. So we looked at what happened when they came into the resuscitation base. We looked at if they received component therapy when they came to the trauma center. That's how we decided where we would start the whole blood in the community, the Trauma 1 Registry. We utilize Trauma 1 here in Palm Beach County. So the next thing that I did was I started looking at what the requirements or what the pre hospital criteria were. And I built out, I have to give credit to GEO at our healthcare district. We built out data elements so that way our trauma registrars capture the data as soon as they come in. So we added a yes, no field if they received whole blood pre hospital, and then we added extra fields for their Vital signs. And that way I can run a report every single morning that I come in, or that my registrars can run a report, or my PI nurses can run a report and we can see all of our pre hospital administrations. The next thing that we did was we collaborated on education. So as you can see, we have the pre hospital component, we have the trauma center component, and then you have the trauma administrative team component. So we did a lot of education. We showed screenshots. I trained my registrars, I trained my PI nurses on what the protocol looks like, what data we needed to abstract. We added this as a hospital specific indicator, so that way it flags our system every time one comes in. When the patients come into the trauma bays, we have communication of the event. So I have my team, whether it's the trauma surgeon or the trauma resuscitation nurses, they notify me pretty much in real time. And then along with Chief Coyle's team notifying him, and then him and I usually within a couple of hours of the event, are on the phone looking at the whole process, looking at the patient's vital signs and looking at what happened when they arrived at the trauma center. The EMS REM report and the whole blood forms are a huge component to this process and the PI that goes on. So we, our EMS providers try to drop the forms with us, the run report and the whole blood form stay at the hospital. So I have a process for my trauma resuscitation nurses to make sure that my registrars and my PI nurses have the ability to get that paperwork in real time the next morning when they pick up that data. And then the trauma registrars are key to this because they're one of the first ones that put eyes on the EMS run report, on the blood paperwork and the notification to me, and then we go into real time performance improvement. So I dig into the chart, I dig into the pre hospital data and I look for, for anything and everything that I can find from my standpoint. I speak with the trauma surgeons, I have conversations in real time with the trauma surgeons to get their feedback. Is it working well? Is it not working well? Where do we have improvement? So we can really evaluate this process and the patients that are receiving it in real time. And then ongoing patient data evaluation, we're collecting that. And that's really important because Chief Coyle and I are in constant communication to see where we can make improvements with the pre hospital protocol and seeing where potentially we can move whole blood in the future.

Absolutely. Thank you, Madonna. And as you can see, she really is the glue that keeps us all together here in Palm Beach County. So thank you. Before we go and turn it back over to Dr. Antevi, I just wanted to talk about one of our notable cases. So this was a 49 year old male. We did get his approval to talk about him specifically. He is, he is part of law enforcement and he was shot. One of the interesting things about, or several interesting things about this case was he was with one of the other municipalities. So in Palm beach county, we have 11 other fire departments within the county. And this was one of those pickoffs like Chief Clark was speaking about, which we learned out in San Antonio as well from Dr. Winkler's group. But essentially this officer was shot. The other unit that was on scene, West Palm Beach Fire Rescue, they had great packing. He was shot in the junctional area. They had a hemostatic gauze pact. It was externally, his bleeding was controlled, but he was extremely pale. He was diaphoretic, he had faint pulses. He didn't necessarily meet the vital signs for our protocol. But we did have one of our most experienced EMS captains on the call as well as one of our medical directors happened to be riding with our EMS captain. So basically the patient's pale, diaphoretic, starting to become tachycardic. Of course his blood pressure, systolic blood pressure was going down and they made the decision to give the whole blood. He immediately had marked improvement, his color improved drastically and obviously he started feeling much better. But Dr. Huss was the attending physician. I want to turn it over to him to talk a little bit about the case from his perspective. What happened when the patient got to the trauma bay. I just happened to be the on call trauma surgeon and it's essentially as it was described, receiving a 49 year old officer with packing and whole blood and routes. The transition was very smooth. I have to say. Once we received the patient, it comes with the little hand pump, Everything was continued to be given up until the last drop. It definitely, based on the initial vital signs that were reported, had an improvement. And at the same time try to realize and imagine, I don't have to show a picture how a high caliber, high power, let's say a 5.56 type bullet penetrating in the groin, what damage it can create and indeed, indeed do quite a lot. Imagine a can of a Red bull, it's about 2 inch in diameter, going from the anterior aspect of the thigh, exiting posteriorly by the buttocks and essentially taking a whole cylinder that's about 2 inch round with it. So we have a lot of vital structures there. You have a nerve, you know, the femoral nerve, femoral artery, femoral vein. And they're all in close proximity. They're all affected, including the private parts. And the EMS crew did exactly what needs to be done, which is, first, pack the wound. You can't really put a tourniquet on it because this is really at the junctional area. There's no place to place a tourniquet.

Effectively.

