Jeff W. Hinshaw: Whole Blood in Rural EMS (8/30/24)

All right, welcome, everybody. It is Friday, August 30, 2024, and we have a great show in store for you guys today. This shows you the power of Twitter, the power of social media. Jeff and I started chatting on social media about the shock index. And then I learned about the blood program that they've been going on for several years now. And an amazing save and putting it all together. I wanted Jeff and his team to get to come on today, talk about, you know, starting a difficult blood program, which is very complicated. And many people on the call know that in a rural part of America here in North Carolina. So, Jeff, if you want to make some introductions, let us know who on your team is there. I know you have a great presentation for us. Take it away, my friend. Thanks so much for joining.

Hey, thanks. I am truly honored to be able to, to talk about our program. Here we are. We consider ourselves the tip of the spear EMS agency. We will talk a little bit more about that in the room with me today. Listening is Jason Revis, our EMS director. Zach Patrick, who's our training officer. David Holbrook, who's our operations officer. And then Dion Nicholson, who's with logistics. We actually have some folks in our training room that are listening. Our EMS medical director, Lance Henninger is behind us. My role is. I'm deputy medical director here. I'll move forward to the next one. Here's where I work, and this is where our department is based out of. This is from Atrium Health, Wake Forest Baptist Medical Center. We're actually the division, excuse me, the Department of Emergency Medicine for the medical school. This facility is an 850 bed, level one trauma center in northwest North Carolina. In fact, we're the only Level 1 trauma center in northwest North Carolina. And as part of the outreach, our particular department of Emergency medicine staffs 4 different community hospitals as well. That's my role at Wilkes. I'm a split position person. I work two thirds time at Main Campus, which you see here. And then you'll see an image of where I work one third of my time at a community hospital as well. But this sets the stage not only for my role, but also the blood bank's role that you'll see here in just a moment. As with any good lecture, I have to make certain that I have no financial disclosures. However, as listed at the bottom of the slide, there will be specific devices that I'll mention because of their impact and what we've done in and with our program here at Wilkes. Excuse me. So some of you may or may not have heard of Wilkes County, North Carolina. Our county seal in front of you here with the great state of Wilkes. And if you look at our county.

