Florida Whole Blood Coalition: Protocol Development (3/31/23)

So I'm starting here. It's exactly one o' clock Eastern time. And the reason we have to start because we have a lot to go over.

My name is Peter Anteby, medical Director here in South Florida. And today we're joined by a great group of people who are already doing whole blood and we already have protocols. But when I started to look at all these protocols, there are some differences. And then I can only imagine if you're out there trying to create your own protocol and you're probably wondering, like, what are the. What are the things we should focus on? So not only are we going to learn from each other, but we're also going to let you R and D. So rip off and duplicate is the word of the day today. At the very end of this meeting, you'll have a QR code and that QR code will give you the entire folder that has every PowerPoint, it has, every protocol, it has SOGs, whatever you need. There's no need for you to go duplicate anything. We have it all for you.

We have a mission. And again, Dr. Pepe, who just joined us, has helped us with this mission, which is the Florida Whole Blood Coalition to develop and sustain an involved, highly collaborative and productive stakeholder group. This is important. Who can promulgate and implement the ongoing use of whole blood, not just across South Florida, but hopefully across the country to that extent. There was a meeting today at EMS on the Hill that I was invited to, thanks to Dr. Peel and Joseph Zalkin, where the Nant is fighting along with NAMSP to get whole blood paid for. So it's not being paid for by us. And we'll talk about that a little bit later.

Our agenda today is some great people involved. And I really have to apologize. There's one particular person that I feel really bad that he's not here. When my assistant was making the meeting, we kind of picked a date and then changed the date. And that's Dr. Jim Roach, who really him and Chief Clark, who will be on today. They really pioneered blood in South Florida after going to San Antonio. So the fact that Jim is on the call, I feel really badly about, but hopefully we will make sure he's on subsequent calls.

Yeah, and I want to second that, Peter, because I absolutely agree. I mean, that both he and Chief Clark were just real, I mean, heroes here in terms of getting this done here in South Florida. So. And despite a lot of, let's say, obstructions and hurdles to get through. So I want to just second your.

Kudos there. So thank you.

Thank you. Thanks, Dr. Pepe. So we're going to start off with Ariel Katz, who is with Q and Flow. That's the warmer that most of us use. We're then going to go talking about creating a whole blood program and invited just an incredible person that Dr. Winkler knows very well. And I've gotten to know, as has Dr. Pepe with Randy Schaefer, who is now helping people create programs all around the country. So I wanted people to get exposure to her. We'll spend the bulk of our time on the whole blood protocol discussion on 35 minutes there. Dr. Pepe will finish us off with a great discussion on txa. I'm going to ask all of our speakers to kind of hone it in and. And let's do things quickly. So without any further ado, Ariel Katz, I'm going to unshare my screen if you want to share. I asked Arielle to talk about how many programs out there are using whole blood. And because he's in the space, he's a CEO of Q& Flow, I asked him to do that. So, Ariel, we could see your screen if you want to just. There you go. You're live.

Okay.

Yeah. Thank you. Thank you so much for hosting me today. So that's. I've been tasked, as Vera said, with the difficult task of trying to come with a number here in an industry that kind of national data is not so much available. So we have tried to come up with that. We actually, in order to be able to come with a number that makes sense, we looked at our commercial engagement and we obviously took some consideration, some adjustment to the fact that there are other good warmers in the market that are being used out there. The point I'm trying to make here, just take this data as indicative and hopefully it is a good representation of reality. And our story really starting in Texas, if you want to look at our model, it starts in Texas for two reasons. First, we are based in Texas. We are based in Plano, as you can tell by my very distinguished southern accent. And secondly, and most importantly, that's where things started to roll up really quickly. So when we looked at where we were in late 17, we were aware as a company, as a vendor, about three agencies giving blood pre hospital at that time. Maybe there were more, possibly there were more, but definitely the situation has completely transformed over the past years. Even Covid didn't manage to really stop it or it only managed to slow it down. And definitely the tailwind coming from Strzok and San Antonio were Very, very significant in building that ecosystem that we have today. Now this is not insignificant if you take into account that there are other agencies that are actually doing it with other products. And I don't have the exact estimation of that. We estimate that about 7.5% to 15% of agencies in Texas are giving blood hospitality today. And that's a significant number. If you try to kind of translate it into national numbers, that will be in the area of 1500-3000 agencies. Obviously we are not there. So that's kind of just to kind of say where Texas is compared to kind of what we see developing in other markets. But the other territories, the other states are developing as well. And we can see like a good traction coming up in, in Virginia and North Carolina and air medical transport in Ohio and Colorado and very good initial engagement in Washington state and in Indiana and in obviously Florida. In essence, we see a very significant presence of agencies across the US in almost every state. We don't have visibility to all the states, but this is the states that we have visibility to. So all these states are coming at anywhere between one and nine agencies based on our model. So with that said, it gets me back to the question, so how many out there? So we understand the model, really how many agencies? And to make it interesting for the forum here, I'm proposing that you go into the chat and start to throw numbers. And the one that will be the closest eventually to the number that I'm going to say in a few slides will get the free warmer for the blood program. But with that said, Rush, I'll give you a couple of hints. So the first hint is that just to see the annual growth year by year again based on our model, maybe accurate, maybe only indicatively accurate, but definitely the trend talks for itself. The interesting part here to see is that last year actually recovered completely from COVID and also that there is kind of a decent distribution between air and ground agencies that are carrying blood. And that's kind of interesting to watch. Obviously air were the kind of the first one to take it on, but the ground is definitely following fairly fast. So our number will eventually come. Now this is the second kind of hint that I'll give will come from that range eventually. This is the total number of agencies against based on our model. And wherever we land eventually on this kind of.

Area, the trend is very significant. You see probably about 10, 10 fold growth over the past five years and that's very significant. And the interesting part is that it's definitely going to continue and it's not going to stop. Another interesting data point is that we estimate that last year there were about 10,000 patients that got blood pre hospitally. And again this is based on our commercial data that we add additional factors to account for the fact that there are other vendors out there delivering a good blood warming solution. So that's kind of the number. I think it's a lot, but definitely it's scratching the surface. If you look at some available data about the potential of giving pre hospital blood odor, I'm not going to get into this study that's well above and beyond the time that we have into that. But if 900,000 is a real number then we are about 1% of the market. So there is still a way to go. So that's probably the time to stop the kind of guessing if you try to or to give the last attempt. We estimate if we have to come to a number in this forum we humbly as a representative of my industry at the moment, I believe that I want to say that the train has left the station and that There are about 325 agencies with some tolerance that are giving blood today pre hospitally and again 10k patients last year. But most importantly, this is not the end of it. Based on the traction that we see, we feel that this is going to grow significantly over the past few years. Now my last comment really is humbly, we feel privileged to be contributing to a program that is so much bigger than all of us. Thank you for doing what you're doing.

Ariel.

Thank you so much for that overview. I'd love to see those numbers and the growth and I want to segue right into a very special person who kind of was trying to hide in the shadows until a lot of us start to figure out who she was. Thanks to the folks in Texas. But Ms. Randy Schaefer, first of all, thank you for your many years of service through our country. Now I know that you have helped many folks prop up their whole blood program. Tell us a little bit about yourself and then what you do to help others to get their whole blood program up and running.