The only thing he can do is pressure and pack it. Well, now we have whole blood, which is an adjunct. And even though he didn't fully fit the criteria, I think the point in this case is the fact that he's strong, he's young, athletic, and therefore, he can compensate a lot more than the average person. And you may not realize that he is in grave danger, and he may not fit the bill of becoming really, you know, tachycardia and hypotensive, but that does not mean that this was not incorrectly given to him. And definitely, as he showed clinically, has improvement, definitely bought, I believe, enough time to then get him to the operating room, where he should have been as soon as possible and allowed us to have a say. And he's doing very well today. So I do not want to show any images because there's no need. I know all of you know what to expect as far as gunshot wounds to any part of the body. This is nothing new for any of you to see. But what's important here is the story. What's important is the. Just the adjunct that we did not have available up until recently, which in certain cases, definitely can make a difference. Awesome. Thank you, Dr. Huss. Before I turn it over back to Dr. Intevi, I just want to say thank you so much to Dr. Holcomb. Dr. Holcomb reached out to us when we started thinking, when we were getting closer to starting our program, and we spoke for about two hours that day, and he wanted to make sure that we were moving in the right direction with our protocol and our equipment. And I really feel like all the people that we thanked earlier and Dr. Holcomb really led us to this point. So, Dr. Holcomb, thank you so much.

Incredible. Incredible. Thank you guys so much. The Palm beach county team and the teamwork you see is just incredible. I want to move the agenda along, and now come on to the Broward Hospital system. And we have two hospital systems, and we're going to give both a chance to discuss here. First, let me bring on Drew Rosenthal and Candice Pineda, who really have shepherded in the the blood into the hospital system. And that's what I wanted to talk about today. So without any further ado, Drew, if you want to unmute your microphone. And then we'll go from you to Candace after that. Thank you.

All right, well, thanks, Peter, for arranging this.

Thanks.

Chief Clark, Dr. Roach, Dr. Holcomb, you guys have really done just an outstanding job in introducing this concept locally. We had kind of a slow start over the last couple of years into the whole blood. But what we found is that anecdotally, it certainly seems to be helping the small number of patients that we've had. Our issue has really been that just as we've started this program, it has been a stepwise upscale and how we are resuscitating the patients, whether they come with whole blood in the pre hospital setting or not, we will use our own indications once they're in the trauma bay for starting our whole blood resuscitation. What we've done is attach the MTP to the whole blood so that if we start the MTP on a male, then we're giving them a whole blood. And if the whole blood is working, then we'll give up to four units. What we found after that is that we'll revert back to our component therapy. It seems to be anecdotally useful, and we've had a few cases where we've seen the ph correct remarkably quickly. We've only had, I don't know, probably fewer than a dozen cases in the hospital where we've used the whole blood, but we've certainly had more cases in the pre hospital setting, as Dr. Roach was demonstrating, and some of the preliminary data. I think what's really missing for us is the ability to collect all of the data prospectively across all of the trauma centers in the county so that we can collectively collect our data so we know that what we're collecting is useful over the next couple of months as we continue to collate these patients together. Candace, did you want to add anything further?

This has been a great collaborative effort, and we have the ability to.

Collaborate.

With our prehospital providers.

And we have a trauma agency, so we get to review these cases each month. And we're really seeing the impact. We've had some very recent cases where it's changed the coagulopathy quickly, and patients that previously would come in with a ph that is not compatible with life.

Is not only staying alive, but going home rather quickly.

So I appreciate everyone's efforts, everyone being on here and look forward to more.

Collaboration, to expanding this.

Yeah, these are anecdotal cases that we're collecting so far. You know, we're really going to need to combine our data with the North District. We're going to need to combine our data with Palm beach and Dade and really get, you know, the entire state's worth of data. If we want to move towards something that's going to be, I guess, what we would consider evidence based right now. I mean, we continue to see, you know, impressive correction of acidosis. And generally the resuscitation process is much smoother for our anesthesiologists. Remember that when we're giving the whole blood, we're giving 600cc more or less with each unit. So if we're giving four units, we've got that ability to give two and a half liters or almost two and a half liters of blood right off the bat, or at least within the first round of resuscitation. And it seems to make sense for all the reasons Dr. Holcomb has mentioned. And I would say that we are very, we're cautious proponents. We work with our blood bank to expand the criteria beyond just the trauma patients. But I think we're definitely making progress and now the momentum is really there.

Yeah, you got it, Drew. And then in a little bit, we're going to plug in the data aspect. I just want to continue with the program here with Dr. Duchesney and Dr. Tatum, who are on in a minute, but let's see if we have our.

I do have one question, Peter, if that's okay. So first of all, it goes to everybody here is that. Well, first of all, when you talk about the acidosis, when you really lost a lot of blood, when it gets low, hemoglobin is an important buffer and you're restoring that beyond the fact of the shock kind of state that you're in. So that's. I'm glad you're actually marking that. That's fantastic there. The other thing I was going to suggest that in your trauma centers, you're always doing, as part of your trauma center review, you always have to go over cases and say, was this a reverse the preventable death? I wonder if you could switch the paradigm here where we're saying this was probably an unpreventable death, yet they survived. It'd be great to help better documentation if you're using the same criteria used before. So just, just a thought for those of you who run that or I'd like to also see how we do that so we can, you know, have better proof that we made a difference here. So. Which is great.

Yeah, I agree with that.

Great points.

Go ahead, Dr. Holcomb.

Hey, Drew, it's John.

As you were kind of going through your discussion, you talked about four units and males only. I think.

Are you guys going to move beyond four units and kind of open this up to females? Are you having that discussion?

