Prehospital Blood - Dr. Antevy

Hi, I'm Dr. Peter Untievi, and this is Critical Levels. EMA's captain says, Stop. We drill the IO, we squeeze in a 500cc bag of whole blood. Literally in like three minutes, the guy wakes up and he says, give me more.

Hello, everyone, and welcome back to another episode of Critical Levels. As always, I'm Zach Canter and thanks to Zoell Medical for their ongoing support and thank you to all of you for listening. Today we're going to talk about pre hospital blood, why it matters, how it's administered, and the logistics of getting it to the right patient at the right time. We're also going to touch on blood adjuncts like TXA and calcium, and discuss some key challenges. Very, very excited and privileged to be sharing the mic today with Dr. Peter Anteby. Dr. Anteby, thank you very much for being here.

Great to be here, Zach. Thanks for having me.

Absolutely. So maybe before we jump into talking about blood today, maybe a little background about who you are and why you've sort of chosen this niche of pre hospital care.

Yeah, I'm still trying to figure out who I am, but what you want.

To be when you grow up.

Exactly. So my name is Peter Anteby. I reside here in South Florida. Left for many years, I was in Los Angeles, did my pediatric training there, went to Pittsburgh, did my pediatric EM fellowship there, and then came back to South Florida. All along, both in LA and in Pittsburgh, what I didn't realize I was doing, I was flying on the helicopter, I was in the back of the ambulances, and I love to be in the trauma bay and I love to be in the emergency department. And as I started progressing through my career, landed myself back in South Florida, I quickly realized that there were some EMS issues. So I just started on my own time, myself and a nurse who I'm still very close with today, Maricar, we would just go to the firehouses and start training and training and we were having so much fun. And one day someone called me up and said, they want you to be their medical director. And I said, I'm just a pediatric guy. And they said, no, no, you should still apply. So, long story short, they hired me as their medical director. This is before even EMS was a specialty and it was the best thing that ever happened to me. Let me tell you, because I love the people. I love the fact that they want the right thing for the patient and there's no red tape. And in Florida, where it's a delegated practice state, which means that, you know, there are Some rules that you have to abide by, but pretty much it's what the medical director wants to do, you can do. Now I have to convince everybody to do it. But. So started off with one agency, ended up with a number of other agencies, and now I'm pretty much full time ems. And I'm in, you know, the very large systems. You know, one agency that has about 1700 paramedics, another one that has 500, and then a few other ones that have probably in the 190 to 200 range, a large private ambulance service, we have, we have helicopters. So we kind of do it all. And it's really the best freaking job in the world because you get to make an impact on an entire population just by having a great protocol that's evidence based. You could do lots of research, have a great CQI program and training, and all of a sudden you have really this recipe for saving a lot of lives across every single age category, across every type of disease. And it really gives the opportunity, I think it's the one specialty that allows you to challenge what's going on in the rest of health care, which are a bunch of sheep who are somewhere off feeding because the grass is greener over there. But the real answer is over there. That's why I love ems.

Yeah, that's a really great perspective. It's kind of neat, you know, the, the jack of all trades. I think that's what, what I like about it too. In your shift, you can see someone that's one minute old all the way to a hundred years old, and you're expected to sort of be an expert in that whole spectrum. A trauma patient, a medical patient. It is very cool. So, speaking of trauma, we know that trauma is a leading cause of death, and it seems that we've been treating this in the same way for dozens of years. Two large bore IVs running your crystalloids wide open for an actively hemorrhaging patient. And we know this is just ridiculous.

Even when studies come out, Zach, that suggest that we should do something different for trauma, people don't even heed that research. And I'll give you a perfect example before we get to the blood part, which is tbi, right? You had the EPIC for TBI trial, which was published by the folks in Arizona, Ben Barbaro, Dan Spate, really legendary people. They spent years on that study. Probably seven or eight years, thousands, probably 20 something thousand patients, and they produced a paper three, four years ago now that should have had a big impact on traumatic brain injury. But as I traveled around the country, I realized that people aren't doing some of the basics for tbi, like, for example, avoiding hypotension, avoiding hypoxia, avoiding hyperventilation. Right. The three H bombs. And people have bad outcomes. So now, as we're going to be talking about here in a minute, we have something else that is very obvious, that is clear as day that it's working. And all the data is showing us that. And so I think this is going to be the one thing that people are going to say, hell, yeah, it works. We're going to do it. And I think it's going to happen really quickly.