Hi. Thank you for the kind introduction. My name is Randy Shafer as Dr. Anteby alluded to. Unfortunately I have a lot of experience with pre hospital blood and whole blood using it on my all my combat deployments starting in 2005. So I had the opportunity when I retired to come to San Antonio and work at Strack and one of my projects was helping set up the prehospital blood program. So I developed an onboarding process, worked really closely with CJ Dr. Jenkins to get it rolled out. I think I rolled it out to 16 agencies, air and ground. And now that I've left track, I'm still passionate about trying to get prehospital blood out. If you notice, I'm wearing a ragged T shirt today and that is in honor of the nine soldiers that were just killed in the aircraft collision for Campbell. My husband is a Blackhawk pilot. He knew one of the pilots. We were Campbell for a year. So this is hit home. And I just had this thought this morning after we were on the call this morning with the congressional efforts, it occurred to me if those nine soldiers had crashed in Afghanistan or Iraq, they would have had a better chance of survival because we have pre hospital blood everywhere there. If they had where they crashed at in Kentucky, there is no prehospital blood in Kentucky. I think their chances of survival would have actually diminished if they had crashed here in the US I think that needs to serve as a wake up call. It's been a pleasure. I actually had a great call with the University of Kentucky at Lexington with a couple of EMS agencies. I did throw down the gauntlet. I said Peter and Tavi in Florida are figuring out this coalition. I want you all to stand up to Kentucky whole blood coalition. So I threw that challenge out.

This is a team sport. There's no way around it. This is not like buying a defibrillator. I just had a great phone call yesterday, very excited from Indiana. He had one or two stumbling blocks with the blood bank. And as we talked through about how to talk with the blood bank, understand their world, they were able to come to a negotiation. So they're going to start carrying blood and they found a local grant to fund their equipment efforts. So a lot of grassroots things going on. But I really would like to make it more at a higher level. We need to unify. We have cardiac registries and stroke registries, but we don't track trauma care as well. It always seems to be. We'll just get them to the hospital, we'll take care of them and I'm not going to accept that anymore as an answer.

Well.

Randy, if you wouldn't mind one of these sessions, I'm going to have scheduled you to talk strictly. I bring you CJ and some other folks to talk about the whole blood bank issue for sure. If you wouldn't mind putting your information in the chat so people can know how to contact you. I'm also going to have Randy come on the Florida EMS webinar, which we do every Tuesday. But you're a resource everyone needs to know about. So thank you so much for being here. We're looking forward to your comments moving forward as well. And very sorry for the, for the losses of those nine soldiers. And I can see how it hits home for you. And we're very, very sorry about that. I'm going to keep moving on. I have something hot off the press. Dr. Holcomb just sent me this. Basically, take out your phone. There's a QR code. The NAMSP just put out a joint statement with ASAP and American College of Surgeons on pre hospital hemorrhage control. And oh, by the way, it includes whole blood, so please.

Look at that. Whenever there's a position statement on anything, it's something to be aware of. And the fact that it includes whole blood and TXA, which Dr. Pepe will talk about later on, please take a look. Okay, let's start with the protocol. So the first person I want to bring in is the person who we've all looked up to. We've all been to his shop. He just given everything from himself. He says you go do it. Which is Dr. C.J. winkler from San Antonio. C.J. welcome.

I want you to talk about obviously we're giving this for trauma and everyone is going to have a trauma protocol. But when you send me your protocols, I noticed you had a trauma protocol, a medical protocol and a pediatric protocol. I was hoping that, and I have two of those up on the screen. I was hoping, cj, that you could talk about.

Why it's important to divvy your protocol up into trauma, medical and even perhaps pediatrics, if you wouldn't mind doing that. Thanks for joining us.

I do look up to both Peter and Paul. I think that really they're the leaders in EMS and they're the best at bringing people together. And that is a true talent in and of itself. So thank you all for having me. So I think first and foremost.

Is that when you're looking to deploy blood, as we did, we really talked about trauma patients, medical patients and pediatric patients before we even gave transfused our first unit of blood. And the reason that was a little outside of the norm, as it were, even though there was no norm, is because the hospitals were only the hospitals have other options besides low title positive blood. They have negative Rh negative. Right. So they don't have to kind of make these tough decisions necessarily. And the prehospital setting, we don't have anything else except this Low tight or O positive. So right away we knew that there was a potential we were going to be transfusing children and.

Females of childbearing age. So we, before we rolled that out, there was actually a really nice study. I don't have it readily available, but McGinnity is the first author on that. And we looked at the people in our trauma system, in our regional system that would potentially be of childbearing age, females of childbearing age, and they would get low tetrah positive blood. So that was first and foremost. And before I say anything else, I'm just going to say something kind of interesting. I don't know if anyone has a guess on the percentage of Rh positive.

People are in Mexico. Citizens of Mexico, anyone have a guess?

It's 96%.

Wow.

So we're in San Antonio where our population is 65% Latino. So these are things that you need to think about before you deploy. So we already kind of knew the numbers of a potential allo immunization for our females of childbearing age. And you've got to weigh that against the risk of dying from hemorrhagic shock. So right away, medical and trauma, how I did that. We, Dr. Jenkins, looked at the amount of trauma patients that got a massive transfusion. We only have two level one trauma centers in San Antonio. One is the only Department of Defense Level 1 Trauma center in the country that treats civilians. And then the other is our university trauma center. So we looked at those. We had a hunch that it was going to be 15 patients a month that would get whole blood pre hospital if we could get to them. And then we looked at. I just did a simple search of blood pressure under 90 with a complaint of GI bleed, hematemesis or otherwise, not specified. What I did not do at the very beginning, and I wish I'd had, was to add the OB patients. So I'm going to say yes, we probably the majority, I know the bulk of our patients we treat with blood or GI patients.

And you know, interestingly, you'd think it was just a GI bleed, but a lot of them are hematemesis. It's been going on for a few days and we get there and the patient's altered mental status is quite often the story. The other patient that I want to spend a little bit, maybe more time on is the OB patient because these patients are drastic. And just for Paul to know that, we have put out a shock index poster before for GI bleed and the shock index goes from 1.4 to 1.0 on average. So it really makes a huge difference. That's not a patient centered outcome, obviously, but just interesting to know. And then postpartum hemorrhage, our first transfusion to a female of childbearing age actually was pregnant. So it was intrapartum hemorrhage. Kind of interesting to note that this, you know, this population also we always think of postpartum hemorrhage, but this was intrapartum hemorrhage. So we've written that up. That is in the. I believe that's in transfusion journal, I'm pretty sure. And that was in 2020 that we wrote that. So this, this lady was interesting. And it just is worth 30 seconds of yalls time that she had placenta previa, placenta accreta, three previous C sections and she was having severe hemorrhaging and she actually was unresponsive. Well, she was altered. She couldn't, she could kind of respond if you yelled at her, but she couldn't say her name or anything. Boyfriend called and the EMS crew on the way to the call had said, called me and said, can we bring this patient to the closest facility instead of bringing her to, you know, a true OB MFM facility? And I was like, sure. Also, why don't we get blood to the scene? And they're like, oh yeah. So we transfused blood. The supervisor, EMS supervisor called me and I was like, absolutely. We transfuse anybody in shock with low tide or O positive whole blood. But actually me, I was very nervous. I didn't sleep very well. That happened about midnight 30. I did not sleep very well because, you know, that that's a rather novel thing to do. But mom and baby live. There was an emergency section at the hospital, so I think that is, you know, in San Antonio we transfuse three to one trauma. So three trauma patients for every medical patient. And we have since October 1st of 2018, we've transfused 1150 units of whole blood and.

Harris County ESD 48, which were the first people to transfuse low titer O positive whole blood on the ground in 2017.