Kind of mantra, if you will, it's imperium intra imperial, which is an empire inside an empire. Our monikers the Great State of Wilkes 1. Because our county is so big and at one point in time there was even discussion about the county seceding from state government at one point in time. So we're a renegade bunch, if you will, and you'll understand that even more in just a minute. So let's tell you a little bit about Wilkes County. The letter of the day will be M. M1. We're the gateway to the Blue Ridge Mountains. So lo and behold, lots of beautiful scenery, especially during what we refer to as leaf looker season, which will be starting here in just a few weeks as the leaves begin to change beautiful colors. Another thing that you may know, notice us for and be famous for is that we sell smiles in a jar and that jar happens to be something clear. And at one point in time we were the moonshine capital of the United States when it comes to production. So there's another M. And last but not least, with the M is motorsports. We are at the the center. We are the NIDUs of NASCAR with North Wilkesboro Motor Speedway. The legends such as Junior Johnson and others that live just right down the road that became part of of the culture that we know as Wilkes county even today. So when Peter and I first started talking, I said I'll make up a syllabus. And so our next letter of the day will be S. We'll talk a little bit about the state of North Carolina, our particular service, our blood source, our statistics, and then we'll close out with truly a sensational save of that kind of is our hallmark, our high water mark for our service. Now I can't start a program talking about our blood programs in North Carolina without giving a shout out to Surry County EMS. They actually started right after Cypress Creek EMS started back in the late 2017, 2018 block after an original kind of pilot program from Onslow County. At this particular point in time, I got to give a shout out to Eric Southern, Justin, Gerald, Dale Harrell, the guys at Surry county ems, which is just up the road. I know all those guys and work with them, but they were trendsetters in this and they kind of pushed the envelope for us and many of us followed just a few years later. So where do we stand in the state of North Carolina right now, this map is updated as of literally two days ago. If the county is red, lo and behold, they have an active blood program. The majority of these are whole blood programs that we're looking at. Then you also see on the screen in front of you those who are investigating the potential to start a whole blood program. I'll go ahead and give a shout out to my dear friend Randy Schaefer, who's on the call with us this morning. And she is so eloquently nicknamed us the Blue Ridge Blood Program. So if you start at Surrey, Wilkes, Yadkin, Caldwell, Burke, McDowell, that follows the area of the escarpment of the Blue Ridge Mountains. So she is so eloquently nicknamed us that. But you can see kind of where we're at at this particular point in time. In the state of North Carolina we have 16 active programs with multiple others that are coming on board hopefully within the next calendar year. Another thing that we have in North Carolina is a prehospital blood coalition made up of stakeholders from different institutions. And we try to be a clearinghouse for policies, protocols, working with the state office of EMS to establish these programs and to be able to help people come online and to share our knowledge for those of us who've gone before. So, so it's easier so we can do that R and D of policies, procedures and things so we don't have to reinvent the wheel. So talk a little bit about us. We're Wilkes county emergency services. We'll talk a little bit about us. Wilkes county unto itself is fairly large, almost 800 square miles. The hospital facility you see on the slide itself is Wilkes Medical Center. This is our community hospital where the majority of our transports go. It's 150 bed community hospital about located about an hour, hour and 10 minutes due west of Winston Salem. Where the trauma center actually is unique to our system is the fact that we actually have an aeromedical asset from our local trauma center that is based at our county airport. As this picture tells the story, we work hand in hand with our colleagues at Air Care. And you'll understand more of this when we talk about our equipment swap out policies that we have and they the fact that we share the same exact equipment from warmers and fluid administration. So it makes the transition of care truly seamless. So why Wilkes County? Again, we are the 13th largest land mass county in the state of North Carolina. Predominantly rural. If you look at this topographic map of Wilkes county, you will notice all those lumps and bumps north, west and south well, that's because that's all mountains and that's tough for us to get to. So you can see where our ambulances are geographically located. Six on duty all the time, 24, 7, 365, with the ability to flex up to eight, of course, with administrative responsibilities and response capabilities throughout the day. Now, one of the things that we'll talk about is how we deployed our blood, and we'll get to that in just a moment. So let's talk a little bit about our story. Bryant Reed, who is our operations officer at the time, in 2019, I was literally wearing him out week after week, asking for numbers. And you say, well, what numbers? The first thing that we did is I asked him to look at trauma patients to begin with and identify trauma patients that were hypotensive to begin with. And then did their blood pressure get better on the way to the hospital? We looked at a calendar year of 2018, and we had 90 trauma patients that were hypotensive at some point in time during our care. Now, it kind of got lost in the weeds as to, you know, did we know if these patients got blood or not? And we couldn't figure that out then, but we did notice the fact that about half of them got better with a fluid bolus, something as simple as 250 or 500 cc's of saline or ringers at the time. So what about those other 45? Those were the people that we