Yeah, we are. You know, what we did initially just to get things rolling and make sure there were, I guess, no hesitation on the part of anyone involved logistically was to do it with our adult population, which is age over 15 and just males. Now our stepwise process most likely will be, will include all males. And after we do all males, then we'll go to postmenopausal females and then we'll eventually get to the entire population. We've just found that it's going to be easier for us, I think, to, you know, to introduce this in a stepwise fashion. But I'm not sure that, you know, that's, I'm not sure that that's the, the best way to do it. It may be the best way at our institution. It may not be the best way everywhere.

I'm going to step out and say this as an old white guy, that your young females may object to have whole blood withheld for them. Right. That's what we have found when we listen to the women that they really say, hey, you know, why are you holding this life saving therapy back from our, from us? Just, just. It's an editorial comment. And then the four units is where most people started. A couple of years ago the ABB kind of put out an informal email about four units, but that since resolve this, there's no issues with license. It's much more of an inventory management issue rather than a true, you know, issue.

Yeah, absolutely. And you know, if it was, you know, if we had our druthers, we would be much more, we'd include the entire population with it. But I think that we've had to introduce it for logistical and bureaucratic reasons on a stepwise process. And at least at our institution, I think we'll be more successful than trying to induce it. Carte blanche, so to speak.

Yeah, I hear you. And a lot of people are doing exactly what you're doing as well. And hopefully this, you know, this step wise, the steps are going to get shorter and shorter and shorter. Right. From a time point of view.

Yeah.

Interested in the women on, on the call here. I'm speaking as an old white guy.

What do the women think, Dr. Holcomb?

A shout out to our blood bank team, who is also on this call.

It was a lot for them to.

To manage to even begin this process.

And they're doing a lot of work in the background. So I appreciate their efforts and I.

Think they hear your comments as well. I appreciate it.

You know, this, as you guys might imagine, everything we've done in Houston and other places around the country and deployed is in very tight collaboration with our blood bank and blood donor colleagues. Doesn't happen without them.

And we are going to talk about the blood bank in a little bit. Great conversation, a great editorial. Dr. Holcomb, is either Jessica Holmes or Dr. Puente on. I want to give you guys one or two minutes also to talk about your experience at Broward in the Broward health system.

Actually, I'm going to echo a lot of what Drew, you said. You know, to me, clearly, it's a.

Way for the future, and we're all on board with it.

I think that the elephant in the.

Room that nobody has mentioned yet is the availability of the blood, and I.

Think that that's what we struggle with the most.

I think part of the reason, Dr.

Holcomb, that we have been so selective.

Of both level ones in Brower is because we just don't have enough whole blood available. So, you know, facing that challenge, you know, we had to pick our battles as to where we're going to use it, Hence the limit on the number of units that we're giving and trying to sort of narrow it down to, you know, the most obvious situations with the males over 15 and so on.

So as a.

As.

And both not here, only here, but.

Also in Palm Beach, I happen to.

Wear hats at both places.

We have the same issue.

We all.

All of our trauma centers down here get supplied by the same blood bank by one blood. So we just got to make sure that we continue to work on making that blood available so we can use it more frequently and increase the protocols. But clearly we've seen some successful stories and the EMS guys are doing a great job.

So far, from what we have reviewed.

We haven't really seen any, you know.

Gross over utilization of it, and. And, you know, we're happy to be on board. I actually had listened to Dr. Holcomb three years ago at the Pan American Trauma meeting in Colombia, gives us the same talk and. And, you know, we all walked away realizing that that was the way of the future. And we do agree.

Dr. Holcomb, you want to make some comments and then we'll move to C.J.

Yeah.

The supply from the donor center obviously is a really big deal. And again, I would emphasize working closely in personal communication with those guys. They live a different world than we do. But now I'm going to rise as a trauma surgeon who spent a lot of my life pre hospital in the Army. Slow, constant, gentle pressure and presence will go a long way. You know, we all, it's very interesting around the country and I was on a phone call yesterday with, with a blood banker and her comment was my colleagues, that the clinical colleagues are not asking for more whole blood. Interesting comment. So I think it's incumbent on all of us to, to articulate the need both pre hospital and hospital frequently, clearly, you know, in a respectful fashion, but constantly. And, and I am convinced that our blood collection colleagues that collect the blood and then put it in, you know, blood banks and all that will be able to supply the whole blood that we need.

So you've heard this person's name many times. He was the spark that, that, that kind of allowed us to kind of take off in our own little locations. But Dr. C.J. winkler, San Antonio, please, if you wouldn't mind coming on board, CJ and talking to us. What I wanted to talk, I mean, listen, C.J. could have done this entire webinar himself, but what I wanted to do is have him talk specifically about the blood bank, the pathologist. I know that you have a vision for not just what you're doing today, but what should happen in the future because you've really brought the blood bank people and the pathologist really tight into your, into your group. So, T.J. winkler, thanks for joining us. And take it away, C.J.

I wanted to ask you a question, though, because I thought I saw Chief Hood on Charlie Hood. Was he not on? Is he still on there? Because I want to give him a shout out for the work that he's done, your fire chief, since what, 2007.

So chiefhood is on. I don't need, as you said, thank you, everyone. Thank you for having me. There's about 1 million thank yous to do. And you know what? Since my, my lecture is about collaboration and building bridges with the pathologist, I'll just take 30 seconds to say those. Thank you. So I think first and foremost, probably got to start with, with John Holcomb, Don Jenkins, Steve Hood, Chief String fellow, Chief Casanova, Lieutenant Bullock and many, many others, Dr. Gomez and Dr. Greebond, who make our program successful. There's a lot of other thank yous I have on my presentation, if I can get the, the right one pulled up. But basically I want hopefully if Chief Hood has his microphone working, we can talk. I'm going to talk about blood pathology, but to get there we had to have funding. If. Chief, if you're able to talk, hey.

