Lt. Bill Bullock: Heroes in Arms - The South Texas Pre-hospital Whole Blood Story

Joining you today from beautiful San Antonio, Texas. Maybe not quite as warm as Florida, but really appreciate the opportunity to come speak. I know everyone's time is very, very valuable and hopefully we can pull something from the meeting that, you know, we didn't know before we showed up. Thank you, Dr. Schaefer, for always being a huge supporter and advocate. And as the first slide says, I'll just get right into it. This is a unique relationship that we have down here in San Antonio, Texas. You know, STRAC is our facilitator and offshoot of the department, Texas Department of Health Human Services, that really facilitates a regional program whose level of sophistication we're proud of. But, but truly is a simple thing when you get down to it. Every strong program is going to have a few components of which of course is ems, and we all want it, we know we need it. There's a few slides up ahead that show why we need it. Of course, we have to have a reliable blood supplier that we're going to forge a relationship with. You will be very close with your blood supplier, there's no doubt about it. And then you need a real intimate relationship as well with the trauma center. And if you do have the state lending a hand with, with, with operational oversight and, and resource, that's, that's sensational as well, but just kind of where we're all starting from. And I want to give a shout out as well to my colleagues across the nation that have dug in and, and made it happen in their niche of the country. You know, the stuff that, that Lieutenant Holly O' Brien puts up online in D.C. it's just incredible. The case studies she shows. Tom Dansfield over in New Orleans and Chief Croyle there in Florida, Leah Rendone up in Massachusetts got it done in the Northeast. Just these are just one of many, many folks that I've had an opportunity to meet throughout the country. We've collaborated and tried to get our programs so they're accepted and this can become practiced throughout the country. But real quickly, just to look at the medicine, I think almost everyone on the call is already a believer. So we're, we're not doing anything to here. Earth shattering, but we all know that trauma is the number one cause of death for individuals under 46 years of old, 46 years of age. A hemorrhage, severe hemorrhage is one of the leading causes of those traumatic fatalities. So EMS identified a major problem that we had that needed to be addressed and we, we did that. The military as the Slide shows showed us that a lot of data studies, case studies, surgeons, medics told us, hey, people have a great survival rate if you can get them the thing that they need closest to the point of injury. And for years in EMS we gave saline. We learned maybe that wasn't such a great idea for various medical reasons that we don't really need to go into in this call, but, but blood was the answer and whole blood at that. Next slide, Doc.

As I'd mentioned, we've got several players here in the Alamo City. We are fortunate to have a lot of retired military here. Dr. Donald Jenkins was the architect of our program, a retired Air Force surgeon that really came up with the idea of getting prehospital blood in a civilian setting. And he teamed up with the COO at the time, Elizabeth Waltman of South Texas Blood and Tissue. Together they enlisted the help of Dr. Leslie Greebon at University Health System, and Colonel Schaefer kind of put the pieces of the puzzle together here in San Antonio, and we were off and running. Next slide. So a little backtrack. Why should we do this? Well, in the past, before blood showed up to through in some EMS regions throughout the country, we had people that were injured from automobile accidents, maybe a cutting, a shooting, causing severe hemorrhagic shock. Also medical origins, you have people, ob, GYN cases and GI bleeds. These people were dying because they were bleeding to death. And in the past, someone had to recognize this situation, contact ems, EMS was activated, responded, took care of their marches, plugged the holes, did what we could, maybe gave some txa, got access, and then we rushed off to the hospital. They weren't getting that blood until we reached definitive care. And that was a matter of minutes to hours, depending on the setting of your EMS system. Dr. Schaefer, I appreciate the slide. This slide's been showed so many times, over and over, but it really highlights the fact that a lot of minutes are lost between when someone is actually injured or has that hemorrhagic shock and what used to happen before they got blood. We all know once you arrive at the hospital, the blood is not just hanging there and waiting. There is a process to get that blood from where it needs to come within the hospital, patient needs to get registered reports given, so forth. So the fact that we could get blood in the pre hospital setting really just, just, really was best for the patients. Next slide, Doc.