identified. Maybe that's our target audience. And when we started looking at the numbers, we said maybe two a month. That'd be a good way to start with 24 a year that we could make an impact with Budweiser. Well, unfortunately, our train got derailed, like many things in 2020 with COVID and it got put on the backside. And I totally understand this, but in the fall of 2021, Jason Revis, who had moved into the operations office at that time, he and I met with Christina Warren and Dr. Faid, who is the medical director for the blood bank at Atrium Health, Wake Forest Baptist. And we came up with this idea. We'd like to take the blood that's in the blood bank and pre deploy it out into the field and see if we could make things better. And Jason and I, who's actually sitting in the room with me now, he'll grin with this. We were actually kind of scared. Were they going to say yes? What was the deal? What was going on? What. What are you guys thinking? You want blood in the field? And lo and behold, Christina said, yep, that's where it needs to be. Blood in the field saves lives. They don't need to, Patient doesn't need to wait till they get to the trauma center to get blood. It should be out on your ambulances. And we literally looked at each other, gave each other a little high five off the camera and go, maybe this is going to work after all. So we, we started a timeline and we thought now that we've got the source for blood now, then we've got to figure out all the other stuff. And it took about a six month window with the fact of hopefully being able to start May 1, 2022 is going to be our start date. And we'll talk a little bit more about that in just a minute. So when we talk about the blood supply, our blood comes from Atrium Health, Wake Forest Baptist. It's our trauma center. That's about an hour east of us here. The blood bank there has a very colorful history. Surrey EMS was initially supported by our blood bank and they have since transitioned to a local hospital in Mount Airy Northern Regional Medical Center. Blood came out to our helicopters in 2017, and that was PAC cells at that time. And since 2018, there's been deployment of other agencies that you could see first would be the helicopters Unto itself. Stokes county came online in 2022 as well. We came in in April. Alexander county came on board this year and Yadkin county came on again just a few weeks ago. Unto itself. Alexander's had their first three administrations within the last month and Yadkin is still yet to have an administration as of yet. So we'll see what happens there. I got to give a shout out to Christina. I know she's embarrassed and smiling at this particular point in time, but this young lady has made quite an impact on the blood programs and EMS in North Carolina to the point where she was awarded the Grave and Graham Previr award for the impact on EMS by our state Office of EMS at our annual awards ceremony ceremony in May of this year. So kudos to Christina and yes, you can cuss me later about the fact that I put this picture out for lots of people to see. All right, with that in mind, why the Kool Aid? Okay, so we got to talk about administration. We talk about we can get the blood. It's expensive. It takes true commitment from an EMS agency to say they're going to deliver blood. And Tim Pennington, who was our director at the time, again, I kept saying, once we had the numbers, Tim, we got to find the warmers we got to find the ability to do pressure infusion. We've got to have this equipment. And it's like, I need you to drink my Kool Aid. It's going to taste good that this is going to change what we do. And eventually he sipped, then he sipped a little more and then we guzzled. And when we guzzled, that's when the good things happen for our service. So let's talk about the equipment and what costs some money. The image that you see on the image to begin with is the Pelican Credo cooler, which is what we started off with, which is an industry standard. The issue is, is our blood would have to come from Baptist every three to five days. Luckily the hospital would actually absorb part of the courier cost. So literally we were hands off. This turned into literally like the secret service and the presidential football. And in fact that's what we nicknamed it was the blood football. And everywhere the the training officer or the supervisor went, the football went with them. Well, in addition to the coolers, we needed a way to warm it and a way to pressure infuse it. I'm a firm believer in with my experience in as a working in the trauma center, cold blood is good, but warm blood is better. We all operate under the philosophy that cold as a clot. So why am I going to give someone something that's 6 degrees Celsius in a trauma patient that's bleeding? Why do I want to make them more cool? So going with the Q and flow warmer was what we went with. Also we decided to we wanted to have the ability to do pressure infusion with this as well. So with 410 medical in the life flow device and all of this is bundled in our blood administration kit. Also in that kit is txa, calcium and Kefzol as well to do a package bundle with this. We have just recently switched in the last year. We now actually have a delta development apru. Our guys have fallen in love with this. Now then we only have to touch the blood once every two weeks and that's handled with the blood bank at our local hospital where we can do switch outs. There we still have one credo cooler in our crystal ball which you'll see in a few minutes. You'll note the fact that we'd love to add a second apru but the guys have really fallen in love with this and love the fact that we don't have to swap out as much our blood product. Again, I've already mentioned a couple things. Life flow is one of These. We were the first EMS agency in North Carolina to institute whole blood that was warmed, that was pressure infused with the life flow when we bundled it together. Other people had programs, but we were the first to come together with this. Interestingly enough, we had such a positive impact with this that our helicopter teams at Baptist now have switched to this device as well. And now then we have