Very cool. So what is that thing?

That thing is whole blood, my friend.

Okay, so before we get into that, why. Why do we want to use whole blood instead of our crystalloids?

Right? I mean, obviously, if, if you ask any, if you ask anyone, hey, if you're losing blood, what do you need? You need blood. And for many years, obviously in the civilian population, no one had ever figured that out logistically, regulatory wise. There were a lot of expenses that go along with. And we'll talk about that in a little bit. And you had this concept of the trauma hospital is right down the street. We had the golden hour. The golden hour. And it's very interesting how no one ever challenged that. And it's very similar to today. This is happening other places in health care. So, for example, sepsis, what do you do with a septic patient? You give them fluids and you give them a presser and then you get them to the hospital. And then what does the hospital have to do? Well, they have, you know, to give antibiotics within, you know, 60, 90 minutes type of thing. Well, why can't we do that? And the more you start to challenge the academics, what I realized is they don't even see EMS as like, it's not even in the rearview mirror. It's not even a blind spot because, like, it's like a really blind, blind area for them. They don't even recognize us as an entity that has any worth. I have a lot of friends who are working in the hospital and I love them, they're good people. But we are finally bringing the realization to the rest of the world that if it's a seconds to minutes issue, EMS has to be primary, period, end of story. And when that domino finally fell, and there's a lot of people to thank, the, you know, Randy Schaefers of the world, John Holcomb, Don Jenkins, C.J. winkler, all the folks in Texas, really military into the United States, into the civilian population. Once that flipped, it still took years for the other folks to say, is that really something that we can do? And to go back to your question, it's quite obvious that a hemorrhaging patient is going to die if they don't get blood. And when you look at the window of time that a hemorrhaging patient has, realistically you're looking at 15 minutes. You've seen it, I've seen it, we all know it. So once you bring that timeframe down to 15 minutes and we have let's say a six to eight minute time to the scene, then the action's happening within minutes of arrival to that patient and that's where the lives are being saved. So that's why blood is really, it's an EMS thing, period.

We're going to break into it in terms of trauma. I just want to circle back on this for just a moment. We know sort of it's the leading cause of death. I'm thinking accidents, falls, violence, firearms, NVCs. And so you're right, we have seen these patients bleed out right in front of us. And I think it's disheartening when you say there is an intervention that we can do to help these, these patients because it is that gap. There's a lot we can do in the pre hospital arena to help an acutely ill patient in front of us. This has always sort of been the gap for me is how do we do better. So you mentioned whole blood. What is in this might seem a little silly, but what is whole blood? What is it made of?

So whole blood is when you go down to the, you know, here we, we call it the big red bus. They come, it's basically the blood busts and you put your arm out and they throw a nice 14 or 18 into your right AC.

I'm diaphragm.

They're basically filling up a bag, right? They're basically filling up a bag of whole blood. It's the actual blood that comes out of your arm and it's got all the components and we can talk about component therapy in a minute, but it's got all the components. Instead of splitting those components out and separating them and using them separately, you're keeping them all in the same bag, plus all of the other thousands of proteins that are also being removed during that process. So all whole blood is basically, it's all of the ingredients in one bag rather than removing the ingredients separately and using them individually.

Okay. So that when you say that components, you mean plasma, red blood cells, that sort of thing.

And platelets.

And platelets. Okay. So you're a proponent of whole blood versus the component therapy.

Yeah. If you look at. In the military, back at the turn of the century, in the 1900s, they were doing this, right? They would have a soldier who was hemorrhaging in battle, one soldier next to him, they would basically take the blood out of this guy and then give it to that guy. Okay. They were doing that in the military long ago then. And I don't know the exact timing, people have written about this, but then someone came along and said, wait a minute, we can take that one bag. We could take it to the processing center. We could split out the three components. We get only the red cells. That's all we have in this bag. We have only platelets. And the platelets are usually pooled from you and me and that person. And there's multiple people pooling that platelet, so there's a risk to that. Right. And then you have the plasma. Now, each of those have a different shelf life, right? So let's say you have a patient who only needed red cells, let's say a patient who's on chemotherapy, and they're becoming anemic. They don't need all the other stuff. They just need the red cells. So in the hospital, you have patients who only need red cells, who only need platelets, who may only need plasma. So it's nice because instead of giving them whole blood, you're giving them the separated parts out. And you also get. If you're the person distributing those three components, you're actually charging more. So let's get down to the dollars and cents of medicine. Those three components are, can be sold to the hospitals at a higher price than the unit itself of whole blood.

