LTC Randi Schaefer: Whole Blood Programs (5/9/23)

All right, thank you.

Oh yeah, no, you have to be able to stay here. You have to. If you to be able to stay here you have to have an Irish accent.

Yeah.

So let's say it's true. So it's good. All right.

All righty.

Let's see.

I'll wait to see. I'm waiting to see where Randy is.

Hold on.

Tatiana, I'm glad you got to make it so much. Haters.

See more blood.

Are you a trauma surgeon?

Oh yeah, I'm a trauma. Way back when. Yeah, exactly.

Right.

When I was.

I was in high school.

I started off with a great pseudonyms back in the day from. I was in high school. I was at boarding school. So I was thinking about that. That was one of the favorite things. So Tatiana sounds like you made it. So good for you. That's fantastic. Good to see you.

Yeah.

Thank you very much for inviting me.

Yeah, you're very welcome. Cha Cha is our representative. She'll be joining us later I hope with meeting she's out of Sarajevo and so it's been great to hear what's going on their country too as well as with increasing trauma and penetrating injury and so on. But it's great to have another perspective from another place out there on the planet. Is Randy on yet?

Peter, she just texted me that she's having. She's shutting it down and coming back on. So give her. Let's give her a quick second.

Did you get the CME for the day?

No, but if you tell it to me, I'll add it to the chat.

Okay. It's from what I remember. 173 6. Let me confirm that.

Okay.

90%. It's 17362 and an eagle. 163.

Well this I'm relieved because I thought I'd be running this meeting today. I'm glad you got it. That's. Is it noisy there at the airport though.

Paul?

I didn't. Tell me if I got it right there. Yeah, I'm double checking another minute or two here.

For.

Randy. Teams team doesn't like all of us unfortunately.

17363 and Eagles is 17 3.

Oh no.

Yours.

Is 17 3. Okay.

17362.

Is Randy on yet?

Yeah. Okay, let's see. Let's see if we see.

Of course I got these people just crowding you on your whole notes.

Sure.

If you can't do it, Peter.

Ah, there she comes.

Good.

Okay, I see her coming on right now.

Aha. There you are. Hi. Hi Randy.

Hey Brand.

Hi. Apologize. It Is not letting it. Pick it. Peter, can I send you or Paul my slides real quick? Or I can just talk without them.

You know what? You know what? If you can.

Maybe. Actually, Paul. Paul's gonna have to go, but.

So I can't do it either from here, I don't think.

Right.

So. So what's the problem? Oh, Randy, why are you having problems with your slideshow? What's good we could see what. What's the problem?

I'm on my phone. It's not letting me log onto my computer.

Okay, got it.

Keeps giving me.

How about.

All right, I can do it.

How about. How about Joseph? Okay.

Yeah.

Joseph, would you mind just telling Randy your email real quick?

No problem. Or I. I can put it in the chat, whichever is easier for you.

Randy, if you could email it to me, that'd be great. I'm so sorry. I do not know why my computer is not cooperating, but my phone is.

So keep in mind that we got to get this finished, you know, in about 50 or so. So if you.

Paul, hang on. Yeah, hang on. Just like, we can give. We can give. Randy, can you give Joseph your email just verbally?

Yeah, it's Randy R a n d I dot Schaefer s c h a f e r@ Schaefer consulting dot net. Which is a confusing email, I realized.

Sorry, I. I should have done it. I should have done it the other way. Joseph, you want. You want to give Randy your email? Sorry about that.

Yeah, it's J.

Z as in zebra, A L K I N at W A K E E M S.

Got it. Okay.

And as soon as it pops up, I'll share that and you can tell me when to move on, but I'll watch for it.

Okay.

Okay. So without any further ado, Randy, while you're doing that, let me start with a quick introduction, and I'd love to pass it over to Paul as well. But thanks, everyone, for coming today. We are being recorded, just FYI on that. It's another Tuesday here for the Florida EMS webinar. And we're very privileged today to have Lt. Col. Randy Schaefer, who has really done an incredible job, you know, helping many organizations, EMS organizations around the country, get up and running with whole blood. And, you know, Randy has a very big wealth of knowledge, and we have learned so much from her. And once we kind of got to connect, we started to take. Hey, let's help each other out. So Paul. Paul knows about the great work Randy's been doing. So Paul, you want to say a Couple of words.