an on scene swap out. We have the same vendors. So if we use life flow on the scene, they literally hand us one off. The helicopter replaces ours and then is replaced at the hospital from there. So again, it is a win win. They also use the same warmer cartridges. So as I mentioned before, when we talk about seamless handoff, that's exactly what you have when a Wilkes County EMS crew interfaces with one of our air care helicopters if we have to do a medevac run. So where does our story begin? Well, in the beginning, we decided that we're going to shoot for May 1st. May 1st, 2020 was going to be our start date. But as some of you may be aware, we have this little music festival in Wilkesboro called Murrellfest. It is one of the 10 largest outdoor Americana music festivals in the United States, bringing in over 100,000 people a year to our town for a three day weekend. So we had this wild idea, maybe we should get the blood coolers a few days early. So on the Wednesday before we were supposed to start, the blood coolers show up at Wilkes County EMS. Little did we know, in the first 26 hours of the program, we would administer blood twice. First to a GI bleed patient, then next to a gentleman who was crushed by a steel roll of material at a local manufacturing plant. So literally within 24 hours, we had administered blood twice and saved two lives with a simple fact of starting a little bit early. This is the news release that came out. A couple of things that I'll note to you in the picture. Jason Revis, who is initially there standing with his hand on the cooler, he's now our new director. Tim Pennington in the background with the walkie talkie accoutrements on his chest, he's our former EMS director. And I got to give Tim a shout out with that. Kevin Foster is one of our now retired EMS supervisors and Jim Bottomly is going to play an important role in our sensational save that we'll talk about here in just a minute. But we seized the moment, we got with the media and we showed them the power of the blood that we gave and we got lots of media attention to begin with showing how powerful this can be and how many impact lives that we can impact. So some of you in here probably grew up in the early 70s or late 60s and there's a television show called Batman. And when Gotham City needed help, they had, they turned on the bat signal so they could ask Batman and Robin to come help. Well, this is our blood signal within our administrative team. When our phones vibrate and you see there one blood drop in an ambulance, that means one unit was given. And if there's two blood drops, well, guess what, we gave both the units for that. We've not gone above 2 yet with a patient. But in our administrative team, this is how we let each other know to sign into eso, look at medical records and see what we need to do so we can do a hot wash immediately after the call and then appropriate follow up from there. So I've told you about a little bit of our story, how we get our blood. So now then, let's talk about our statistics. As you can see in front of you, in 2022 again, 13 transfusions, 12 of those arrived alive to the emergency department. Of those 13, 10 were discharged home. Of the 13, we had four that received additional blood products in the hospital. And you can see the numbers there, 2023, the acuity went up fair amount. We doubled the number of people who required the blood administration in the hospital. And you can see our numbers so far for 2024 as well. We're making people better in the field. So some other numbers that you probably want to know. Who are we giving blood to? Well, everybody thinks it's going to be trauma. Come to western North Carolina where people are elderly and lack primary care. As you can see, straight up GI bleeds are where the money's at for us. That's by far the most common reason for us to transfuse a patient is going to be the GI bleed. And then interestingly enough, trauma falls off pretty quick. Penetrating trauma, literally. Our first year, no motor vehicle collision patients got blood only one each. The last two years we have finally had our first OB GYN patient that required blood. And then we have this unique category. And so everybody wants to. What's unique? What's a unique case? Well, you could be crushed by a one ton roll of steel. You can fall out of a tree and have a mesenteric tear from where you bleed into your abdomen. You could have seen a GI surgeon and during your colonoscopy have a sigmoid perforation from which you're now bleeding. From be attacked by a dog, have a retroperitoneal hemorrhage from having a kidney ureteral stent placed and also almost exsanguinate from having a varicose vein hemorrhage. So those our unique cases that we have had over the last three years. So when we bundle things, we decided straight up to bundle. The first two years our priority was blood, then txa, then calcium and then antibiotics. We've since reversed that. As you can see in 2024, our calcium administration immediately follows blood administration with this. And you can see there's about a 50% drip versus pressure infused rate for all our years across all takers with this slight variability year to year. But in the grand scope of things, about half our people get pressure infused blood. So who gets our blood? About 65% of them are male. And typically these are the elderly portions of our community. Literally the 50s, 60s, 70s and 80s is where we are impacting the most people. Peter, speaking to your world, we have not done a pediatric administration as of yet. We think that will eventually be coming. We are not looking forward to it from that sense with pediatric trauma, but we do know that eventually that is going to happen. So it sounds like we've done a great job. So now then, let's talk about the bad side of this. We track everything here as much as we possibly can. The first thing that we tracked is we tracked our misses. Okay, in 22, we 2022, we had 10 misses. The most common reason, the fact the crew was concentrating on airway management or we had IV access issues, or literally we were just so close to the hospital, literally less than five minutes away. Christina, she actually.