I've got Deputy Chief Andrew Estrada with me. We've already mentioned Lt. Bullock and Assistant Chief Ramon Casanova. And so I just want to take a couple seconds and thank you guys for allowing us to just have a couple minutes with you today. And Dr. Holcomb, you started off talking about crystalloids and dude, I was an old paramedic back in the day. And so two large bore normal saline lactated ringers and they bled Kool Aid out by the time we got to the hospital. So I'm so excited about this. And then to Chief Clark, you didn't steal anything from us. We collaborated and I have family in Florida and we want them to be taken care of also. So this whole thing is about partnerships, it's about relationships. And Dr. Winkler is going to go into that in depth. But we have a lot of partners here in the city of San Antonio that we work with to make sure that we can give blood to people that need it. We're so excited. We've given 10, 30 units of blood to the citizens of this, to the residents of this community since we started this program. So our probably first or second patient was a trauma code upside down in a creek with multi systems trauma. She's walking around taking care of her two kids today. If I gave her your number, you could call her. So we are witnesses that this works. We have worked with a lot of other agencies from New York to Oklahoma City and Dallas on going out and spreading this message. So we will go anywhere and talk to anybody and answer any question that can help you get a program started. Currently we dispatch blood on any type of shooting, stabbing, pedestrians, automobile pins, any traumatic type incident. And we have eight units in this city that can respond and deliver blood. So our blood supply is about 14 days. We don't waste it. We turn it back over to the blood tissue center if we're not using it. But again, we have given blood to patients from 2 to 97.

We do have a program and we have unfortunately had to use it before where we get blood out to MCIS. So we got 40 units of blood out to Uvalde and we had another scare up in Braunfels, just north of San Antonio. We got 40 units on scene within about 30 minutes.

So we've heard a lot of stuff about, you know, you know, about why we should be doing it and the experience people have had. But I think the overriding problem we've seen in the polls that we've carried out and what you're about to tell us is that. And we heard from people today, it's the supply, it's the sourcing, by the way, that this is everything, like your Brothers in Arms program. And also it is the funding as well. Okay. So at the top of the list. And so if you don't mind, you want to take us away on that. And there you go again.

So many thank yous. And it's all about collaboration. So chiefhood hit it out the park. Basically.

All of these players right here. We met in a room for three hours a week for years to make this work. I say that and people don't believe me. No, we met at lunch and we had lunch and we ate. We broke bread. And there's something about breaking bread with folks that. That gets their guard down. And we basically had all these people in the room and were able to talk to the pathologist. So South Texas Blood and Tissue center and University Health, as Chief said, basically, if we don't use our blood, we give it back to South Texas Blood and Tissue center and then they give it to University Health System. So the funding happened from a grant that was written by Dr. Jenkins and Strack. So we had $150,000 up front. So that money was given. The reason that's important is that money was given to South Texas Blood and Tissue Center. Just a blank check. Because if you think about it, Dr. Holcomb said a lot of medics on this call are like, why are you dumb doctors using component therapy instead of whole blood anyway? Right? Like, it's a good question. It is a good question. And I don't have an answer for. And that was even done before every other physician's time on this call. But basically, you know, whole blood makes more sense. But the pathologist doesn't have a bag to make whole blood or the ability to test for whole blood sometimes. So it costs a little bit of money to build that program up. We gave them that money. So the cost was not a factor with the blood center and the blood pathologist. Chief Hood asked city council for the funding. They gave us the funding for that for five years, $500,000. So we don't charge anyone for blood in San Antonio. And then Strat kind of ties everything together. This is that rotation system we're talking about. And the reason that matters, if you really think about what's happening. This is a busy slide. You can look at it later. But basically what happens is when Lieutenant Bullock is on his supervisor vehicle and he transfuses blood 24 7, he just goes to the blood center and gets a new unit of blood.

If we don't use the blood, then he brings the blood back to the blood center. If we don't use it in two weeks, he brings the blood back to the blood center and gives it to the trauma center. So we don't pay for that. That takes a relationship. That takes a relationship with.

Your blood center. I don't know if this is showing up. Sorry I don't have the screen maximized. My computer's kind of wonky. But basically, ems, meet the blood bank. So that's ems, that's you, everybody most more or less on the left for the blood bank. That's you on the right. So what I've really, really learned is that I have to get my paramedic brain and my EMS doctor brain to accept that pathologists have a culture of safety. And you think you have a culture of safety in EMS and you don't compared to pathologists, and they communicate that way. I used to joke, and I know it's recorded, but I'll say this to the pathologist. I used to say pathology is the land of no. When you ask him something, the first answer is always no. Then the fifth answer is no. And Holcomb said it. And I don't want it to go by without people really thinking about, john knows everything. Everything I thought of John did 20 years ago. But when you talk to folks, it's gentle pressure, it's continual pressure, saying, this is what's good for the patient. This is what's helpful. We have a culture of being progressive and on the bleeding edge, as it were, in ems. And the blood pathologist has a culture of regulation and safety. And that's important for you to understand when you start building this relationship. So one thing I know everyone says blood bank, but if your blood bank is a blood center, please call them a blood center. Okay? It's like, you know, if you're a trauma surgeon, you want to be called a trauma surgeon. If you're EroDoc, you want to be called an ER doc, right? Understand the role and the responsibilities of everyone at that blood bank. Everyone's there. It's difficult.