They, they transfuse three to one medical to trauma. And I know I've said that before, Peter and Paul both have heard me say that before. But it really does depend on your community kind of how you're going to build your program and what patients that you're going to think of. One last thing before we go on, I've taken a lot of time here is that if you have OB birthing centers or anything like that. I would reach out to them and talk to them, discuss with them a they should potentially have blood themselves. But if they don't, certainly let them know that you have that as a resource because we have responded to quite a few of those birthing centers and home births as well. All right, I'm gonna pause because I, I talked way more than five minutes.

That was awesome, cj. It's funny, I spoke to Eric bank after he spoke at the NEMT and his their first dose blood unit was in 2017. So look how long you guys in Texas have been rolling along here until the rest of us have caught on. So excellent. Thank you so much for that. The next topic I want to move on to. So we've kind of hit it that there's a medical aspect and a trauma aspect. Now I want to move on to what type of blood should you carry and who I want to bring in for this is Dr. Meg Marino and Major Tom Dransfield from New Orleans EMS. Tom and Meg, welcome. Tell us what you all do, which is a little different than what we do, what maybe some of the rest of us do and how it's going.

Thank you so much Peter for having us. So in New Orleans we use PRBCs. Leuka reduced PRBCs instead of whole blood. And there are a couple of different reasons for this. First of all, we had conversations with the trauma center and they didn't want us taking the blood from them. We tried explaining that the more blood that we give in the pre hospital setting, the less blood they'll need to give in the hospital setting. But they still felt like we were going to be taking some things, taking a precious resource from them. The other reason we use PRBCs is we are able to trade them out with the blood center here. So.

We don't have any wasted blood, any blood that's expiring, we just turn it back into the blood center and they give us another bag. So we have very few wasted blood products using that program. So those were the reasons we went with PRBCs instead of instead of whole blood. I don't know of other organizations that are using PRBCs. I'd love to hear from others who are, but it's worked out really well for us and our data has shown pretty positive results. I like to say we're decreasing the murder rate in the city of New Orleans with our, with our blood program.

And you really have. My question for you is you guys have done a wonderful job and you know Your data is really changing the minds of a lot of people. How Many units of PRBCs are you using compared to, let's say, a whole blood unit?

So we're doing two units of PRBCs for every patient greater than 10 years old and then one unit of PRBCs for patients between the ages of 5 and 10.

Right. So I wanted to make that distinction. And that's because the unit of PRBCs, the volume is a smaller volume, correct? Yeah.

It's 300.

Right. That's what it is. I just wanted people to understand that if you're going to go with one or the other, that there is that logistical thing.

Go ahead, Paul. Yeah, absolutely.

Director Marino, do you also give TXA as well, in terms of your.

We do. We give 2 grams of TXA day, 2 units of PRBCs and 2 grams of calcium.

And the same thing. Antonio, just so you know, I don't know about the calcium, but the. But I just want to make sure. But I'm just gonna. Because that'll lead into my talk. And the other thing is, Meg, if you might. Not you. If you might. To answer a little bit what Randy was saying. You guys have actually looked at starting up a registry down there, Correct. And is that relevant to her, to her conversation? Are we missing something there? Yeah.

So we have a trauma pre hospital blood registry that we're part of here through Tulane University. And, you know, by getting all of the data from all of the different agencies that are doing pre hospital blood, we're able to come up with new data to help guide us in the future.

Excellent.

And yeah, if people don't know about that, you can hit us up offline. Yeah, we've been pushing a lot of people towards the registry. If you're not in it, you should be. Excellent.

Let's make that a theme next time, Peter. Okay, we'll come back.

Yeah, absolutely. We need to talk about that in more detail. I agree. Okay. Dr. Marino. Thank you. Major Dransfield, you want to comment or make any other comments on what?

No, I think Dr. Marino covered most of what I was going to say. But basically we do the. The order that we tell our guys.

To do it in.

You do your two units of blood, two grams of calcium, and then you do the TXAs if you have time. So that's our batting order, basically, is we get the blood first and the calcium if you have time. We call it lanyap is what we call it here. That's a little something extra. You get the txa, so. And we're also doing cold blood. That's another way.

Oh, you froze up on us.

All right. But he says they give cold blood, meaning they're not warming it up. And that's something that let's talk about later if we have time. But I want to keep moving along because we have a pretty big agenda. But, Tom, is that what you were saying, that you use cold blood, not warm blood? Correct, Correct.

That's what I was pointing out.

Cold blood. Yeah. That's a very interesting concept. And let's say that for the end, if people want to stick around, what I want to move to next, only because I want to really go through a lot of the protocol items here, is I want to go Back to you, C.J. we kind of stole this from you, which is the who gets whole blood. And I remember that when Dr. Roach and Chief Clark kind of took these vital signs and brought them over here, we started to say, hey, how can we get more people included? Can you talk about how you develop these vital sign parameters? And are these restrictive or in your opinion, non restrictive for people who. To get whole blood in your community?

Yeah. Great questions, Peter. See, I got your name right that time. Great question. So they're. They're actually more restrictive than I have in my rural. In my suburban systems. So this is a shock index of 1.2 with the heart rate and the blood pressure. So if you didn't know that, that 110 over 90 is 1.22, the original. So where I got that bullet point from, that second bullet point, I borrowed that from Pamper and combat trials, and they borrowed it from a lot of European studies. And really what we had was massive transfusion protocols. Shock index. Like, who got a massive transfusion protocol from. In the hospital from bleeding from hemorrhagic shock. I can't remember the country, sorry, Germany or France or whichever country, but someone published a huge RCT on this. So a lot of that shock index has kind of been studied. I would argue that a shock index of 1.0 is also perfectly acceptable. If you read the Combat and Pamper trials, the shock index of 1.2, roughly. Forgive me, correct me in the notes, but one of those had a fatality rate of 13%. One had a fatality rate of around 30%. So my Southeast Texas public school math says probably we're going to have about a 25% fatality rate with the shock index of 1.2 for hemorrhaging trauma patients and then the systolic blood pressure. A lot literature is less than 90, less than 80 or less than 70. Five years ago I was in my office, you know, in my, in my smoking jacket trying to think about what exactly to do. Had my pipe and one of my smart colleagues in there, we read a bunch of research studies and we went with 70 as an individual marker. 90 is also used, we went with 70. So that's why I say this might be a little more restrictive than needed, but we wanted to be good stewards of a product that we did not have a lot of. The End Tidal CO2 is interesting. In San Antonio we use End Tidal CO2 less than 25 to say you're in septic shock and have for 10 years. Now a lot of those studies we borrowed from Florida.

And we feel that it's a surrogate for lactate. So we use end tidal CO2 less than 25 to transfuse blood. Dr. Pepe, the other Paul on this.

Call.