Gets worried when I show her these numbers. We had 15 Mrs. In 2023. Imagine we could have doubled our administrations if we had been able to one, get blood to the location in an appropriate time. Or again, the most common reason that we see that we do not get a chance to administer blood is the fact our crews are focusing on management of the airway before we hand off to the helicopter transport service. And I have no issues with that. Airways needs to be addressed, to say the least. We all know that the blood helps our hemodynamics. Blood does not stop bleeding. So that's something that we have to consider in our management process. Interestingly enough, as we can continue down the letter S of the day. We've had two sensitivity reactions during our three years. These were two delayed hemolytic transfusion reactions. One is an anti A antibody whole blood that was transfused to a group a patient. Then we had an E positive whole blood that was transfused to an anti E antibody patient. These delayed transfusion reactions occur at about 1 in every 2,500 transfusions. Neither of these patients had negative outcomes. And again one of the things that's unique about our program, all of our transfusions are reviewed by a board certified medical transfusion specialist physician for appropriateness of the transfusion. Not only does it go through our quality management program, but it also gets reviewed at the medical center as well. So neither of those patients had a negative outcome. One of the things that you noticed on our slides was we looked at drip versus pressure infused and some of these numbers have been used across the nation. The one thing that was instituted about 18 months ago was the shock index. Peter and I were talking before we came online. We've used the shock index for almost a year and a half now to as an indicator of when we're going to transfuse. And we're pretty aggressive with this. We all know that in that most of the time a normal shock index is about 0.7. So we go anywhere from 0.8 to 1 is where we'll drip blood and then anything over one will start pressure infusion. So this is the slide that started Peter and I talking to each other via Twitter. With this he had posted a link to a research paper about shock index. I said well what about these numbers? So our average outcomers trauma versus medical our average pre administration shock index is 1.3 with a high of two and a half with a low of 0.7. Now that person most likely was in our very first year. So that low would probably not have been transfused in today's world unless there was some extenuating circumstance post administration we make people better. Average shock index of 0.87. Some people could probably get more blood but more than likely this is a handoff to an aircraft or we were able to timely get them to the hospital with that. So I think this is where I think the rubber really meets the road for us is how well we treat patients and how we make them better. One thing that medical directors get nervous about is seen times. So these are our numbers. These do not include numbers from this year but this is from 22 and 23 all comers the Wilkes County EMS. Our average scene time for any call is 17 minutes. So we broke. I had the ops guys look at this and we broke it down into medical versus scene and averaging about 16 and a half minutes for medical calls, about 15 minutes for trauma. And yes, the numbers do go up a little bit. And I attribute part of this to the fact that this was a new program. We were still figuring out how to do part of it, but we have gotten faster. We've gotten better with our handoff, getting the blood to the crew and the crew moving on to the hospital. With time and again, I'll take seven extra minutes on scene to give somebody the ability to have 2 units of whole blood while they're being resuscitated, while on their way to a trauma center. I think that's a trade off that I think most any of us would take. That number was over 10, I would probably get worried. But being where it's at right now, I'm very happy when it comes to that. Closing out with a couple things. Sensational save. And Peter has seen the video that's out on social media about this. This is in July of last year. There was a young man with an accidental negative, or, excuse me, negligent discharge of a firearm into his leg. Well, that projectile actually transected his popliteal artery. Now, this is one of those situations where the planets aligned for good. He wrecked while driving himself to the hospital. He wrecked in the front yard of a volunteer firefighter who happened to be chief of the local fire department, who goes out into his front yard, opens the door, finds a large amount of blood in the floorboard. The patient is in cardiac arrest and starts cpr. Luckily, that morning, Jim Bottomley, who was the blood medic for the day, was already in the geographic area handling another call. Received this call, got to the scene again, traumatic cardiac arrest here. Started resuscitation, and the crew made the decision to aggressively treat him with our two units of blood. Got return of spontaneous circulation on the scene. Was met there but with a helicopter. The gentleman received additional whole blood impact cells on the way to the hospital. Received even additional blood products at the local trauma center. Spent two weeks in the hospital, spent two weeks in a rehab unit, then was discharged to home fully functional with exception of a mild paralysis in the leg and also a little bit of neurocognitive dysfunction because of the anoxia during the cardiac arrest. This was from our survivor reunion that we had just this spring to bring him and his family back. His mom is so appreciative of what we did that day and how we literally saved his life and raised him from the dead that day, just with the power of the whole blood unto itself. He would not be alive today if it wasn't for that. Closing out with a quick snapshot. We are very proud of where we're at. We, we gauge ourselves as a tip of the spear type EMS agency. In fact, we're the only EMS agency in North Carolina that gives prehospital thrombolytics for stemis as well. So we push the envelope with what we do in, in rural North Carolina, we highlight our unique supply model. Having a hospital trauma center supply us blood that comes to our local hospital that in turn gets mixed back in the system. We've become a test agency for equipment and techniques. Delta development. The hospital, when we talked about going with, with that particular unit, got one to try. And so we worked with those folks there. We also, we thought we were going to get O negative blood when we started this. Little did we know we got O positive. So the blood bank was using us as research guinea pigs as to whether or not this was safe. So they were doing research with us along beside us while we were taking care of patients. As far as change for the future, as we look in our crystal ball, we just expanded staff education so we have more blood medics now. We've modified our protocol to where it's now blood, then calcium, then TXA with antibiotics. And we're toying with the idea of can we put blood on every ambulance rather than just on coolers on supervisor and training officer vehicles? I don't know. It would be two more units, but we'll just have to see on that. But obviously we are making a difference with what we do since starting the program. We have a brothers in arms program. We've had multiple blood drives here and our folks who work here have truly bought into our system and they are part of what we do here in hosting these blood drives. And they give back knowing full well that that unit of blood may be used on a patient that we treat here in Wilkes County. In summary, our hypothesis was correct. We can safely carry, administer and administrate blood in a moderately busy rural EMS agency. By the way, we run about 12,000 calls a year. So I think we're busy, but we're still rural. Our numbers prove that we make people better. And the model of a medical center supplied blood program is very unique. But as Randy can comment if she's able to, and Christina will, it has been amazingly successful for our particular program. Now, no good lecture for me is good without some religious reference. So we, we live in the Bible belt of the southeast and we're good Southern Baptist. And so we'll all stand and Sing together first, second, last hymn number, I believe cuts off there in the. In the red back hymnal. There is truly power in the blood. And we believe that here wholeheartedly with what we do. So with that in mind, I'm going to give a shout out to all of our guys at Wilk cms, from our ops team to the guys and gals who are the boots on the ground, in the trenches, who administer this to our partners at our hospital and our aeromedical assets that we truly make a difference and we are very proud to serve the citizens of this county.