Well, first of all, you got to understand she's got the military background in which they were doing this, and it has, you know, really boots on the ground experience with it. But most importantly for us, she really helped. She was the person that really helped to spearhead the program in San Antonio with folks like, you know, with, you know, C.J. winkler and the group there, and really was, I would say, an fic, a facilitator in chief in terms of working with the blood bank, getting everybody else to cooperate. And so she has. She's really great. And she's now at the forefront of trying to help us figure out how to fund it across the country, how to get it done right. And so. And what metrics we should be looking at to help justify the program and more importantly for some of us, to expand the programs.

So with that, Randy, thanks for being here.

Okay.

Thank you so much. Again, I apologize. I logged on like six minutes early because in the military, if you're not five minutes early, you're late. So, yeah, I'm totally frustrated. But, Joseph, if you get a chance to load those, what I'll just start talking is I want to give you a crash course and looking at things you need to consider when you're setting up a program or if you have a program, things, how we can get this expanded across the country. So the question is always asked, can we do this? The answer is yes. The American association of Blood Bankers put it into their guidelines, and what they did was they tucked it under the emergency release blood protocols. So all of you that have worked in an emergency department are familiar with when a patient comes in and we don't have time to type and cross or type and screen, we do emergency release. Well, now, that used to be limited to plasma pack cells and platelets. Now whole blood is included. Awesome. If you can go down to the next slide.

Next slide.

And the military has been doing it over 20 years. My first experience with whole blood, actually, my expertise is in fresh whole blood. I started doing that in 2005 at the role three at the combat Support Hospital. When we would blow through our supplies of what we had on the shelf, we didn't have refill capabilities. So I became an expert in setting up threshold blood collection and walking blood banks. As we saw the utility of threshold blood in the trauma setting, we needed to think of ways to push it out forward. So there were some first attempts with the rangers doing their fresh whole blood programs. And then we realized to get it on a larger scale, we needed to do cold stored whole blood. And towards my third deployment in 1617 is when we really started pushing in those cold stored units into theater and we really started seeing improved outcomes with any component PAC cells, freeze dried plasma or whole blood in the pre hospital setting. So we've got a lot of experience to draw from. So civilian implementation it is allowed in all 50 states by air. But not all EMS helicopter agencies are carrying prehospital blood ground. I put a great big question mark because nobody really knows. However, in the last two weeks I've been privileged to work with Eric bank and we have developed the first database on what we believe are ground EMS agencies that are carrying blood. It's in its very ugly baby stages but we're going to try to get it heat mapped out for everybody and we could have a whole discussion about who's doing it. So right now we've got about 80 ground agencies that we're tracking is doing it in 20 states, predominantly in the rural and suburban populations of the top 10 most populous cities in the U.S. there is only one agency that is doing pre hospital blood and that's San Antonio. It's not being done in New York, Chicago, Houston, etc. So we have a call to action to really re evaluate where it's being given. Right now we're tracking about 80 hospitals that are using whole blood. You can go out to the next slide.

I'm not going to spend a lot of time on this because I'm speaking to an audience who guessed this. So we need to start reframing time. Probably the number one pushback I get, especially the metropolitan area about prehospital blood is well, we only have a 20 minute transport time. Everybody is so fixated on that variable and I really want them to start expanding their thinking that time starts from the moment of injury. But we don't know how long it took until EMS arrived or a bystander saw it. I'm working on a case study up in Michigan right now with a crew. The patient was ejected from his motorcycle and they don't know when an EMS crew happened to find them as they were driving back to the station. So we have all kinds of variables in there right off the get go. You all know your scene times and how long it takes you to get to a scene. Those are fixed variables. Probably 10 to 13 minutes transport time. 20 minutes is always the number that's thrown out. So if you ask probably any medic in the country, oh it's about 20 minutes, you know when they're looking in the suburban setting, I would argue maybe 20 minutes. There might be some plus or minus depending on traffic, especially here in San Antonio. And then when you get to the hospital, this is where I really want to knock down. Some of this thinking is that time doesn't magically stop as soon as you go through those glass doors. More importantly, blood doesn't magically infuse when you get to those glass doors. There is time and it's shocking the amount of time. If you are not in a level one trauma center that can turn to a refrigerator and pull it out and start infusing it, it is up to 20 minutes. And I know this because I lost my mind at Fort Hood when we went into a new hospital and I saw patients dying in front of me. And I was so frustrated with fighting with the blood bank and then feeling like it took forever to get the blood to the bedside. So I started a project to prevent proved blood bank wrong. And I took a stopwatch out and from the time it was recognized that blood was needed until it started infusing into the patient where it belongs was 20 minutes. That's a whole lot of dying that can go on. So if someone says, well, it's only a 20 minute transport time, push back and get them to understand that this is a continuum with so many variables that we cannot control. And we know that you can die a whole lot of times even during a 20 minute transport time. So go to the next slide, please.