So in South Texas, we give whole blood. Ours is low titer, O positive. We use a titer level of less than 256we, we're borrowing that we at South Texas and, and South Texas Blood and Tissue in the South Texas region because that's what the military standard is. And as I'd mentioned, Dr. Jenkins was a program architect, so it seemed to fit. Some different blood centers throughout the nation are going to use a different cutoff for tighter levels. We don't use O negative even though we would love to. There's just honestly a supply problem. The demand is bigger than the supply. Only 7% of the donors out in the nation are O negative. And typically that blood in South Texas is reserved for children with some serious hemolytic conditions and cancer patients. Whole blood obviously is composed of RBCs, platelets and plasma. It may be in your corner of the nation that whole blood may not be available and that's a complication that you're going to have to work through. If you can get RBCs, terrific. A great step in the right direction. If platelets or plasma are your only option, then that's better than saline as well. As I said, we're all moving in the right direction. This is the system we have. The blood we use also is non leukal reduced from South Texas blood and tissue and that allows us to have a 35 day shelf life because the preservative that's used in the bags for non Leukal Reduced CPDA1 allows for that 35 day shelf life. I know some blood centers do leukoreduce their blood which shortens the duration of that blood unit life to 21 days. One thing, just a mention is platelet function data is shown is probably reduced by a certain percentage. So that's one byproduct of the leukoreduction. But you do get those white blood cells out of there. In our system, South Texas Blood and Tissue will obtain a a unit from a donor on day one and it gets moved out to our EMS systems throughout the region from day two through 15 of the life of the blood. During this time, cold change management is maintained and temperature readings are distributed to various agencies throughout the region, including South Texas Blood and Tissue, all of our EMS agencies, University Hospital. So every stakeholder in the process has fidelity as to the temperature of those units and where they're at. Basically, if EMS uses the blood within the first 15 days of its shelf life, they'll contact South Texas Blood and Tissue and we're resupplied, we've got blood on the trucks again and we're ready to roll. In the event that they don't use it in the first 15 days of its shelf life, it returned to South Texas Blood and Tissue as per AABB guidelines. There's an inspection on the blood unit, and then that blood unit is then distributed to our local trauma center, UC University Hospital, for day 18 through 35 of the shelf life of the blood. The system that was created was a collaborative effort by many folks here in the South Texas region, facilitated by strac. Executive Director Eric Epley is proud of this system because of the low waste ratio that we're able to maintain less than 1% at the present time. Next slide.

So this is an example of the fidelity that goes on throughout our region. EMS executives and practitioners, as well as the trauma center and.

The trauma center and South Texas Blood and Tissue. We all have fidelity on how many of our low, tighter O positive units are out in the field as well as how many are on the shelves at South Texas Blood and Tissue. That being said, we can anticipate if there's a large demand or maybe a large disaster, a mass casualty situation. Where are we sitting in terms of what's available over at South Texas Blood and Tissue and what's on the horizon in terms of donors and what we're looking like in the future? So we all have a vested interest in making sure the supply and the demand kind of match up. Next slide, Doc.

Here's an example of all of the EMS units in our region that carry blood and the amount of time that they have for the 15 days before it's going to need to be turned in to Southex blood tissue and distributed then to University Hospital. The little graph on the left shows the current inventory at University Hospitals. So we know how much is on their shelves as well. If we were to bring in someone that needs mass transfusion protocol. Next slide, Doug.

So this is really the focal point of this conversation. A lot of EMS systems that are going to want to start a program will approach their blood center, and the blood center may have some trepidation. They may be a little hesitant to want to sell whole blood, honestly, because it hasn't demand. There's been no demand for that at this point in time. Dr. Antevi, I throw back to you for just a second as a physician, what does the hospital want in terms of ordering blood products.

As far as our hospital?

Yeah. Like when the hospital orders blood, do they order whole blood typically, or do they make a different order?

Yeah, well, exactly. At our hospitals, at least. This has changed in the last couple years. But they've ordered the components, basically, is.