They, Dr. Pepe basically and I talked about this, I don't know, five years ago and he has a lot of interesting takes on it being a pulmonologist, critical care doctor. So he'll get his chance to kind of shoot down my theory. But I will say that this is kind of the catch. All the end Tidal CO2, obviously someone could cut their arm and be breathing real fast and have an end tidal CO2 of 24 and be running around in a small lack, right? So you got to, you got to remember, see what's up there in all caps and bolded and italicized hemorrhagic shock. Got to be in suspected hemorrhagic shock. And then you're going to see the last bullet point is 65 and up is a shock index of 1.0. And full disclosure, everyone on this call, in my big metropolitan system, I would prefer to say shock index but it's really tough. I have a 50 to 100 new paramedics every year and it's really tough to teach heart rate over blood pressure. You think it's easy, but you can get mixed up on scene in real time. And so I just teach heart rate over blood pressure. But ultimately if they have a shock index of 1.0, so that could be a heart rate of 98 and a blood pressure of 96 and a 66 year old that would be acceptable. And then the witness traumatic arrest is just because that's in there. Because I was a paramedic for a long time before I went to med school and, and I've seen some entrapped patients arrest on Me after trying to cut them out for 30 minutes. And, you know, what I knew at the time was, you know, physicians, doctors would tell me that, well, they probably just had an abdominal bleed and it was pretty slow and. Or reasonably slow. And, you know, they just would have needed a little blood and a surgeon there. So that one is purely me. A lot of people have some heartburn about that particular bullet point. I'm going to stop there.

Peter, can I make a comment?

I was going to call on you? Yeah, go ahead, Dr. Pepe.

So, first of all, I'm going to do this next time we have this. I want to give a presentation about things you should be using, metrics that you should be using and a lot. C.J. and I are totally in sync on this. What's interesting is that we are talking about this, is that, for example, let's say you had a blood pressure of 70, right? That would be, you know, not less than 70, but you had a blood pressure of 70 and your heart rate was, you know, was 70. Right. So that you could have a shock index of 1 there. But what we've seen, both in the studies that we've done in South Florida, we already begin to see preliminarily, is that we will have people who are crashing and their heart rates are going down. And so there has to be that wiggle room that most of you have written into your protocols about the judgment call. And that's one where you're seeing. They're obviously going more bunny. You make. So the shock index. Make sure there's a, you know, there's limitation. Secondly, along the lines of better utilization. We know there are a lot of people who have absolutely normal blood pressure pulses and all that, and yet some of them will still have lactates over four. They go to surgery later on. So we're going to have to look at that. And we'll look at criteria like if they are pulseless, maybe there are people we won't resuscitate. So I think that's all down the line. It's speculation, but it is more things for us to be thinking about as study this and develop metrics for following this. Okay.

Right. And that. That's. I agree, Paul. That's why the data is so critical. And, you know, that's why we, we trust in you. Thank. We're thankful to have you on our team.

It's the data and looking at individual patients, too. Not just, not just the assembly data.

Yes, 100. Okay. Well, speaking of shock index, you guys set me up perfectly because I have a great friend, many of you know him as a pediatric ICU doctor, EMS medical director. He's also creator of the Life Flow, which we, which many of us use. Mark, can you talk to us about shock index real quickly because you speak about this really well.

Sure I would. I'm glad to hear C.J. say he's thinking about using it. I'd wondered, C.J. if you were, and I understand the complexity of the calculation in the moment, but it does seem like some of the current criteria that people activate their blood, Blood Protocol 4 might miss some patients who would deserve it. So just like Paul mentioned or someone mentioned someone with a shock index of 1, but their heart rate's, you know, under 110 and their blood pressure is over 90, they still could qualify. And especially in combination with a low end title, I can't think of someone I've seen in the trauma bay with hemorrhagic shock and an elevated shock index who doesn't also have a low end title. So it's a great confirmatory marker if you do use it. Interestingly, the data that Meg and Tom are producing out of New Orleans, their average shock index among their patients is 1.4, so super high, and resolves to about 0.8 by hospital arrival on average. So a pretty dramatic shift. They have a really sick patient population. But I guess the question is, should we include in the protocols, in addition to the other criteria, shock index over one and all that is is your blood pressure equals your heart rate or your heart rate is above your blood pressure. And I'm curious about opinions from CJ and Peter, you whether that just adds too much complexity or whether that captures more patients who deserve blood. And I think, Peter, in your area, and I see some of the folks from BSO on, maybe some of the surgeons have even pushed back on the use of blood, saying it's being used potentially too much. And that may be because the patients look a lot better by the time they get to the hospital and they didn't think they deserved it. But the shock index certainly can be a good additional parameter, I think, as a trigger, whether it's trauma or obstetric hemorrhage or GI bleed. I, I think it's an awesome indicator.

You know, it'd be good if, if the monitor companies just put it on the freaking screen.

Yep, that's a good idea. Actually, I asked them that five years ago and I don't. They didn't really understand why I was asking, but, you know, I don't.

I do want to address Paul's comment that bradycardia or relative bradycardia in the face of hemorrhagic shock is a, is actually a pre arrest condition. So there's a point at which someone is, has been hypotensive for so long that their heart rate begins to wind down and then the shock index becomes irrelevant because they may have a systolic of 60 and a pressure and a heart rate of 60. So with that caveat, I do still think it's an awesome additional indicator of need for pre hospital blood.

And this is going to be more, you know, kind of borne out in the, in the data that's being collected through the registry and it's already being shown. So I think that it's something that everyone should be looking at. Okay, let's keep, let's keep moving on. We talked about end tidal CO2. CJ mentioned from Florida. That's Dr. Hunter from Orlando. He gets the credit for figuring out end tidal of 25 or lower equals sepsis. It's been published a number of times that under 25 in trauma means you're hemorrhaging. And it's just a factor of the fact that you have less volume of blood being circulated and you have less end tidal CO2 coming around the bend. And so end tidal CO2, however, you know, the question is CJ in your protocol, it's any of these vital signs or an end title. So will you use an end title of under 25 as a single reason to give blood?

Yeah, we do. And I bet we're parsing this out as I speak, but I know it's going to be our number one reason we transfuse.

I bet. Yeah, we would love to see that data. I mean, that's something we need to learn from. Yeah, go ahead, Mark.

I just have to point out this is from my own trauma center. That paper.

Okay.

And our chief of trauma there is on the list. And we now apply entitled cannula the minute the patient arrives in the trauma bay on every patient for this reason because it's an additional, if not a determining factor. It's an additional point that tells you the degree of shock.

The question is, again, it's going back to this unit of blood that we don't want to waste and people are skeptical or scared of.

Exactly.

And getting chewed out at the facility. Right. Why'd you give it that it needed. So I think as we learn more, I have a feeling that intel and CO2 is going to become, is going to take more of a. Of A higher place in people's protocols. So this conversation is meant to talk about protocols. That's why we're. We don't have all the answers today, but we're throwing some things in. Go ahead, Paul.

But the, the, the. But the point here, both the shock index and looking at the individual patient, whether it's bradycardic, you know, relative bradycardia, all that, and the anti L CO2, is to do the. These are the metrics we follow and we see. How often does that predict it? I mean, if it's predicting 80 of the time or maybe 50 of the time, that's a pretty good triage. Possibly, right?

Yep, that's. Yep, that's exactly right. And again, as you're creating your protocol, these are the decisions you're going to have to make. These are not easy ones to make. I'm sure CJ and Randy guys lost a lot of sleep before this protocol went out. We're just reaping the benefits after you guys have done it. But now it's time to study it. And we appreciate that.

Okay, Peter, one quick comment. Another thing that I lost a lot of sleep over is do we treat isolated GSW to the head with whole blood? And I would say my medics had a lot of heartburn that I said we really probably shouldn't be because they're not truly in hemorrhagic shock, but they still do. I don't necessarily bring them in for qa, QI or anything, but there was a signal, I remember, out of some early data out of Pittsburgh that was using whole blood with isolated GSW they had in the statistically significant. But we're talking like P of 0.08 that actually had some benefit. I think that was a mortality benefit, but I just wanted to throw that in there. That's the other thing that gives me a little heartburn is because that messes the end tidal CO2 up as well.