Has anyone ever thought about why blood donations are. You have to donate, why they're free. Why you don't have to pay for them. We can save question and answer till the end, but just think about that. Think about the difficulty you have to convince someone to give part of their body to you. So it's a. It's a difficult thing. You've got to speak that language. Also when you're talking to blood banks and pathologists, you gotta speak their language, and their language is regulation and safety. And one way I found to broach that is to say we are really good with our medications, particularly we are good with narcotics. We keep them locked on a safe in the ambulance. We actually write down every morning, you know, if we use them or not. And that is the dea. Those people have guns. So we actually know how to keep a medical product safe on the ambulance, a medication safe on the ambulance. And then the last little part. And I talked about this, and this is subtle, I just don't have time to really go into it. But Dr. Pepe and had kind of picked up on this right away that. Know your hospitals, if you have more than one trauma center in your area.

With a blood bank presumptively, usually trauma centers have blood banks in their hospital. Tell them you, you appreciate a program where you can trade your blood in. If you don't use it in a few weeks, just tell them that's what you appreciate. And I'll tell you, it goes a long way to explaining to them, we don't have anything prehospital. We have normal saline. Or then the fancy word after we learn normal saline is bad for you. Permissive hypotension, which is a fancy way to say do nothing. Right? So when you tell them that, hey, look, we don't have anything prehospital, as Chief Hood said, his family's in Florida. If you have blood for the pre hospital setting, please use it on my family number. And then I put this little joke on the bottom of the slide. A priest, a rabbit and a deacon walk into a blood bank. I think I might be a typo, said the rabbit. So is that a dumb joke? That's a terrible joke. But I texted that to my pathologist, the boss of South Texas Blood and Tissue center pathologist. And she laughed. She said, I have shown that like 20 times to other blood pathologists throughout the country. And she's like. And I texted a few. Oh, this is from my EMS med director. So it's all about relationships. It's all about relationships. There's nothing more to be said. That's what the title of the Slide is people are human. I know it's hard to imagine you think they're out to get you, especially when it comes to the land of no pathology. But they actually have concerns. They're very good at what they do. Show up to their conferences if you get a chance. Invite them to speak at your conferences.

They like that. Publish with them. I have published with our blood pathologist. That is also very important for those folks. And I'll finish here and I'll say that we do have a national whole blood academy. That's what everyone has given me way too much credit. It's not me, it's everyone where we'll teach a couple, two times a year. We just pick the dates. Actually on the blood call before this blood call, we pick the dates. So two times next year we'll do the whole blood academy. And then we'll also we're going to host a national whole blood summit. And I hope every single person on this call can make it to San Antonio next year. We don't have a date picked out, but we did that before COVID hit John was there Sperry guy yet all the. I could name drop every single American, Red Cross bosses, military bosses, everybody was there. This is where you get to come and tell your story at a national summit. So I'm going to cede my time. Thank you for putting up with me for incredible.

And I tell you what, I hope people were taking notes on that. You dropped so many great pearls there. And for the blood bank folks who are on, get ready for the onslaught of EMS folks coming your way. Charlie and Jim and Heath, if you can. If you can go through very quickly the logistical considerations, because I do want people to know what they're in for as far as purchasing products that we have vetted and then. And the cost of those products. So if you maybe take like just a few minutes to do that, we'd appreciate it.

Yeah. Heath, I'll let you go ahead and get started about what you guys are doing. Then we could talk about what we're doing. I think what. I think what everyone needs to take out of this is there's several different ways of doing it. I know what San Antonio does is a little different than what Nolo does. I know it's a little different than what BSO does. And then BSO in Palm beach county does something very similar. But I'll let Heath kind of walk through what their process is and I'll add some. Maybe a couple additional things at the end.

Yeah, sure. So we're gonna Put the price list up. The first caveat, I'll tell you is there, there are other products out there. This is no direct statement saying this is the only thing you can use. The, I guess the, the one difference on that or the one caveat to that would be probably the lifelow, because that was a game changer for us. We've never found anything that can help us deliver blood anywhere near as quickly and as efficiently and safely as the, the lifeload gun. So it's a shameless plug for Dr. Appeal because it's really a fantastic product. That said, we've had. We've had great success through our Q and Flow warmer series. There are other warmers out there. I have no experience with them. Other providers might be able to speak to them, but we've had very good luck with what we've been using. Interestingly enough, we started with the blood Box cooler. It turns out Palm beach went to the Pelican Credo. And at around the same time I actually made the same transition over to that because it provided a smaller form factor for me and an EC135 helicopter that actually, you know, any little bit extra room I can generate for my guys and girls, any space I can create is a good thing. So even something as small as that is important to us. You guys can see all the prices. I don't necessarily need to name them for you. There are disposable aspects of this, your initial investment beyond the cooler for actual transport of your blood products. If you go with a freezer, refrigerator, as I did through Elmer, or if you just went with the cooler, there's different ways to set it up.