What they've ordered exactly. So the blood centers are giving the customers what they want. Their customers prior to our arrival were the hospitals and they wanted components. So EMS asking them to have a pretty massive process change along with some the business ramifications, financial changes with that is a pretty big lift for the hospital center. Additionally, they may be hesitant because there's not enough supply out there nationally to begin with. I think everyone on the call understands that there is a, there's a supply shortage throughout the nation. So your blood centers may be a little bit hesitant to to want to fill take on more contracts when it's already difficult to fulfill the ones that they have. Herein lies the answer, at least what South Texas has done. So so South Texas Blood and Tissue instituted a program called Brothers in Arms where those low titer O positive donors were put into a group called the Brothers in Arms and they received an email upon qualification to the program. You're O positive, you have low tight or blood, we'd like you to join the Brothers in Arms. Those subsequent donations would then be placed on the ambulances or the air carriers or end up at the trauma center or when they join this program, South Texas Blood and Tissue will send them an email saying you've joined the program. They congratulations. We also send a follow up text that lets those donors know where their blood unit ended up. So for instance, Brothers in Arm may get a text that says your blood unit was distributed to the San Antonio Fire Department today. So as they drive around town, the donors say, hey, my blood might be on that ambulance or that supervisor's truck today.

Additionally, they're issued a challenge coin on the year that they join so they have a little tactile reminder that we really appreciate what you're doing. We also will send a feedback in cases where EMS is able to to get South Texas Blood and Tissue some information regarding really kind of landmark saves. Much like you had Dr. Antevi in South Texas with the chief's daughter who had the severe hemorrhage from the tonsillectomy. We found that that closed loop communication really has created a loyalty that's really galvanized the donor base. And what maybe originally was thought of as a challenge has really become more of a solution where these donors, as you see 6,500 of them, they come about 2.5 times a year. And most blood centers, if you ask them, hey, if your donors come 2.5 times a year, would you be pleased with that? They would be ecstatic. The national average is going to be substantially lower. More in the 1.1 time a year range. So you've created donors that are loyal to a program that then return more often, thus increasing your overall amount of units that you have. These donors have a show rate of over 80%. When they say they're going to come and set an appointment, they come. We understand things come up in life and there could be complications, but they make it a very high priority. As mentioned with the rotational system, we have Dr. Schaefer, Tracy Rose over there at strac. Eric Epley, as I'd mentioned, worked so hard to set up this system with a waist ratio of less than 1%. And when it says waist ratio, what that means is the. There may have been some units that went out of temperatures in EMS possession, very rare instances, or they got to University Hospital and there just was a lull in demand. And some, a few units may have outdated. But extremely rare for either one of those scenarios to occur.

Here you see the donor show rates for South Texas blood and tissue for the last few years. Always really strong numbers. 2023, 2024. I need to update these slides. We're back above 80%. So we see a great show rate which also, if you ask most blood centers in the country, would you be pleased with that number? They would be ecstatic.

Just a case study here that we had in San Antonio, really landmark save. We were called to a female that was found in a bathtub by a family member. A placenta previana breptia, a pool of blood, serious bleeding, full term pregnancy. You see her pressure was 60 over palp. This, you know, we're knocking on decompensated shock right here. End tidal was extremely low. Baby and mom in severe distress. Definitely saline. Was was not going to be the answer in this case. We were able to transfer, use a unit that actually started in her apartment. She loaded into the ambulance, taken emergency to the er. She got subsequent units there. At the er, there was the cesarean section. They were in the hospital for a little while, but overall made a full recovery. I think just a really remarkable story because in this particular instance, that first unit gave those surgeons OB GYN doctor a chance to save both those patients and. And literally this singular donation saved two lives in this instance.

Next slide, doc. The program's expanded and developed all throughout South Texas. We've got over 40 EMS agencies now that carry blood and we're able to flex if needed for mass casualty disaster scenarios. Low tide or opas. Heroes in arms. Blood was on scene at the Uvalde disaster and some units were Administered, you know, terrible tragedy. But I felt proud of the way that our region was able to respond and get those units there in just over an hour. A mass casualty pack, a large package. And prior to that hour point in time, we had EMS units from around the region descending upon Uvalde to have blood there for anyone that might need it.