Interesting. Okay. Yeah, that's an ethical dilemma there. Thanks for that, C.J. all right. Captain Marcoline of Loudoun County, Virginia, also has started a program from. For quite some time. I was very grateful to see a great presentation here and Dr. Peel gave in Virginia. Captain, if you're there, talk to us about. Because I was looking through your protocol about checking temperature, how often you repeat vital signs. Talk to us about what you see there.

Okay.

Well, first I just want to say.

Thank you for including me in this.

Because I'm really humbled to be part of this little work group here. This is great.

So, yeah.

So our Procedure document, you know, and.

Everything I've read all the literature says take the patient's temperature, you know, take.

It before you start administering the blood. And then what we want to do is take it approximately five minutes afterwards. And especially now that we can get.

A full unit of blood in using the life flow, you know, within three minutes or so and that taking that.

Temperature again is important.

Actually the call this morning with the.

With the pre hospital work group, I.

Was actually there in person at the folks out of Harris county were saying how, you know, most of our patients.

Are hypothermic to start, which is a very good point.

They've lost blood, they're hypothermic and that.

You can see like sometimes one to one and a half degrees of temperature improvement from, you know, just administering warm blood.

So I think, I think those, in.

Terms of the temperature, it's very important to do it, you know, before you.

Administer and then about, you know, five minutes afterwards.

But then, you know, like we talked about doing capnography shock index which I've.

Been trying to push our, you know.

Providers, they know about it but I think they're being, you know, they need to be pushed in that direction. Hey, make sure you're getting the shock index and documented in your, you know, your reports.

So you know, heart rate, blood pressure.

You know, we trend our lifepaks to about five minutes or to five minutes. You know, we're doing this, we do.

It for three minutes for our side, but five minutes for blood just to.

Keep track of all that. And then like I said, do the.

Temperature at your first 5 minute interval.

Awesome. Now I'm going to bring in a interesting kind of contrasting point. Let's go back to Major Transfield and Dr. Marino who don't cool their blood. Have you seen an issue with giving cold fluid to a patient who is in trauma patient? What are their temperatures looking like when you show up to the trauma center?

So we're seeing a change in temperature from 0.5 to 1 degree. We're not seeing any adverse effects from this. People in Europe have been giving cold blood for more than five years and they have also not seen any adverse effects initially. I'm embarrassed to say the reason we didn't buy the warmer is because we couldn't afford it. It was during budget cuts and we were really scraping by with every penny we could and so we just couldn't afford the warmer and we were like, let's just see what happens. But now it's become such a simple process.

Are continuing on even when our budget is doing a little bit better.

And you guys are measuring this along the way so that you'll. We'll be able to see the data. I know. Through the registry. Correct, Correct.

Yeah. They.

They track all that, and we track it in house, and that's what part of what we were doing with all that. So we tell the crews we do an initial temp, and then we do a. Basically a post temp with one unit and then try to get one before you get off at the ER and then try to get the error. The first one they get is like, we'd like to see. But they're giving us good feedback on the data on the back end, through the working group, through Tulane. They're helping us out with that.

Fascinating. All right, great. Thank you guys for that. David Long, are you here from Tidewater, EMS executive Director.

Yes, sir.

David has gone and is going big project, the entire Tidewater region, and he's trying to roll out blood everywhere. So, first of all, David, thank you for joining us. I wanted you to talk about dosing of blood. Like, how much do we give in general?

Sure. So one of the things that when we looked at our region, I have some very rural areas that are impacted by time and distance, even with the use of helicopter, you know, EMS services. So.

We wanted to make sure that we were going to be able to manage a trauma patient appropriately. So we predominantly are using a single unit of whole blood, so that 450, 500cc's in our urban settings, but we're prepared.

To give up to two units coming out of our rural environments. We're still doing more research there to determine, you know, what might be the catalyst to say, you know.

If there's clear, you know, I guess information would indicate, you know, two is preferred to one. But thus far, for what we've been doing with the one in our urban settings, we're getting pretty, pretty phenomenal results. So we've had 13 administrations to date, and we've nine of those. Nine of those 13 patients are alive. I've only got one left in the hospital, and that was actually two days ago, a motorcycle accident with open pelvic fracture. With the degree of aortic injury and the fact that the patient is alive today again, and I think that was due to the timeliness of getting the blood on board again, we're seeing some pretty incredible stuff. I will make one comment real quick about the cold. So we did have one patient, one case where they forgot to turn the switch on the blood warmer. On and it was a gunshot wound to the abdomen, and the patient complained to the crew about being cold.

Interesting. Interesting. Well, I'm wondering if we can just get a quick response from, let's say, cj. Meg, we already know your response. You give two units of PAC cells, but, cj, let's hear from Chief Coyle. Captain Galino, average number of units per patient that you're seeing, you're needing, is it one or two?

Metropolitan. It's going to be one. Unless they're trapped. Then we do give two. Probably out of those 1150 patients, we've given two units to maybe 25 of those. Maybe. Yeah, not more than 50. Probably around 25 to 30.

Okay. And Mark.

We'Re one pretty much almost with every patient with our.

Almost 30, with the exception of, I.

Think maybe two patients where we've had.

Two units and you guys have short transport times. I'm presuming we do.

We have.

I mean, our closest trauma center is less than 10 minutes away.

Sometimes it's a five minute, depending where you are in the first two area.

Yeah. Chief Coyle, Palm Beach County.

Yeah, we've had four patients that received two units out of 42 that we've transfused. So we've identified that there was probably another four or five that would have benefited from an additional unit. I just didn't have it on the.

Truck at that time.

Okay, that's good. Okay, so just keep that in mind. For the adult, it's basically, it's one unit, maybe a second. So you'll see all that in the protocols that we share in a little bit at the end of the presentation. I want to move. Yeah, go ahead.

Can I make a comment on that? I'd love to know CJ's input as well on kind of parameters for titration. So we were on the call with Dr. Holcomb this morning reminding everyone to practice a hypotensive resuscitation, meaning in penetrating torso trauma where you can't tourniquet the injury, you don't want to over resuscitate. And it doesn't seem like, certainly from the New Orleans experience, that two units have been too much or that a normal systolic blood pressure coming in the trauma bay has been too much, meaning to cause excess bleeding. But I guess it's hard to assign parameters and really totally understand the injury you're dealing with to know them. But I would suggest, or actually solicit feedback from CJ On. Is there a blood pressure number you're looking for? 9080 systolic minimum. And then in TBI. Peter, thinking about the EPIC TBI study, when we have combination of torso trauma or extremity trauma and a traumatic brain injury, we know this patient's knee is systolic probably over 110 to preserve their brain. And how do you balance those and how do you titrate the blood in during your pre hospital interval? So I'm open to feedback or suggestions on that.

Great, great question.

C.J.

You want to take that one?

Yeah. Mark, always a fantastic question. I love it when you do that to me at a live conference. Now it's recorded for posterity.

So I was easy on you this time, though.

Actually, you were very gentle on me this time. Thanks. So, okay, first and foremost, the answer to the question, are we stopping at a blood pressure? We only carry one unit. Our average transport times are eight and a half minutes. So that really, it takes. The fastest we can get blood into a patient's about four and a half minutes with our setup now. So we could potentially almost get one and a half or two in and they can just continue in the er. So there's nothing against two. We just only have the resources for one. Generally, we just get about one in. The other thing is we don't stop. So one thing that'll happen or has happened to most of y' all probably is while we're waiting for the blood to get to the scene or the supervisors intercepting the EMS crew, they've given normal saline sometimes and that blood pressure now is above 70 or the shock index is below 1.2. But it was. The shock index was before saline above 1.2. And my. I've just told my crews many times over the last few years, we're still going to give the blood. So even if the parameters are in, we know the problem is they're in hemorrhagic shock. The saline did not fix that, probably exacerbated it.