That was our biggest expenditure. I think we spent upwards of $11,000 on our helmer units. That that was prior to my, my ascendancy or however you want to refer to me taking over this job or lunacy, maybe the. That was our biggest, biggest one. Followed up by the Q and Flow. That that's a hefty price initially. But remember, this is a durable good. You're going to use it over a number of years and if you're going to look at cost per use, it goes down every time you use it. You got anything else on that, Charlie? I'm sorry, no.

Yeah, we just to kind of give.

Everyone a little bit of perspective as far as what Heath uses and I use in Palm Beach County. It's really the same thing. So we use. We both use the Life Flow, we both use the Warriors. We both have two helmer fridges. I know after speaking to the folks out at nola, they, they are not using the big helmer fridges. They're just, they have the freezer to keep the tick panels cool that go in the actual cooler. So we're using the same coolers that San Antonio is using. You saw the temp stick on there. That's another tidbit that we picked up from San Antonio when we did the whole Blood Academy. They really showed us how to, how to, you know, to monitor our temperatures constantly. So that's something we picked up and we're utilizing. I could tell you as far as the Q and flow, the team is great there. Ariel, as far as Lifelo, Dr. Peel and his team have been amazing. They come out, they do in service training for us. We've been very fortunate and blessed to work with Qin Flow as well as Lifelo. So that's it for me.

All right, Charlie, thank you so much. And Heath, you guys, really, the reason we put that up is because what we really want to do is give people a very clear understanding of what is in it for you here. We don't think it's unreasonable what these costs are and we're very grateful for those.

Products that we talked about that we have vetted.

Hey, Doc, on that. I'm sorry, 10 seconds. I forgot to close out my thought on this. So beyond that initial capital investment, from there you're just maintaining your actual consumables, which would be lifelow if you decide to use it, or what other ancillary device you use to help deliver your actual blood. If you use a word warmer like the Q and flow, there's a disposable aspect of that, the actual blood warmer part. But you're looking at, just for the most part, you're looking at the actual cost of the blood products themselves. If you. I didn't realize it's exactly how San Antonio had funded. That's brilliant. I, I hope to try to mimic that. But if you're in a position like I am currently, where you're actually paying per use, it can be a little cost prohibitive. Which again goes back to the idea. As you know, Dr. Puente mentioned the same thing I had kind of driven at earlier with the idea of using this group to hopefully identify ways to drive down cost and increase supply. Your day to day operations though, once your past investment is, it really is just the blood products themselves. So it's not that bad once you get over the sticker shock. Looking at the initial purchase prices.

Dr. Duchesne and Dr. Tatum, thank you both for joining us. This, I believe, may be the most important part of this whole process is the data. A lot of naysayers out there. So, Dr. Duchesne, Dr. Tatum, please take it away and intro us to what you're doing and how everyone can get involved with your registry.

You're on mute.

You're on mute.

Still on mute, Juan.

The joy of zoom.

There you go.

Okay.

Yes, thank you. Good to have you here. Thanks. It's good to see you.

Yeah.

Nice to see all of you guys. I wish we'll be everybody in the same place, but it's great to do this. So definitely it's time to do a formal registry. I believe there is so much we can learn from what everybody's doing independently. And in 2021, we put a study together, about 800 MTPs done in charity Hospital, University Medical center, just to see how we were doing with resuscitation and moving the pendulum. So this is the kind of patients that we were dealing with. And to our surprise, and this was published in Shock Journal, we basically demonstrated that mortality also went up and down, was basically consistently the 7% of which tourniquet and whole blood were the ones that were sending some kind of stuff signal of improved survival. Later on the next year, we presented the impact of time to surgery on mortality in hypertensive patients. And this was a double ast multicenter study. And basically not to anybody's surprise, as we know, non compressible torso hemorrhage patients die within the first 30 minutes. And as we know, we have the golden hour, 60 minutes for decoration purposes only. And as we demonstrated, Basically it takes 30 minutes for these kind of patients to arrive to our trauma centers. And from there it took on average 74 to 88 minutes to get a hypotensive patient that is bleeding from the torso to get to the or. So based on that, we started putting our brains together and started thinking, what can we do better to move this pendulum of resuscitation? As everybody, some of the old school brain cells out there, they said that the only thing that the ambulance needs is diesel. Well, I think it's time to move that pendulum because that's definitely wrong. We haven't moved the mortality curve doing that. And because of that, we've been pushing for not only stopping the hemorrhage on the spot with tourniquets.

But we need to start thinking about circulation first as well. And as everybody knows, it's been published by Pamper Trial and Combat Casualties, that the administration of blood products before Arriving to the formal destinations had improved definitely life and saved lives. The same thing based on the Pamper trial. So why, why I'm doing this? The main reason why I decided to do this and to push for pre hospital blood, specifically knee illness is because of this specific study. Because I was so excited when this came out, but I was so frustrated with the outcomes. And this is the reason why we're doing this, because I believe that there's many other ways to improve these outcomes. So we started our program or actually the whole get together pre Covid, believe it or not and we started thinking about how we're going to get the blood products, who was going to be giving us the blood. And this is basically what we decided to go with. With the only CMS we work hand in hand and the goal was to give 2 units of packered blood cells with 2 of calcium and 2 TXA. We did advanced recitative education to all the medics of neoni. CMS took us two days. It was very nice and collaborative and this was the first tool that we use for database in the pre hospital setting. And then from that we start getting some information. Information that was really cool. The average time to administration in a fast paced urban setting was 8.6 minutes. So far we've given 175 total units. We actually predicted 92 units for a year span and we surpassed that. The average volume of administration was 552mls per patient. When we compare on the scene versus en route, most of the patients received the first unit on the scene seen and the rest en route. And this is one of the first things that we actually demonstrated, we've been demonstrating is that there's a big difference in the shock index when the medics arrive from 0.95 blood given arrived to the hospital 0.6.