This was a great article in GEMS that came out when I was teaching the San Antonio medics on how to do blood and talking about meaningful interventions. Are we doing something that is really making an impact or are we just throwing things at the patient?

Looking at that data, you know the odds of death increase every minute until they reach a surgical suite or. I love this part. Receive damage control resuscitation or massive transfusion protocols. You all have the opportunity to do effective DCR and MTP before the patient ever arrives to the hospital. Why are we waiting until they get to the hospital to start blood? MTP is, as you all know, is 10 units over a 24 hour period. Why are we not starting that in the field where we can really start going after this time? Damage control resuscitation needs to be extended out past the emergency department. We have mastered this in the military and it's time we start bringing that thinking to the civilian side. Next slide. I apologize. I know I'm talking really fast. I want to make sure we get through this. And then what's a meaningful Intervention. Well, the data is starting to show that prehospital blood is indeed a meaningful intervention. And this is the data out of San Antonio from University Hospital and Brook Army Medical center looking at changes in shock index, decreased use of crystalloid and more important, the ones that I really want you to start talking to your blood bankers about is there is a decreased requirement for component therapy upon arrival to the hospital. So even if we can't, you know, plea to their compassion, this is the right thing to do or clinically improving them. All right then I'm going to help you save blood products on your shelf. If you help me start this program, we're going to make a difference. Next slide.

Not just for trauma patients. When we started the program here in San Antonio, especially on the air side, really thought that trauma, man, it's the bee's knees. This is all the trauma patients. It's going to be sexy. Well, as I started collecting the data from the 18 helicopter bases, I noticed a trend quickly emerging that our very first patient in the South Texas area was not a trauma patient. It was out on the border three hours away. He was three days status post tna. So he blew his clot and they could not control his bleeding at a freestanding ER out on the border. So that was actually our first patient. Uncontrolled bleeding from a nosebleed from his tonsillectomy. He's the one that got a first products and that sort of heightened my awareness and I started looking and it was GI bleeds, especially patients in liver failure. Then we started with the ob. I'll tell you if you want to talk to CJ Winkler about the first time he had to make the call to give it to an OB patient. He texted about having a heart attack, wondering if he made the right decision. And I'm going to support him and say yes, you did. We're seeing a lot of obuse with good outcomes. So there's a couple of examples of the work looking at trauma non trauma patients. Next slide.

And here's just a quick snapshot of what is the non trauma use is looking like. And I did it from the outer stretches of the region inward. So Carnes county is about an hour and a half away from the trauma center. 15,000 people in the entire county. Low volume, but you would argue they probably have the highest needs and they are the furthest away. They are one of the furthest away from the level one trauma centers. 50%. It's split between medical and non medical really looking at OB dialysis, fistulas, apparently if you all in Florida have the same problem we do in here in Texas we got a whole lot of kidney failure patients that are on dialysis. And we've had wrote up a couple of key studies on those dialysis. Fistules blowing and then giving them ground, medics giving them blood. And then we come into more of a suburban setting. So this is Eric bank at Harris County ESD 48. 60% of his patients are medical. And then here in San Antonio, even in the gun and knife club, it's still 40% are medical, non trauma patients. So don't dismiss that population when you're looking at building your pre hospital blood plan. Next slide please.