So we are going to continue to give the blood as far as a blood pressure. Yeah, we. We actually, for our TBIs, we try to get the blood pressure above 100 or 110. If we can figure out, you know, we follow the EPIC trial. Great study. We follow the EPIC trial and try to get their blood pressure up. Absolutely.

One thing I can do to add to it, Peter, is that looking at the earlier data in Palm beach county that Charlie was talking about, they. They actually almost normalized blood pressure. They were well over 100, 120, 140 after the unit of blood. So you, you may See that response and so do you. That's. So keep that in mind. And the average cases that I saw so far went from like 1.8 to 1.2. If you took out those guys who are having. Going more abundant on us, you know. Right. I think you see it almost right away in effect with the, with the one unit. So. But it may need more.

Right. That's just another metric we need to keep out for. Looking out for during. When we collection. Yeah, exactly. All right. We're going to keep on moving because we have a lot of time. So real quick, you give it IV or IO and there's a crazy doctor who got like 300,000 YouTube views for drilling his own leg with an IO. You can watch the video with your QR code there. But Mark.

IV or IO, does it matter?

I didn't, I didn't know that you put this up.

What is the minimum size of the IV catheter required, if any?

I mean it's the catheter you can get in and 24.

I can use a 24.

Ah, probably not, but maybe a 22. But that's more in a child. So I'd say if you're not able to get a 18 or 20 or 16 quickly in an adult, then you're going to go straight for an IO. And if there's torso trauma, you probably don't want to put it where you see here in the picture because that blood may leak out into the injury. Right. So I know from. And Tom and Meg can speak to this. I think about half of their admins are through a humeral head IO and so they're still able to get two units of pack cells, which ends up being 6 or 700 mils, probably somewhere between 5 and 700 mils.

And 2 of calcium and TXA within that 10 minute ride. So they're able to administer it through what we wouldn't think of as a traditional IV access point, namely that the humeral head and that probably flows a little faster there. I know, CJ, you allow your folks to put in femoral iOS which is cool, and that's a faster flow, but you probably don't want to wait. If someone's shot in the belly, you're probably not going to put it there. So I'm curious.

That's exactly right, Mark. Yeah, that's. I'm waiting for your distal femur IO video.

I'll do that next. I'll do that next.

I will say in San Antonio, I'm always trying. The next thing I am doing Research on it for an abdominal tourniquet for blunt or penetrating pelvic below the umbilicus. So you. Obviously, a distal femur or a tibial IO would not work. So we have to go humeral head or an IV in the upper extremities.

And then I just did some work with one of the military groups last week, and they use a lot of sternals. Fast one sternals. I don't know if anyone carries those or not, but that would be another option. But, Peter, I think you get in the access you can, and if there's a struggle with getting a big enough iv, then straight to IO, probably.

And the reason this came up is because I see protocols that say 20. It's got to be 20 gauge or higher or IO. Right. So I just.

And.

But this. This distinction between lower or upper based on where the injury is hugely important, and I think that's just another. Another important caveat. Okay.

I'd love to hear Tom's input real quick on his crew using iOS and what their experience is.

Yeah, they mainly go to it on those a lot just because it's quicker, easier.

We.

We advocate that. We advocate Igels, just a super glottic.

If they need to get an airway.

But that's after they do all their march stuff. We. So as we. We totally believe in that concept, and that's what we preach here. And they get to experience a lot of trauma here. So that's the good and the bad. But they. They stop the bleeding, control it, even if it doesn't. If it's not bleeding. A lot of times in the early stages, they were reported like, well, it wasn't bleeding. And then we gave them blood, and then it started bleeding. It's like, well, duh.

Okay.

That's what. That's what the thing is. So that's. That's the main thing. But I would say probably 86 of our stuff is IO and the rest of it's peripheral. Most of us ac, so.

Wow. Okay, very good. That's a great discussion. We're gonna keep moving, guys. I'm just trying to throw things at people so that they understand. Think through this when you're making the protocol should whole blood impact scene time. And I don't think Chief Clark. Let's see. Is Chief Clark on the call?

I don't think so.

But what I'm going to do is I'm going to bring in my EMS chief from Davie, Florida, Chief Dan Moran. Dan, are you on?

Hey, good afternoon. Hey, there you are. Hey, Dan. Thanks for coming on. We work very closely with bso. Obviously, they carry the blood in Broward County. Talk to us about the case we had with the rendezvous with BSO. Tell us how Dr. Roach and Chief Clark have set this up so that it's just really quick.

Absolutely.

We had two cases, both with the rendezvous. One was a stab wound to the neck. Patient was administered TXA along with whole blood. The EMS captain basically shows up with our rescue truck along the route to the trauma facility. They park their unit on the side of the road, jump in the back of the truck with the rescue crew, and start administering the whole blood within.

You know, one minute max.

Very impressive to see their setup and how quickly they can actually begin delivering it. The second was a severe TBI case. The EMS captain actually was driving through our city at the time when it happened, arrived on scene and asked if we needed blood. I said yes. He jumped in the back of the truck and again, blood on board within 30 to 45 seconds. It is amazing to see their setup and how quick they can begin to deliver.

And thank you, Chief. And the reason I put this in almost every protocol says something to the effect of do not stay on scene and do not delay care to give blood. Does anyone disagree with that?

Okay, I don't disagree with that, Peter, but I did not put it in my protocols on purpose. And that really caused a lot of heartache with my EMS supervisors because I just feel it's a mid management decision. I can't possibly predict every situation. I don't want them to delay care, obviously, but like, if I say it in a protocol, then it becomes black and white. And so I told them. I told them, just, you know, get the patient to the hospital as fast as possible and get them blood.

Okay, awesome. And for those of you who are expecting to leave at 2:00pm Eastern, sorry, this will go a little late, but it's going to be recorded. We're going to keep getting through here. I figured it would take. It would take longer than we wanted to. But I want to bring in Chief Coyle and Dr. Pepe. Should we be giving whole blood to patients in cardiac arrest? I know that lots of us have data on that. Paul and Charlie, you guys recently crunched the data in Palm beach and you know, the BSO data. Dr. Pepe. Actually, let's start with Chief Coyle and then let's. Let's finish it off with Dr. Pepe. Chief Coyle, what are your thoughts?

Yeah, so I'll just give you our brief data. Like I said, We've had 42 patients enrolled. Out of the 42, 16 have been in traumatic arrest. Out of the 16, eight of them have been penetrating and eight of them have been blunt trauma. And then if you look at finger thoracostomies or interventions, we performed out of the eight, two of them for the penetrating and then one for the blunt cases. If I give you our Ross rates with the traumatic arrest overall, out of the 16 cases, we're at 19%. If I look at the penetrating, it's 25% Ross. So two out of the eight, and then if you look at the blunt trauma, it's 13%. Unfortunately, out of the 16, all of them did not live to walk out of the trauma facility. However, two of the penetrating actually died hours later in the or. So it's one of those things that, you know, those Ross numbers would probably be pretty impressive when you first start measuring your cardiac arrest when it comes to medical. But I don't know what that correlates to the trauma world and our data is so limited right now that it's really hard for me to give any really. It would be arbitrary for me to tell you whether or not we should or we shouldn't, at least from our data. Small subset.