And this is just a quick snapshot of what we're gathering and I just want you to pay attention. Out of these 95 patients, the ones that arrive to to the hospital with signs of life, we have 11.3% mortality. Now this is only in the group that have received blood. We have other patients that haven't received blood. So that's the purpose of why we're here, to see if we can actually develop a good registry so we can actually have good data of what is the best modality for resuscitation. This is again the shock index. And for those that arrive to the hospital with signs of life, 11.3% died. Of the one that survived, 95% were alive within 24 hours. And 72 hours, 92%. So now I'm going to let Dr. Tatum, which is the brain behind the registry.

So I will cover. Juan gave you the why and I'll sort of give you the what and the how. I've highlighted my email address at the bottom of that first slide. So this is what will happen if you guys want to jump in and join the registry. So all the, you know, the bureaucracy that we need to wade through, you'll obviously need IRB coverage, EMS providers. You can work with your hospital partners to do this. We'll execute a data use agreement between Tulane and your institution. You'll be issued a two lane email address and you'll have to go through two lane redcap training, which is somewhat pain. It's not that painful, it's moderately painful, but it's quick, you'll get it done very quickly and then you'll never have to do it again. And I will assist you. And this is a John Stockton joke for anybody who's a basketball fan. And if I had known San Antonio would have been on, I could have used Tim Duncan. But anyway, I will help. So you're not going to be out there waiting through this yourself. This is what I'll need to give you red cap account access. I'll just need a list of things. We'll have to create an account for you. It's fairly straightforward. I'll send this to you whenever we start having conversations by email. So this is basically what we're capturing in the registry right now. We're going to modify that data collection tool that Juan showed. We're going to be a lot more in depth from the pre hospital side and from the in hospital side. There's a lot obviously on the pre hospital side that we're really interested in. But we want to know a lot about the specific injuries and the in hospital outcomes and some, some surgical interventions and those types of things too. So we're expounding on that, that data capture tool quite a bit. So this is a very broad inclusion criteria. We're looking for anybody who got, you know, 2 grams of TXA pre hospital, whether they got component or whole blood, you know, packed cells or whole blood. Anyone with signs of hemorrhagic shock, systolics less than 90 or tachycardic, with a heart rate of 110 or better.

And the reason we're including even these patients with signs of hemorrhagic shock who maybe didn't get blood, we need a comparison group. We need someone to Compare our recipients to. It'll be really great to compare PAC cells to whole blood at some point when we get sufficient numbers. But it would be really nice to compare it to patients in hemorrhagic shock who didn't get blood.

And this includes, I want to say real quickly, we'll have to figure out how to do this. But patients with signs of life at the scene who got TXA or whole blood or PAC cells, if they died en route, often they don't end up in the hospital's trauma registry, which is where a lot of our patients, you know, typically we pull from that registry. But we'll want to capture those patients too. We want this to be a really comprehensive look. Look at all these severely injured patients and who's surviving and who's not and seeing where the benefit is. The basic things, very, very common transfers, obviously confound time and other things. Pregnant women, incarcerated individuals and burn patients with more than 20% total body surface area. And if you have questions, just email me.

Let's see. Ken Shepke, are you here? Dr. Shepker, I had the honor of introducing the Deputy Secretary of Health for the state of Florida. He's an EMS medical director obviously as well, for many Systems. Actually, Paul, Dr. Pappy, I'm not sure if you saw this, but Ken was just voted as a top 10.

Healthcare.

Ken, what was it?

You were like the.

Yeah. In the state of Florida.

So it was the most influential people in affecting your health. But etc. What it comes down to, it's really most influential.

Right. We, we, we know Ken is a visionary and we're so proud to call him a friend and the fact he's up at the state level. So Dr. Shepke, take it away and give us your.

Yeah, I keep getting all these awards and he has to get an extra room now to actually.

Well, thank you very much for that introduction. This has been really amazing and thank you so much for organizing it. It's clearly something we need. And I'll just kind of summarize some of the things that I think we're all saying. First of all, when you're leaking out red stuff, it's important to replace it with red stuff, not clear stuff. And if you're leaking out whole blood, you should replace it with whole blood, not components of blood. And it sounds like that should just be common sense. And it really took a bunch of science and smart people on this call to really point out the common sense thing. I'm going to add one more common sense thing is that if you have a seconds to minutes emergency, where it is really important to do something as soon as someone arrives in the er, then it's even more important to do it before they arrive in the ER in the prehospital field. And I think that's true beyond just whole blood. And we see that over a whole host of things and certainly a lot of people on this call have enacted a lot of those things, whether it be prehospital antibiotics or septic shock or fracture or now whole blood. Clearly, EMS has been a real leader in pushing the bar in advancing medicine, especially for the second semester emergencies. I do want to thank all the experts that we have on the call, of course Dr. Winkler and Dr. Holcomb for bringing us together. Of course Dr. Pepe and Dr. Entebbe, the great connectors.