Wow. Well, Jeff, I'm going to stand up and give you an amen, my brother. That was amazing.

First of all, I. I have to say that this has broken records. We. You. You have now broken the record for the most people alive on this webinar since we started in Covid. So it just proves the point that this is a very important topic and people really want to know how you did it. I have two other people on your team that I want to bring in in a second. Then I want to bring in Randy. My question is, who pays for this? So who pays for the blood? Who pays for the Q and flow? Who plays for the liff flow? Are you. Is this all being sponsored at the hospital level? That's really my question.

No, it is a combination event. Peter. What happens here is we. We basically we started off and we paid for the Q and flow. We paid for the warmers to begin with. We kind of ate the cost for the administration of the life flow to begin with. Now then, if we transport the patient via aeromedical asset, the patient actually gets the charge on the back end because we'll use it as a helicopter asset. But if the patient is brought just by ground, by a ground asset, no, we still have to eat the cost. As we all know, CMS and the issues with pre hospital blood administration, again, we're not being able to charge for that per se as far as the charging for the blood. As long as we go to an atrium Health Wake Forest Baptist facility, which is basically 99% of who we transport to that blood charge gets passed on to them in their emergency department building. We do not charge for the transfusion, only the blood product to itself. And Christina can comment a little bit more on that on the back end as well when it comes to part of the billing aspect.

Perfect. So let me bring in Christina right now. So Christina, you are a very integral part of this. Many of us in EMS have now recognized, thanks to people like Randy, how important you are. Can you tell us who you are, what you do, and why do you like EMS so much?

Sure.

So, yeah, I'm the manager of the blood bank here at the trauma center in Winston Salem for Baptist. So for me, I think blood needs to be out in the field. My daughter's third day of high school, there was a shooting at her school. My initial thought is, oh, no, there's not blood in my county. So it would be better if it happened in a more rural county in that aspect. So for me, it's always planning. Just because it's not done doesn't mean we can't do it. As long as we uphold the regulations, how can we get it done? Billing is something that doesn't necessarily concern me at this time because the regulations just haven't caught up with the practices. So at some point, our billing will be a little bit more seamlessly done than what it currently is. But, yeah, I mean, I grew up in the backwoods of North Carolina and one of these rural counties. It takes a really long time to get to the hospital, and Wilkes is lucky that they have a community hospital. Three of the other counties that we serve, the only blood that's in those counties is what's on the ambulances that we provide.

Wow.

Maybe I'll connect with you. And Randy, at some point, I would like to do a separate webinar with blood bankers because you guys are so important, and more of us EMS folks need to know more about you. But just for the sake of time, I'm going to bring on Dr. Lance Hennegar. So Lance is the medical director at Wilts. And so, Lance, you started this several years ago. What in the world made you think that in a rural place you could do this? Did people think you were crazy? What obstacles did you go through? And what would you recommend to other medical directors who are on the call, who are thinking, I can't do something like this?

First, I have to start by. A lot of the legwork started before I took over as medical director. So I recommend you come on after all that is done. But I think identifying the need is probably the first thing that you do, and then establishing a champion. I come from military background. It's a huge logistic undertaking to do this and bringing three to sometimes four to five agencies together to make this happening. So, obviously, Jeff Hinshaw is our blood champion and promoting most of what we do and then just getting all the agencies on board and making sure everybody has a voice at the table. So I think logistics is the hardest part. And don't start from scratch. We had the benefit of seeing what other people have done locally and nationally, and we have a program that's working well, and we'll be happy to help other people set it up.

That's. That's really great. Thank you so much for that offer. I'm going to bring in Randy Schaefer. So Lieutenant Colonel Randy Schaefer retired, who has not retired at all because she is basically just killing it in a good way. So for those of you who don't know Randy, she's the one who helps set up the original blood programs in Texas and actually helping people around the country. Anyone who calls me, I say, you have to have a call with Randy and then maybe get her on board on your team so she can help you set up your program. So, Randy, thanks for being on. You heard all this. You've seen the big programs, the urban, the suburban, the rural. I would love to hear your comments on what you heard today from Jeff and his team and just overall thoughts about blood in the rural parts of this country.

Absolutely. Huge fans of my friends in North Carolina there. I call Christina my blood unicorn because.

There'S not.