Blood logistics simply come down to keep the product cold, warm it up to put it back in the patient and rapidly infuse it into the patient. Here are some examples of companies that I have worked with or found their product to be useful. I won't spend a lot of time on that. Just think about those three basic principles. And when you look at interoperability of equipment, you know, in the hospital we have the Level 1 or the Belmont, which rapidly infuses it and warms it. Well, we don't have that in the prehospital setting.

The rapid infusers don't necessarily are not compatible with the warmers or the warmers are so slow that it doesn't go in at any meaningful rate. Think about the ability to do both. Rapidly infuse it and warm it at the same time. Next slide.

And then some other equipment. That little green dot, believe it or not, took much months and months of effort. That is called a safety view 10 and that is something that we used in the military and put that on the back of our blood bags because we transport blood all over the world. Blood gets drawn here in San Antonio and it is put in a cardboard box and sent on an aircraft into theater. Even when I was moving around theater, I'd put blood in a box, cardboard box, use it to prop my feet up on in the back of the C130. And there's no strict crazy requirements out there. It's really amazing when you get into their world. So we use the safety view 10 in the military. And it's like when your turkey's done and it pops and you can't change it. It's the same thing. If that blood gets out of temperature between 1 to 10 degrees centigrade, that will change color and it's irreversible. So you will know at some point there was a temperature excursion.

Also One of the things we did with the blood bank is I talked about the irreversible really is not super.

Intense requirements for temperature monitoring. We increased our own internal requirements for monitoring temperature that exceed theirs. And we did that by adding in some monitors into the blood cooler so that we could continuously monitor the temperature of the blood cooler which is not something that they do in that cardboard box as it's to be going going all around the country.

Also consider buying a small compact refrigerator. I bought these for $120 off Amazon for San Antonio Fire Department. It just needs something. These blood coolers all require their internal elements to be frozen. So it doesn't need to be a big fancy freezer. Literally 120 bucks off Amazon. I ordered eight of them for each of the stations. And then if you haven't ever administered blood yourself, it does require special blood filter tubing. You can't use the same IV tubing. Next slide.

And this is important, I think we can all relate to this. It's pattern recognition, knowledge translation and guts to take action based upon limited information. This is our world. We live in risk mitigation. Next slide. But that is not who we are partnering with. In this blood bank is the exact opposite of emergency medicine. It's not a knock on them, it's just that they are in a much more risk averse profession. They live by that book and if it's not in the book and it's not being followed, they tend to get a little uncomfortable or not want to participate. Again, it's not a bad thing. It's just understanding we are two different cultures and we have to figure out how to come together and meet in the middle so that we can get this capability into your hands in the pre hospital setting. Next slide.

This is one we could spend days on. But really quick. Just things to consider when you're talking to a blood vendor or a blood bank and there is a difference between the two. A blood vendor simply sells the product, they collect the donations and turn around and sell it. So a great example of that would be American Red Cross. They you go in, donate your blood, get your T shirt, they take that blood, they process it and then they sell it to their end customer. A blood bank may not have that ability to collect and process units. So most hospitals are blood banks where they get the product in, they manage their inventory and then they get it to the patient within their system. So know who you're talking to and what role they play. So figuring out which vendor serves your area.

Ask them what Additives they're using, is it CPD or CPDA? One to their products. Why does that matter? Well, one is 21 days shelf life and the other is a 35 day shelf life that's going to impact your operations and how you're managing your blood program and the rotation versus one way. Here in San Antonio we're able to get the ability for EMS agencies to have return privileges. Again, that's a word that's super important in the blood bank. Ask for return privileges so that the blood can be returned to the blood vendor or even the blood bank before it expires so that it is not wasted. And here in San Antonio, our agencies don't get charged if it is not used. Storage versus transport again, just words in their world that make a difference. If you say we are going to store blood at the EMS station, their heads are going to spin. But if you talk to them about putting in a state of transport while it's out with you, that gives them a little more assurance and it doesn't require quite the rigorous regulation if it's in a state of transport and hemovigilance. It's very important in their world. So we need to develop systems and processes that support the ability to track that blood from cradle to grave from the blood vendor issuing it to you, which patient it goes to, where that patient goes in the hospital or whatever receiving facility that they're going to validation. It's just, it's a, it's an organization that validates everything. They may ask you to validate your blood coolers, validate the process. That's okay if you can work with them on that. Give them the blood cooler you want to use. Let them validate it. It's important. And I have some stories that C.J. and I were just. It was eye opening to see how that blood bank and the blood vendor industry works. One thing that you would get pushback on potentially is that, well, you're going to take away from our current donor pool and we're already short. Well, the fact is, is that when they're going on TV and asking for blood donations, they're really asking for O negative. If you can talk to them and help them understand that low titer positive whole blood will allow them to seek out potentially new donors into their system and then they can take those O negs and really deliver them to the patients that truly have a requirement for O negative blood. Next slide please.