Great summary. Well said, Dr. Pepe.

Yeah, so I think this should be a topic, like I said, for future conversations. But their preliminary thing is that at a cross the planet is that most people have the same experience where they just don't make it their pulseless at first. I think Chief Coyle brings up a good point that we're not focused on blood. We're not just focused. You got to do all the basics. Is the airway intact? What's the cardiac rhythm? You know, all those kinds of things. The tension pneumothories are, they've been rolled out. All that stuff has to be, you know, checked out first. And. But we may get to the point where if we see someone out there who looks pretty much hemorrhaged out and when you look at the, the chambers and you know, there's no like an ultrasound is like Chief Coyle suggests, we get out there and we see and their heart's not beating, it may be a way to help us with better blood utilization. So I think we need to look at this for utilization. I don't think the answer is right in right now. And I think we got to get that whole registry together to see if there's a signal about who might make it in that group. And I don't know if any answer to that Charlie, do you agree with what I just said?

100%. And I really, you know, when we think of cardiac arrest or pit crew cardiac arrest for medical patients, it. This is vastly different than that. When you look at traumatic arrest, you know, the whole algorithm has to change. The whole approach has to change. So I think a lot of it's going to have to do with when the whole blood gets on board and what interventions are taking preferential treatment over the other. I'm sure Dr. Winkler's got much more data on this, but for us, I.

Think you need to re.

Change the game in the approach to the arrest.

Yeah, I was going to bring CJ in next. CJ, you have over 1,000 uses. Tell us about your data with arrest patients.

Interestingly, if you really want to save a traumatic arrest patient, I think for the cheapest you can, a pleural decompression is your best bang for the buck. So pleural decompression, I mean, if they're in tension pneumo, you can fix that right quick with the spear or we do instrument thoracostomies. As far as other treatments, we do the classic marches. You can't really argue with the death. In a battlefield study by Eastridge, putting a tourniquet on someone is extremely useful. I would like to try to prove if I could get enough patients. Is that abdominal tourniquet that the military is also using helpful then? Blood is one piece.

As.

As Chief Coyle said, blood is one piece, I think is really helpful. It seems to show we're improving shock index and early mortality. We've published, but not overall mortality yet. Still working on it.

Okay. All right.

Yeah. One more thing I would add to that is that first of all, I'm going to get on my, you know, bandwagon, so to speak, as they say. And I don't call it traumatic rest. If anything, what I do call it is I have to first think about this as post traumatic circulatory arrest or feeling pulses and looking at me, because some of these guys still may have a heart that's beating, but it can't pump because it's obstructed because of the tendon. Pericardial tamponade, or it's just empty. Right. That's number one. So we just got to make sure that we're thinking that they will become cardiac arrest later where they're asystolic and no heartbeat, et cetera. But up front, what we often call traumatic cardiac arrest is really a post traumatic circuitry arrest about to become a traumatic related cardiac arrest. And the other thing I would mention on those lines is that you bring up a good point. I want to reinforce what CJ said is that you have a peripheral wound that you bled out from or exsanguinated from to that point that theoretically could be more salvageable than someone that you can't get immediate control of here because you've tourniqueted them off and now you can give them some blood on top of that and you might be able to get those guys back. And so I think what we're bringing up here is that we really have to sort of do a good job of classifying our post traumatic circulatory rest cases as well.

Excellent.

Peter, I wanted to comment on. I think Tom can speak to this, but they have had about seven, I believe, roscs with pre hospital blood and without thoracostomy. I agree with CJ that that should be done if possible. But I think a survivor or two who walked out of the hospital, Tom and Meg, if that's not right, and that doesn't prove anything other than it's possible. And you know, if someone has a V fib arrest, they need electricity. If someone has a aspectial arrest, they need oxygen. If they have a traumatic arrest, even though I agree, Paul, that's maybe not the best term. Restoring circulation is the only cure, not epi. And so it's possible. I guess it's a matter of choosing the right patient.

But let's say that that's the whole point. If we look as a group, we find out who did survive.

Yeah.

We go back and find out what were the factors there, you know, why did they survive? You know, was there something common thing like an extremity injury that got, you know, tourniquet at.

Yep. And, and by the way, there's lots of great questions in the chat. We're going to try and get to those. But I want to get through this first. Several people are giving calcium. So. So David Long, let's start with you. Let's move to Megan and Tom afterwards. We're not going to go into the whole thing here, but you all have decided to just give the calcium. So David start with you and then Megan go next.

I'll just say real quick with Randy's assistance. We've been talking through that here for us and currently we have it with the second unit of blood. We're working aggressively to push that up to again with a. With that initial unit of blood. And where our conversation actually has spent most of the time is whether we're going to give calorie or whether we're going to give calcium gluconate. Realize that with the gluconate, you know, we're talking about, you know, three times the dose versus what we would get with a single, you know, unit of calcium chloride. But from patient safety standpoint, particularly if we can't ensure great vascular placement, we just think it's the right thing to do from, from a patient perspective, as far as access, availability, cost, all those things are really negligible. So our pharmacies are working well with us in that respect. So hope to have that resolved within the next 45 days.

Excellent. And then, Major or Dr. Marino.

You.

Want to talk about your calcium protocol?

Oh, yeah.

Well, the ones. Go ahead, Doc.

Okay. Sorry. I was muted. Yes, we've been given calcium and it's been going really well. We give it because the PRBCs have more citrate in it than whole blood does. And so because of that, the patients are more at risk of developing hypocalcemia. So we really feel that the calcium is an integral part of this triad of the blood. TXA and calcium.

Excellent. Major, you want to add on to that?

Yeah, I mean, that pretty much covers it. We just worry about the hypocalcemia, and it's become seamless. It's like, like I said earlier, it's like we do the 222 is what.

We tell our guys.

That's how we train. 2 blood, 2 calcium, and then the 2 TXA. So it's almost like muscle memory to them. They got that down 2, 2, 2. And they get upset when they don't get to the txa, they really get upset. They think like they're gonna be in trouble. I say you're not in trouble for anything. You know, you're doing the best. This is the blood. That's what they really needed, so.

Right. And Randy reminds us that there is the calcium trial kicking off soon, and that's going to be very important. I spoke to Eric Bank. He said that if you're in cardiac arrest, they give the calcium up front. If not, they give it with the second unit. Cj, any discussion on calcium on your end?

Yeah, I think we'll eventually go there. Interestingly, here's a concept for the researchers here. So we got so far out ahead of ourselves in a good way on blood that we have no case match group, we have no control group. Right. We get blood to pretty much everyone. So it's kind of. We don't. We'll never be able to do a true RCT like they just did Dr. Porter and Dr. Cotton, they're two independent RCT hospital studies of blood versus component therapy. So we didn't weren't able to do blood versus normal saline. Right. Which I would love to go back and do. So I didn't want to make that mistake again for calcium. So we're going to do a true RCT for Kelsey.

No.

Way to go.

See, you guys are doing it right in San antonio. Thank you, CJ.

So Dr. Marino and Major Dransfield, you're one of the only. I should have said the only ones. But you have very specific item in your protocol talking about consent for blood. Can you talk about why you did that and should everybody else have that? And then I'll get to you, David, after that.

Go ahead, Meg.