And there's a lot of hospitals that aren't willing to get involved in providing blood to ems. And, Christina, I just have a quick question for you. You have been audited for by the AABB Joint Commission and various accrediting bodies. Did you get in trouble for helping EMS by providing their blood?

No. So I don't believe that I would be able to get in trouble because there's nobody that oversees these programs. There is no regulations that tell us what to do or how to do it. Everything that all the programs that we run through ems, I treat them as if the blood was still in my blood bank. So I'm upholding CAP standards, AABB standards, FDA standards, to whatever would be applicable in my lab. Whatever I have to do, I make them do so. They may not understand or like it very much, but, you know, we make them do the alarm checks and the temperature monitoring and everything like that for the units. So, no, we've been inspected by all of those agencies, and they all seem to be impressed with the programs.

I had a feeling that's what you were going to say. So, on that note, Peter, for all of the hospitals that are having angst about this, you can do it, right?

And that's why we need you and we need Christina. And you know, this presentation is going to go far and wide. A lot of people need to hear it. And I think we need to have another presentation just by you and Christina and others to continue that message. I know Joseph Zalkin is on the call. I'm not sure he's able to talk, but I wanted to give a shout out because Jeff did mention the coalition, the rd. Joseph, are you on the call? Can you mention and comment how important the coalition is and the work you guys have done?

Sure. Can you hear me?

Yeah.

Okay. Shout out to everybody who presented and who is supporting these programs. The coalition is a backyard clearinghouse, so we have a statewide coalition in North Carolina. Our website is in the chat, just connecting people and having resources available. Sample protocols, samples for consent. Who needs to be at the table when you're setting up your program are so important. Blood banks have rules and they're different than our rules in the EMS world. And so there's got to be a opportunity to have that conversation. And you need to know your backyard resources.

Right. And you guys are able to provide that. You have regular meetings, etc. So thank you so much for what you do at the state and nationally with namsp. Let's go to Lou Steinberg. Lou, go ahead. Hi.

I just had two questions. One, many of the medical directors are doing the TXA first. You switched your protocol. Why did you switch your protocol to TXA last?

Either Jeff or Dr. Henninger want to be sorry.

I was looking in fact in in my ops team is here. We're probably giving blood right now on a call that and then I was just showing our CAD information here. So pardon me for being distracted for just a minute. Can you restate the question for one second? Lou, I am so sorry. Sure.

Many of the systems are giving TXA first, especially since it's probably on almost all the units it can be set up and administered right away. I note that you switched yours to last after the other two. Was there a reason why you switched TXA to the end instead of upfront?

Yeah. One is the fact that still at this particular point in time we don't give the 2 grams im like our military partners do. We still have to drip it. Also, I believe that there is that fourth leg to the trauma triangle of death in the sense of hypocalcemia. One, I think the research is out there that shows hypocalcemia exists in peritrauma patients then much less the fact if we're giving them blood that is chelated otherwise. The other thing is our protocols in trauma, if you don't give blood, if you consider it we actually go ahead and give calcium empirically. And this is actually coming from our trauma surgeons at our referring facility. We have an agreement with them. They actually came to us initially wanting to put ice stats on the ambulances to check for. For calcium levels. And we all know that that dyscalcaemia. Is that a word? Is a bad thing. Too high is bad, too low is bad. This kind of like Goldilocks and porridge. Okay. You got to have it the right spot. But we feel like that. That going with the calcium first, we can drip that in. You know, I think TXA works, but I think at this particular point in time, we feel like there is more return on our investment from calcium than the txa, and our trauma guys were perfectly happy with that.

Okay, in part two, maybe I missed it, and I'll apologize if I did. I saw your criteria for drip versus push on the blood. What is your overall criteria for giving blood?

I actually did not put that slide in for the moment of time. Our state has a generic protocol. You're looking at hypotension. You're looking at tachycardia. There are age ranges that we look at for this as well, of course. Signs of exsanguinating, hemorrhage, things such as aortic catastrophes, OBGYN bleeding, things along that lines. It is a hodgepodge of when you know there is either internal or external hemorrhage that I'd be more than happy to share with you. I deleted that literally for the sake of time.

Okay. But it'll be in the state online protocol.

Yes. Yes. You can look at the NCEP document that is online through our North Carolina office of ems. And there's generic criteria that are there. And then certain blood administration agencies have maybe tweaked that a little bit. The one that we have is traumatic cardiac arrest. If we have a crew that arrives on scene of a traumatic arrest within five minutes, we go ahead with blood unless there are signs of obvious death otherwise.

Okay. Thank you.

Oh, sure, Lou.