Prehospital blood product priority. So this is out of the joint drama system. These are the Guidelines that we worked with.

There's a great group of folks who we want to get low titer O positive whole blood out to everybody. But the fact of the matter is is that what we did in the military is not going to translate well over to the civilian. It's a sheer numbers game. So I encourage agencies that if they can't get low tide or O positive whole blood, let's look at the blood product priority list and see what you can get. I have started some agencies with plasma because they that's what the blood bank was willing to give them. Others with PAC sales, anything is better than what we're currently doing now. I also don't want to get voted off the pre hospital blood island. But if saline is your only choice because that's all you have access to, let's make sure that we warm it up and we rapidly infuse it. I think one of the interesting numbers is that I pulled this out of One of the EMS reports that there are over 70/000 registered EMS vehicles in this country. So even if you take out a quarter or half, you know, for other reasons that they're not doing.

You know that the 911 or the pre hospital response, it's still a lot of agencies. We can't possibly cover them all with blood or blood products. There's just not enough to go around. So I would encourage, you know, EMS medical directors, the industry really start pushing science and research into alternative options. We've been using freeze dried plasma for decades overseas on an FDA waiver and has shown it works. I believe that is part of the solution on how we're going to decrease pre hospital deaths due to hemorrhage is that we need to get these into the hands of our medics on the civilian side so that I can get it into every rural EMS agency, every agency that can't afford fresh products. A lot of options. So we really want to push R and D now and not wait for the next war as sometimes I think we're a little slow to act until there's funding and a need for military uses. Next slide.

I'm just going to touch really quickly because I know we're running short on time here but think about how as an EMS agency you're going to talk to the emergency department and the blood bank at the receiving facility. The but this patient did indeed receive an emergency release product. So we used a carbon copy tool here. Very high tech ehrs don't talk to each other and they definitely don't talk to each other. In real time. So we went back to the 1970s to pull out some of that high tech work and just use a carbon copy. EMS agency keeps the top copy, ER gets the middle copy and the blood bank gets the bottom copy. And that's how we share that information. Information that contains the blood unit identifier, that unique code in there that can help track that blood use. Also we leave the segments, the blood bag with the segments in the ER. 25 years of trauma nurse, I never knew what that little. I always called it a pigtail that's rubber banded to the blood bag. Turns out it actually is a technical name, it's called a segment. And when I ask for emergency release blood in the er, they clip that off at the blood bank and save it so that if there are any post transfusion complications, they can run that segment against the patient's blood. So let's replicate that process in the pre hospital setting and the EMS crews dropping off the patient leave the blood bag, leave the paperwork and then that receiving facility has the option to do it. Any post transfusion testing that they would like to next slide.

Capturing its use. Make sure it gets put into your electronic healthcare record. Really talk to your local hospitals about including it into the trauma registry and consider a method for capturing non trauma uses. I was able to work with our level three and our level four trauma registrars here that they were, since it was a low volume, were able to collect the non trauma uses and the medical uses. So we could really start understanding who is getting it and where they were getting blood. Then Tulane University is attempting to start the first national prehospital blood registry. So consider joining that registry or if there's any other registries out there, please let me know. Right now we just don't have a great way to aggregate data to really see if we're getting after the problem. And then continuous PI. Yes. Take a look at who got it, but most importantly who did not get it. And that was actually I turned that into my doctoral project with San Antonio Fire is before we gave ourselves too many pats on the back that we were getting prehospital blood out to the right patients. We wanted to make sure we didn't have a blind spot and were missing patients. So we did a project looking at missed opportunities. The patient met criteria but did not get it. We wanted to dig into it, wanted to make sure that if it was an operational reason, a dispatch reason, if it was a training reason, or if it was just straight up a clinical mess, that they didn't administer it, which had some interesting data results which we don't have time to talk about today, but it was pretty eye opening. Next slide. I've got two. You know, Dr. Antefi, you're doing it right. Your role model is getting all the stakeholders involved to sit around the table. I just got off a phone call with normal Northeast Georgia Trauma System. They successfully have completed their three year long pilot project to get school practice changed in the state of Georgia. And it was great sitting in that room with them virtually and listening to the progress they've made and how to go after this from a regional effort. It's been fantastic. Next slide.