Research and develop is really, really important. Obviously anybody on this phone call values that. You know, my call to you, to everyone on the call, before I, I stop talking is let's keep proving that it works. We need data, we need people to get out there and write articles, peer reviewed EMS world gems, you know, you name it. Because we really have to show that this is saving lives. One of the great offshoots of the article that you see in the center there from trauma and acute care surgery from here in South Texas was there was a great byproduct of some patients that were studied that received pre hospital care, I'm sorry, blood versus those that didn't receive pre hospital blood. And the interesting byproduct was that mass transfusions reduced dramatically for those patients that got blood in the pre hospital setting. It was a huge cost savings to our trauma center as well as a net gain for the number of units, blood units available because of the reduction of those mass transfusions. So great win for the hospital, the blood center, of course the patients were saving lives, you know, excellent there. But I just, I advocate for anyone that's interested, read, write, research.

Go to your local blood center, find out how things work there, ask to look behind the curtain, ask for a tour, ask questions. They're very, very welcoming. I started with South Texas Blood and Tissue because literally I was chasing the breadcrumbs down the trail. I wanted to know where that blood came from, what did it take to get that blood there in the hands of ems? And appreciate as an EMS practitioner the amount of work that is done by your trauma surgeons, your medical directors, the blood centers, a whole lot goes into getting that on your rig and treated as the precious resource that it is. If you have any questions, that's my contact information. I'm just one representative of many folks here in South Texas. We do have something called the National Whole Blood Academy that we do annually if you want a comprehensive two day program on, on how things really work. I know Chief Charlie Coyle and his crew came from Palm beach and they instituted a whole lot of what we discussed at that, that, that academy. And now they're up and flying and saving lives, which is just awesome.

Wow, Lieutenant Bullock. Amazing. And I see Dr. Pepe has unmuted himself. Paul, I know you're going to be heading over to your webinar. Love for you to make some comments and then I'll move over to some other folks.

Hey Bill, everybody's emphasizing before you got on how fantastic you've been and what a great contribution it's been here. So but and thank you for presenting this. I want if you don't mind, please emphasize something to our audience here about one is that your coordination with the tissue blood and tissue folks early on was to look for low tighter. Right. It specifically create a cadre of low tighter folks. Right. Number one. And they and created that kind of a registry. So just if you could comment on that. Secondly, the commentary is that this has had a beyond the thing about saving blood because you prevented the multiple transfusions later is the issue that it actually became a great thing for the blood bank, so to speak as some people will call them that they were now there was this great purpose here as well. And so it helped with blood, you know, blood gathering, blood collecting altogether for that community. So it's a positive thing for them. So can you comment on those two issues?

Yeah, absolutely Doc, absolutely. So we, we did target all of our OPAs and then we do tighter testing every day. We we tighter test 20 OPS donors that haven't already been tested. And I neglected to say that when we did a branding change from brothers in arms to heroes in arms, that was when we included female donors. Initially it was just male donors because we needed to do an HLA the females. It's an extra step and expense but it really expanded the number of donors that we had and they willingly jumped on it and have been just terrific. So yeah, getting that zoned in, those are the donors that we want that low tighter level. And then notification that hey, you've qualified for this program has just been really powerful.

Also harnessing the power of the media in your local area is really significant that hey, if our EMS system can do this with our blood center, we are on the, the bleeding edge. So we say the tip of the spear that we're going to save lives that that other folks aren't honestly. So. Yeah, no, no doubt. And then the, the, the savings on, on the, the mass transfusions at the hospital, it's just been incredible because it's a net game for the, in the entire blood center. Then they can allocate more blood to other EMS agencies or to other customers or other patients or dedicate more units where maybe at times we've had to be more judicious or use a lot of stewardship with patients in need that you as a physician can really give those patients exactly what they need rather than having to be a little bit more withholding.

I'm going to head over to the other meeting, but we are going to cover the new paper that came out and give the results about whether you get transfusion reactions more or less. Is the target too high, too low? But. So I think CJ Just got called over the Texas Medical Board. So I think David hopefully will present it for us. And if you want to join us, maybe Peter will send you a link. Okay, so thank you very much everyone. I'm sorry to take up the time, but I got to switch over. But thank you for a great job and the job you're continuing to do. Okay, thanks.