Great question, Lou. You will notice the same questions always come up, and this is why the research needs to continue. You'll. We'll hear about the calcium question, the ordering. We'll hear about criteria for blood to make sure that we're not giving blood inappropriately, etc. That takes too often to someone who doesn't need it. If you haven't experienced this yet, you will. Where you come into the. Into the trauma bay after giving blood. The guy's now awake, not intubated, because you gave the blood first. And the trauma surgeon will look at a guy who looks good and, and then start saying, this guy didn't need the blood. Why did you give it? So you better have those ducks in a row and you better have that shock index and you better have those vital signs and you better have a protocol with some flexibility because if you make it a very stringent black and white like the case you spoke about, you know, you have to make sure that the paramedic also has been, is given some leeway to give that blood when it doesn't exactly fit that box. And so these are all things we need to continue discussing, but we're out of time and there are many people on the call today that I would love to hear from. Let's continue the blood conversation. If anybody else has the blood program and wants to present on here, I would love to have you. This was an amazing presentation. I'm going to put this up on YouTube hopefully by the end of today. Jeff and your entire team, thank you so much. Before we go, I do want to bring in Tanner, who's my co host and partner in crime. We've had so many people on today that I, I'm leaving Tanner for the end. But Tanner, for those of you who don't know Tanner, he is a phenom. He is not only paramedic, but he's in Medical School, MD, PhD, and he's written more papers than I'm old. So he's, he's the future of our profession. So, Tanner, thoughts, comments on what you heard today and in general. Yeah, no.

Wonderful presentation. I definitely think with the, with these blood programs, the rural counties, the rural areas of the United States is where we're going to see the bang for our buck and see all of these great saves. Like the story that was told today. I'd say that that guy was really lucky. But I think a larger part of that, larger part than luck was probably your dedication to bringing this program to fruition. Just one comment I had about some of the data that was presented about your patients. I think some critics of these programs might look at your figures on what proportion of patients get blood administered after hospital arrival and suggests there's a lot of over triage going on and maybe blood wastage because, you know, a high proportion of the patients aren't actually getting blood in the emergency department, the trauma bay. But I think especially for whole blood administration, something we have to think about is, you know, this is we're actually giving these patients clotting factors and improving Their ability to clot and, and kind of obtain hemostasis. And so, you know, the data that's out there suggests that giving whole blood might actually decrease resource utilization in the hospital. And so what we're seeing might actually be an effect of the treatment and not an effect of over triage. So that's the. I won't keep anybody any longer. That's the only, Only comment I'll make.

That's. That's actually, that's actually.

Go ahead. Yeah. No, no, no, no.

That. I think that the reason they're not getting more blood is because we're making them better. I truly believe that and I think our numbers prove that. Again, there's always going to be a naysayer that may exist there, but I think the reason they don't have to get more blood is because we make them better. Or if they do have more blood administered, they're really that sick and they really needed it in the field otherwise. But again, that's my very biased take.

On this right now and our blood program. They're actually getting blood. They're not just getting the pack red cells. They're getting up front, whole blood. That's what we did in the austere military environment with a walking blood bank, since you're getting those clotting factors up front, like Tanner says, which is a lot more than the PRBCs that you'd get even showing up to an ER with emergency release. So I think it is better, faster, appropriate faster.

And I think, to Tanner's point, that if we make the pitch to the hospital, that this is indeed saving them money, a lot of money. Because if you engage in an MPP at the hospital level, where you could have given one or two units early on and saved them 10, 15, 20 units of blood down the line. Someone's got to write that paper, Randy, paper. And so that. It's very clear there. So, Jeff, I'm going to give you the final word. Take us away. A lot of people here, they're staying on. They're inspired. Give us your last words. And again, thank you so much for joining today, you and your entire team.

Hey, thanks, Peter. Again, truly humbled and honored to show our data here. Really proud of the boots on the ground and the ops guys here that have made this all happen. I will just say this again. I've made this statement before. We're a tip of the spear Agency dream big. You can do this. I firmly believe this is one of the biggest modifiers of the EMS compass that we have seen since CPAP and some other things probably in the 80s. We have an opportunity here to impact lives on multiple levels here and multiple pathologies. And I think we're doing our patients a disservice if we don't explore giving blood products in the field. I think I should challenge EMS medical directors and operations folks. Try to make this happen. You really need to do some self reflection, figure out your numbers, figure out who you're actually treating, and then go make a difference.

That was beautiful. Well said, my friend. Thank you everybody. Have a great weekend. Enjoy your families. Stay safe out there. And let's go to Paul Pepe's webinar. It's on the link in the chat to your right. Click on it and let's continue the conversation and we'll continue it online on Twitter and LinkedIn. Take care, everybody. Thank you.