And team efforts. We not just talking to your trauma surgeons, talk to your OB docs, talk to your nurses. If you want to make nurses lives easier at the hospital, tell them instead of counting up dozens and dozens of component therapy bags after an mtp, tell them I got you one thing, one product. It's going to be a lot easier to manage and we truly will be giving the patient what they need. You aren't going to be yelling at the blood bank to get stuff defrosted and sent to you. So you'll have great advocates if you get the nurses on board. Blood vendors again, I can talk to you later on or some of you offline about how to get them on your side and surrounding agencies coordinate with air and ground. We need to make it a continuum of care. Give it by ground. Helicopter gives it, hospital gives it. We've had great successes doing that. Law enforcement opening up that aperture to them. I worked with the Texas Rangers. It was really super cool. I'm still waiting for my big white hat and my badge. But they're the first tactical ems. They're doing high risk missions way out on the border and we set them up with a program where they use two units of cold stored whole blood. If they go through that, then they start doing drawing from the folks on the scene to do fresh whole blood until they can get them transported to a higher level of care. So a lot of options. Bottom line, prehospital blood as a team sport has much better outcomes. Next slide.

And then this is the time when we need to come together and start figuring out a way to systematically start removing the barriers. So part of this group, the prehospital Blood transfusion reimbursement working group, this should knock your socks off. We've got American association of Blood Bankers America, America's Blood Blood Center. We've got very great clinicians. We have some industry folks that are coming Together to start lobbying Congress to start getting some of this reimbursement for blood costs, blood products. Look at scope of practice and increase the awareness of broad applicability of this. Our rural facilities, our rural patients need it. All different patients that this is just not about trauma. So really want to put together, if anybody knows of any other efforts going on to lobby for changes, please let me know because I really want to start getting everybody assembled and going in the right direction. And I think that's where we're going to start seeing some change. Next slide.

And this will be the last one. So I'm not, I'm not smart, I'm just a soldier. I just know Alexa, it's not a life saving intervention. It's an exercise in futility and frustration. So there's my.

Four minutes over. Is that okay?

That was amazing. Well, Randy, listen, thank you so much. I mean clearly your service did not end on the battlefield. You are, you have done incredible work. This collaboration that really I think is probably going to center around your work is very critical. You're right. We have to have everyone at the table. I spent, I spent two hours yesterday with one of the fathers who lost a child of Parkland, actually went to elementary school with him. So I've known him for quite a long time. He has the ear of the President, he has the ear of senators. And he said to me outright yesterday, Pete, what can I do? How can I help? So what I'm going to do is I'm going to speak to you offline and I'm going to see if we can make some connections there. But it's clear that this wave has started. You started it, but we're going to need you to continue to help us move it forward. There were so many great points you dropped here in this just the past 30 minutes that I had no idea about. I know there's a lot of people on the call who probably want to make some comments. How can they contact you.

If they want to get in touch with you? Or should I just type your email into the chat?

If you could type my email into the chat, that's great.

Okay, I'll do that here in a second and then let me just do that real quick. And we're going to be going over to Paul's webinar, if that's okay.

Absolutely.

Let me just do this and I'll put it right there. Paste. Okay, there it is. So we gotcha. Thank you so much, Randy. I'm sure we'll be connecting offline and sorry we don't have time for any other questions, unfortunately. But thank you so much for doing this today.

All right. Thank you. Please reach out if any of you all have questions. We'll talk to you soon.

All right, Excellent. Thank you. And, Angus, if you can take us away.