Bye bye. Thanks, Paul. Appreciate it. Lieutenant, the wind that you and Paul just described with respect to the mtp, the reduction of number of units being used, I would also like to mention, and maybe you can expand on it and others could too, which is the fact that we're bringing many more patients alive to the hospital and the hospital is also getting that second win of patients who are now in their ICU and their ORs for two weeks. And we've seen a number of those patients who we know would have died in the field who have not been delivered to a hospital. Hospital does the miraculous work of saving their life and then they get that win as well. So I think there's a double win for the hospital systems. Have you seen that in Texas as well?

Oh, no doubt, Doc. We, we as pre hospital providers need to give the surgeons a fighting chance. You know that the patients we were bringing them were a lot of time, impossible cases that they just couldn't win. And it's got to get disheartening after a time to just not have a. A real fighting shot. So getting that blood on board and just a little stability is assisting those surgeons. So I think it's, it's a tr. Tremendous win. And then on the flip side, if you are an EMS supervisor out there, executive level, this is going to put wind beneath the sails of some of your medics that you've never seen before. You know, how many times have we had to pronounce a patient in the field if you've done this a long time and it can get discouraging. But now with this intervention, we're saving folks that we never would and getting transports over to the hospital like I said to give those surgeons a fighting chance. And to the families of patients, there's an emotional component that if there's a severe auto accident and I'm a parent, if I'm told my child's been in an auto accident and I need to rush to the hospital and they're in surgery, you know, you give that parent some hope and they get there and they're processing versus a knock on the door from a police officer informing them that, you know, their loved one passed away. In an NBC. One of my medical directors, I don't want to disclose too much information here, but just had an extremely serious situation involving his father with a vehicular accident. And the very program that we designed here in South Texas, honestly is the reason that his data's alive today. So it hits home. Everywhere you look, there's a difference. And as you'd mentioned, Doc, the ICU time and getting those patients well to be with their loved ones again eventually.

Yeah, that's great. And that is a tremendous story. I did hear that story, and it's really incredible.

Just real quick because I want to bring Tanner in, but part of the story that I got from you yesterday, that I wanted you to throw in a little bit today is the fact that here you are a lieutenant in San Antonio, and then somehow or another you kind of crawled your way into the South Texas blood and tissue, and you become a very integral part of why all of these connections are happening, all these community events, etc. The state of Florida, and thanks to Dr. Jamison, Dr. Lozano and others have started now the Florida center for ems, where there are people in this state who are perhaps, maybe at a point in their career where they want to say, I want to be like Bill, right, And do something special with blood. Can you give us a short, maybe inspirational kind of moment there of how you ended up jumping onto the blood side and maybe other people on this call could potentially do the same thing.

No, absolutely, Doc. And I mean, you really answered it in asking it. And the truth is, as medical professionals, be it EMS or in the hospital wherever, we're very passionate about our profession and life safety. But let me tell you this. The folks that work in those blood centers match our passion and then some. I'm going to tell you, they're very driven by their mission. They understand that obtaining those units, being from the tele recruitment team to the testing team to the distribution team, people's lives, their health is depending on obtaining those units. And I felt that passion in working with South Texas blood and tissue and literally it's like a magnet that just kind of drew me in some fortuitous things. Worked out where I was also finishing grad school and really wanted to learn and write and read. So I really challenge anyone that's kind of at that crossroads in their career where you're looking for a new challenge and you want to learn more and seek more to, like I said, knock on the door of the blood center, send that email that you're not sure if you should hit, if you should hit send, because it seems awkward and it's a cold invite or something like that. But to learn about their processes and respect that. And what it really comes down to is, is there's mutual respect in all stakeholders in our system and you have to learn their language and they have to learn your language. And in South Texas, I don't want you to think it was easy. It was a, it was a process. We broke bread. We, we, we argued, we discussed, we worked through problems, we collaborated in the end. But for me, I just felt that that tremendous energy at South Texas Blood and Tissue and I needed to be part of it. I literally just kind of went, kept, kept insisting, can I be around? Can I volunteer? Can I know what's going on? We need to get more community outreach and so forth. And, and eventually I think I pestered them to the point where they were like, all right, we'll put you on part time and, and do your thing and spread the, spread the word. But really the message, it sells itself, but it lets you see a lot of different components too, with medic, medical, academia, places where you can spread the message of this.