So as far as the state of Florida goes, I really think that this is a great opportunity. We see fantastic collaboration, more so than I've seen in my three year career at emergency medicine, ems, where EMS is really driving positive change in collaboration with our partners from the hospital. Really making great strides, not just in trauma and in this particular topic, but in all sorts of areas. And I really, really like to see that continue to occur. Anything that you all need me to do at the state level to try to reduce barriers to the care that the EMS medical director is doing at the local front, I'm certainly willing to help out. So Peter, thanks again for putting this on and I'll turn it back over to you.

Thanks, Ken. You know, I think that the, that's a perfect segue into what I want John and Paul and CJ to talk about right now, which is how do we pay for this stuff? So John, let's start with you.

Hey, Peter. Thank you, Ken. John Holcomb, you know, as we kind of worked our way through many of the issues that you guys have talked about, and I'll just go back to one of them. It took us three years of meetings to get components pre hospital, but once we had components pre hospital, it only took us one year of meetings to get whole blood pre hospital. Just speaking about those little steps along the way and Eric bank and, and the guys did a great job here in Houston doing that.

The question that we've kind of worked through over the years is billing, how to get reimbursed for blood products and the things that you need on the rigs to deliver blood products to patients. You know, we have Level 1 data published in Journal of Medicine that blood products prehospital improve outcome yet the group that led that study had to pull plasma off their helicopters because they couldn't bill for it.

At some point, as you know, in your position, a lot of things come down to economics. I think you can help us with this.

Push through maybe in Florida, because you guys are doing a lot of innovative things and maybe at the national level over.

Yeah, certainly anything I can do. I will look into the reimbursement from that standpoint. I think EMS reimbursement is definitely a topic that's coming up. I think we all believe that community paramedicine is one of the ways that we should go. Rather than just bringing patients to the er, we should be bringing the ER to the patients. Kind of like what we're just describing on this call as well. And that does change the billing. And it's been a topic that we've certainly been happening at the Florida Department of Health and with our colleagues over at the Agency of Healthcare Administration, where that administers the Medicaid for the state. And that's. So you definitely have someone who agrees with that in Maine. I do want to point out one more obvious topic that it's kind of funny that we. A lot of these things are really common sense. And then science proves the common sense. We've been able to take these folks who have hemorrhagic shock in the field and resuscitate them with clear fluids and make their blood pressure look better and everything looks great. And they get to the ER and it looks like we have a save only for the patient later on to die from multi organ system failure. And that is because at the cellular level, these cells are going through hypoxia and get hypoxic damage. That shows up. It begins a biochemical cascade that ends in cell death several days later. But what you all are doing now, by giving that blood really early on in this process, you're preventing that later on down the road multi system organ failure. So again, I applaud you for all your efforts.

D.J. you actually brought up how you paid for this, that the strat gave 150k to the, to the blood bank. And a few people have commented that that may be a good idea. So, Ken, this is for you and maybe for others.

There is a problem when the hospital per se would pay for the blood and then give it to ems. They can't do that. They can't be charging or, you know, EMS cannot be recuperating money that way. Is what CJ's doing in Strac and his team something that's doable here.

Yeah.

You know, it's going to come down to partnership, the local level. And I do think that's a brilliant way of handling it so that EMS makes the investment to purchase this life saving product that has a relatively short shelf life, but then has an evergreen product. Because as the product is getting close to its shelf life, we don't use it as much as the hospitals do for all the surgeries that they're doing. So if we could then get the pathologist to agree, as Dr. Winkler pointed out, that allow us to swap our aging unit for a newer unit so that the first that this life saving product doesn't go to waste. But also from a financial standpoint, we don't lose the finances. From an EMS agency standpoint, I certainly think that is a really brilliant and relatively simple, at least on the surface, simple solution. Although that's going to take a lot of relationships and a lot of trust building because I know exactly what Dr. Wick was talking about. When you get to your blood bank, folks, they are very hypersensitive about being careful about what patients get. Transfers. But I do think that that is one possibility.

At the end of the day, at the end of the day, if somebody would run the numbers on let's say Jim and Heath's program in Broward. Sheriff, they've given 80 people blood and let's say that they gave 80 units of blood. Let's just call that 40,000 bucks.

Right.

40,000 bucks. And look how many lives it has saved. Right. So we shouldn't be putting a price, I think, on this.

On whole blood, in my opinion. I think. Can you and I have had this conversation, we need to just do this.

Yeah.

And even goes beyond what you're talking about. And you're right, Peter, there are a lot of economic calculations where we talk not only dollars per life saved, but dollars for years of life saved. And this is the disease, gunshot wounds and car crashes that is very frequently the younger population. Population. So you disproportionately save many extra lives. Any years of lives because of the younger population. This disease tends to take 100.

Go ahead, John. And then C.J. after that.

Yeah. And C.J. is probably going to say this. You know, most, most people start a pre hospital blood program to include whole blood with trauma patients very rapidly expands to non trauma patients. Maternal fetal bleeding, ectopics, postpartum hemorrhage, GI bleeders, those sort of things can frequently end up actually being more common than the trauma patient.

Over cj.

Yeah. John is so good I completely forgot to thank Chief Bank. If I go without thanking Eric, then all is lost. And thank you Eric bank for I had pre wedding jitters before we rolled out blood the night before. He talked me down for a few hours so he deserves a lot of the credit. Along with John Dr. Holcomb, of course. So there's a couple of things when I think about funding a if we.