I think the consent for blood is if there's someone who's able to say, no, we don't want blood, then you should listen to them. Otherwise we kind of just presume that everyone wants us to save their lives and we move forward. So we do have something, you know, some Jehovah's Witnesses will have a bracelet or something, something notifying the team that they don't want blood. Otherwise we just presume that everyone does.

So the reason I brought this in is because you actually spelled it out in your protocol, which I thought was interesting that I, you know, again trying to prime people that if you're going to make a whole blood protocol, should you have language about consent in there? So that's why I was bringing up some time. You want to say something? Yeah.

Well, the way the reason main language, we did it. We were trying to figure out any loopholes that were going to come back on the back end for us and like consent problems and stuff like that. And like Dr. Marino said, like most of our people are unresponsive, but the ones that are still responsive, the medics ask them. And then documented in the chart like, hey, ask verbal consent for blood. And they said yes. We've only had, I believe one person said no. And then they sat there for a few minutes and they started feeling bad and they said like, yeah, yeah, do it, do it. And it's like, so that's the only one I know of that the medics have told me about. But yeah, it was one of those things that when I went to research that there was nothing out there for pre hospital as far as consent. All you saw was everything in hospital and big lawyer type things that drug on with mainly with kids. And the Jehovah's Witness communities, you know, back there and all that. So they were long drawn out things. So this was kind of like Dr. Nichols helped us write all this stuff and get it all done. Dr. Emily Nichols was instrumental in that with us.

And Dr. Lee is writing some good questions about is that informed consent? Should we go under implied consent? But I think that with whatever we do, and I don't want to spend too much time on this, we really have to just consider this as an issue. And cj, you mentioned something about an employee. You want to talk about that? What happened to your agency?

Yeah. So we had Jehovah's Witness church leaders from all of South Texas come talk to us before, right. When we started our program, and they asked if we could give them some type of wristband or something. We said we would honor any wristband they had or anything, but that's a little bit difficult to pull off. As far as the employees.

We had two Jehovah's Witness employees in EMS division, and they both asked their respective church leaders what they thought about it, and one of them elected to not be in the EMS division so they wouldn't transfuse blood.

Okay, wow. Interesting stuff. So another. Another good topic. I wanted to put that up. I'm going to very quickly go into kids, age cutoffs, vital sign criteria, dosing strategies. I'm going to go really quickly here. So this is our protocol in Palm Beach County. We chose five years and over. Why? I looked at all the data from our trauma center for the past several years, and we had never given blood to anyone under 5. So our dosing is 10 per kilo. The life flow gives 10, 10 ccs at a time. So it's a pretty easy calculation there. So that's number one. What we did was kind of. I took CJ's vital signs, I looked at some pediatric stuff, did some calculations, and then try to make it as simple as I could. So I just kept it at 70, the same as he had. And then I just bumped up the SVP. Sorry. I bumped down the SVP to 80 and the heart rate up to 120. And that's what it is. So there's no, like, you know, different ages, different sizes. Just a reminder, this is what is for the adults. So when you look at that, you could see that it's just very easy and simple to understand. Moving on. I actually called some folks from Cardinal Glennon Children's Hospital in St. Louis, and they said, here's our data, because I wanted to see what Type of data. They actually had seen three patients under the age of five in that year, all gsws. Everybody else, however, was five and over. And you can see that this is in hospital. Blood transfusions that they're doing. And Cardinal Glenn. And so congrats to them for doing such great work.

Moving on. We're almost done to the equipment.

So before you go ahead, if the. If the kid is looking sick, moribund, and dying, you can still call. And you also have a protocol that if they're under 5, they could call the doc, right?

Yeah. Yes, yes, yes. Thanks. Thank you for that, Dr. Pepe. All right, so basically, call medical director, have direct access to us at all times. Call. Hey, we're on a scene, three year old, blah, blah, blah. Yeah, go ahead and give it. Right, so. And the actual dosing is still available to them. We just want a phone call that may go away, but for now we'll leave it like that.

Chief Coyle, Chief Clark is not here. Talk about the equipment. I'll start with the credo cooler. Talk about that real quick.

Yeah, so we have the exact cooler you see here. The credo. The credo Pro Med cooler. It holds two units. For us, they make a smaller size, a medium size, and a real big size. We have the medium size, which, again, we took this straight from strac. STRAC did a phenomenal job in qualifying what products should be used. They actually did extensive testing. And when you go to Strax whole blood Academy, they actually give you a binder with all the testing they did. So it made it. It made it very simple for us to come back and make a decision. Because once again, Dr. Winkler and his crew out there did all the work for us. So we are guilty of ripping off and duplicating that. We use the Warrior as well. One thing that I think we use, maybe that I'm not sure if they use, is the life flow, you know, which we've had great success. And some of the cases that we've been able to infuse the two units in, I largely attribute that to the life flow. I think the quickest administration we had was three minutes with the life flow. So, you know, it makes it very simple on a 15 minute transport, you know, if you're able to get the first unit in three minutes and then, you know, we. We do have one of those big helm refrigerators, the blood bank refrigerators. But the reality is the only time the blood hits that refrigerator is when one blood comes to drop off blood. Because the reality is every drop of blood that we have, we carry on the trucks in the Credo cooler. Originally, we were keeping a backup bag of blood in the Helm refrigerator. And then there was calls where there was multiple gunshot victims, but we only had one unit of whole blood because the other one was back in the refrigerator as a backup. So it didn't make sense for us to have a cooler that can contain two units of blood, but we only have one unit of blood in it. And the other one's back at the station because it's a pickoff point for several of our EMS supervisors. So that's pretty much our setup here. It matches identically to what they're doing down in Broward. You know, I worked very closely with Chief Clark, as well as Dr. Roach, and they're using the same setup with the Warrior, as well as the Life Flow and the Credo coolers. And then they have one of the big blood refrigerators. And then these freezers that we have at each one of our stations are essentially for the tick panels that go into that cooler. So we swap out. Every 24 hours, we swap out these tick panels, and basically that allows that cooler to go back to temperature. Another thing that we stole from strictly from SHRAC was the temp stick, which has been pivotal because we've had a couple of issues with our coolers where they've been left open. And the little temp stick alerts their phones that they carry. And basically the phone alerts and says that you're right out of temperature, and they've been able to go and remedy. And it's actually saved us a couple of units of whole blood. So, again, I appreciate the opportunity to talk about it, but really, I was a mastermind in stealing from. And I did speak to New Orleans strac, bso, New Orleans. And then, boom, here's Palm Beach County. Yeah, Like, I created it myself.

R D, R and D, baby. Very good.

Yeah, we did that very well.

Right, And I appreciate that, Charlie. Here's Exactly. This is Air 85. BSO, Air 85. And this is, again, Chief Moran described. This is what they'll. They'll just take this, what you see right here, and jump into the back of our unit, and they go, and they leave their vehicle, the Suburban, right on the street. Obviously, not the air folks, but the EMS 17, which is the ground folks, to do that. All right, we come to the close to the end of our program, a very important topic. Go ahead, Dr. Peppy.

I'm going to suggest that I could do this either next time, let everybody else go because. And also I have about 60 NBA traders over here waiting to talk to me.

We can definitely pause this. What I'll do then is I'll stop it here, but I'll open it up for. There's a lot of questions. So I'll take the questions from the crowd.

I will say if you want to get the message across, essentially what I was going to show you is how we got to the conclusion that we won give 2 grams up front in the pre hospital arena.

And some studies have shown that you get half of them to get it on board within 30, 40 minutes. Our protocols will say.