That's great and I hope other people are inspired to do that. I want to bring in Tanner Smita, who's my co host for this webinar and he's a research phenom, MD, PhD student in West Virginia. Tanner, love to hear your comment.

Yeah, I'll keep it brief. I just have one comment and then one quick question for you. So, you know, the one thing that I really loved about the description of your program in terms of the methodology was the keeping the people engaged by telling them kind of when they're, when and where their blood is going to be utilized. In the, in the past year, I actually donated blood for the, for the first time and have started donating. And I know the, the Red Cross does a similar thing. They have an app, they let you follow your blood throughout processing and then they tell you the geographic location where it's sent to a, to a receiving facility. And so I think that that kind of aspect of keeping donors engaged is kind of a really brilliant point that I think should be replicated by other programs trying to simulate your success. In terms of a question, so you mentioned having the ability within your region to kind of flex these, these resources in case of mass casualty events. Is there kind of a formalized system in place for doing that or is there, is there a protocol or is this something that can just be done in real time by coordinating with agencies that you know to carry this resource?

That's a tremendous question. So no, we do have a memorandum of understanding facilitated by STRAC and two ways that we could, we could either be proactive or reactive. We actually, as a region will, will check out mass casualty volumes of blood. We call it an MCI pushback. And we will pre position those at major events all around the San Antonio region. New Year's Eve, for instance, we had some at the MLK march, so we have units around in case something was to happen. In the event that nothing does, we return those units, it's a full refund. And the great part is it's kind of a non stressed real time exercise. So we're developing that muscle memory as a system, as a region, so that if something does come up, we are able to react. If it was a reactionary situation like Uvalde, there is a process in place. Now, I didn't mention we meet regularly, once a month minimum, as a region, the blood center, the hospital, Dr. Jenkins is the chair and then the EMS agencies to discuss different nuances of programs, challenges that we've had, things that have come up, good saves, things like that. And in the course of those meetings we've discussed what we did in Uvalde and we've had a couple other instances where a large cache has been requested. And South Texas Blood and Tissue has just been a wonderful partner and, and got it out to us either in our trucks or you saw the picture with the helicopter. They have a helo pad at their blood center where they can actually air life blood. Really anywhere in the state. We can get it over to San Antonio International Airport. And we claim that we can get blood anywhere in the state of Texas in two hours. And Amarillo is a pretty long way in El Paso, but. But we feel we can. One other point I just wanted to mention real quick. You'd mentioned the donors and keeping them engaged and so forth. Something else is South Texas Blood and Tissue does. And I know blood centers are limited by budgets and time and staffing. And things like that. But we do an annual appreciation event where donors are. A specific donor is linked up with a recipient of a really kind of high profile case with, where they get to meet the donor and they get to meet the EMS crew that saved their life. We had a severe obgyn call, different than the one I chronicled in the case study, but she got to meet her 86 year old donor who's been a lifetime donor, and the EMS crew that transfused that day to save her and they got to meet the baby that she subsequently had after the ectopic pregnancy. So when you have meetings like that and we're inviting new donors to the Heroes in Arms program, selected donors get invited. It really galvanizes that emotional connection.

We talk about closure in EMS for the actual paramedic, the emt, paramedics, so they can have closure on the call. But then what you're describing is that closure where you actually have the meetups, just like we do for trauma or just like we do for stroke, cardiac arrest. And I think that is so much more powerful for the longevity of someone's career. We have people now here in Broward county who are going to retire, but are not even thinking of retirement anymore because of the blood program here. So I want to thank you for all the inspiration you've given us, all the people you've helped. You're naming names at all these departments of people who reached out to you and you took their call just like you took mine. And I want to close it out by seeing if Randy will make a couple of final comments before we move over to Dr. Pepe's webinar. And then I see a hand raised. So let's go to John Barry first and then we're going to go to Randy. Go ahead, John.

Hey, thanks, Doc. And hey, Randy, Bill. Great to see you all again. My name is John Barry. I'm a retired army blood banker and an alumni of both South Texas Blood and Tissue and the South Texas Blood Consortium. So I work hand in hand with Randy and Bill setting this thing up. And I just wanted to underscore something that Bill already touched on. But it's such a compelling argument to engage both blood centers and hospitals is that it's not just mass transfusions, but the retrospective study that we published in south in Journal of Acute Care and Trauma Surgery showed that an adoption by a hospital, whether they have mass transfusions or not, but the adoption of the hospitals in our area of this short dated low tide or whole blood, that's recycled from the ambulances and it's used in trauma and medically. So it's used across the facility. It corresponded to an overall decrease in volume and spend of blood products writ large. And that's huge because one of the big pushbacks by blood centers, suppliers and hospitals is, well, you can't give me the blood that I need all the time when I need it. But we have data now that shows they need less. It decreases for the bean counters, it decreases the spend, but more importantly the volume over the whole enterprise. So I just think that's a compelling argument to put in your toolbox when you engage in these conversations with both suppliers and hospitals. That may be a little reticent.

I think. I think it's those data that have to be at the forefront now because I think people have gone over the. We've already gotten over the hump. Does it work? At least 99% of us have. And now we have to talk to the bean counters and allow them to understand of the. Of this win win argument. So I don't think I've read that paper, John, and I. I'm looking forward to reading it. So if someone can send that to me or I'll, I'll look for it and then we'll, we'll put it out on the socials. Because that's the argument that needs to be made. Right. It's now the people who spend the money, who are trying to save the money, that's who. The people who can get it to the next level, to the middle of the bell curve, rather than the 200 agencies who were the first adopter.

So 100% and I think a paper that needs to be written, the data is a little less neat, but I think it could be put together is just getting those patients to the ER to that trauma center, to that gaining hospital less sick in better hemodynamic shape. It corresponds with a reduction in the cost of interventions overall, not just the blood products. So that's something. If somebody has the databases and the know how, that's the other part of that argument that is going to be. Be very important.

Yes, 100% agree. And that's why we have Tanner on here because he's our research guru. So Tanner, we're depending on you to make that happen.

John, thank you for the input. John was one of the very original architects with Randy. He's moved, but yeah, it takes a lot of people to make the soup. There's no doubt about that.

Well, John, thank you for coming on the webinar it's great to meet you for the first time and thanks for all the work you've done. And now let's move on to and let's close it out with Randy Schaefer. So Randy, you've heard what Lieutenant Bullock had to say today. Any comments or feedback for you as we take it away here?

No, just appreciate all the work. And a lot of these programs are.

Set up by lieutenants like Bill who say, all right, let's roll up our.

Sleeves and get it done.

And he's been a fantastic partner and I look forward to working with him more to help roll out programs across.

The country and have you, you've done so much in that respect and we are thankful for that. So Lieutenant Bullock, give us your final comments. Take us away, inspire us as we continue to do and try to do what you've done down there in South Texas.

Honestly, what I'm going to tell you is go out and make friends because you can't do it on your own. An EMS system may want it so badly, but you've got to develop those relationships from everyone that John Barry had mentioned. You need to work as a unified.

You need to work as a unit to get it done. So before you can save lives and give blood, you got to make friends.

Awesome. And you, you kind of remind us of this guy. I just, I just read this book, Dr. Ron Stewart's memoir, someone sent it to me, Dr. Stevenson. And all through the book he tells stories like the ones you told us today. And making change doesn't happen overnight. It requires collaboration, communication, leadership, long term vision. And you clearly had that from the start as well as Randy and John. So thank all of you. Thanks for joining us today and please join Dr. Pepe's webinar which is in progress using the link in the chat. If you wanted cme, that's in the chat as well. So for myself and my co host Tanner Smita, thank you all for joining us and we'll see you again next Friday. Take care everybody.

Thank you, Doc.

Thanks. Thanks Bill. Appreciate you. Amazing.