Gotcha.

And so for years, that happened. So what did the folks in the trauma bay do? There were all these studies, and they're all online. You can go look them up where they then start to ask, at what ratio do you give a hemorrhaging trauma patient these components?

You hear one to one to one and all these different things.

And they did all this research on all this stuff, right? And the problem with one to one to one is that you have a patient who's bleeding out. They're in the trauma bay, the nurse runs in with the cooler, and now all of a sudden there's one iv and you're like, oh, God, what do I do now? So invariably, you're hanging up, let's say the PRBCs first. And then all of a sudden there's a big sheet of. And then someone starts another iv and all of a sudden you have all these different components hanging where all along, all along, all we ever needed, the entire time was whole blood. But nobody, for a long time, decades, ever thought to just get whole blood. These hospitals didn't even store it, they didn't stock it, they couldn't even buy it until this whole process happened, thanks to the folks in Texas. It's insane.

Very neat. So I'm, you know, hardly a paramedic these days and certainly not a hematologist, but you know, there's always this worry about a blood type. And in the hospital you can type these patients and sort of give them what's best, best appropriate for them pre hospitally. How do we get around that? And what is a blood type?

Yes, that's a great question. O negative is the universal donor. So if you're O negative, you basically have no antibodies, you don't have any antibodies to A or B and there's no Rh factor. So basically you're O negative. It's perfect. You can give it to anybody and they will not react for the most part. Right. The problem is only 7% of the population are O negative. So trying to get a blood program started where you're using whole blood, there's no way in the world that you could fill capacity. And by the way, before we get off on another tangent, that is a major issue now that all these EMS systems are getting online. We have to find more donors which we can get to. So they said, okay, O negative, we can't do. What can we do? Well, it turns out that people who are O positive, but they're low, tighter O positive, meaning that they don't have enough of the antigen to actually form a response by the person receiving that blood. And there's a titer that if it's below this titer, then it's called low titer. And once you're qualified as a low titer donor, then you're low titer forever. And you, Zach, or me, Peter, can be that donor in that community. So there are 40% of the population is O positive. Right. So now you have a much bigger pool of people. So once that domino fell, all of a sudden I was like, okay, we can actually do this. And the folks who started this thing, they had a really brilliant idea. They said, okay, let's test all of our frontline personnel, police, firefighters, anyone in public safety. And they had A pool of enough people where you get a text on your phone and it says, hey, Zadak, we need your blood. And when it's personalized, you come in and you say, yeah, and you hold your arm out. And the beauty of what they did, which I think really has to be done in order for this to work, is that if your unit of blood, Zach, was used on a patient, you get a text.

Oh, that's neat.

Yeah, you're gonna get a text that says, zach, congratulations. Your unit of blood was just administered to a patient.

That's cool.

So I guarantee you the next time you get that text, you're going to run. So it turns out their donors are donating every time they get the text that they're getting a massive response. So that's cool. Pick the O positive, low, tighter people, find them, connect them to the story, make them people who are either public safety, they work in the hospital. The reason I'm telling you all this is because there's no reason for even the most rural of environments. So our team just went to Alaska and they went to a rural location and they spoke to a bunch of military folks about doing exactly this. You don't have to be next to the large trauma center to actually get the low tatter O positive blood.

Very fascinating. Okay, so let's get into the meat and potatoes then, of trying to move this needle to try and save lives, to bring, you know, this huge, tremendous advance in pre hospital care to patients. So who, who do we give blood to pre hospitally?

Right. So you have to really have a protocol that spells all of these things out. The obvious ones are the acutely hemorrhaging trauma patient. That's number one, first and foremost. And most people will start with that. I think as we continue along, people will just encompass all the people, which we'll get to now in a minute. But when you have a trauma patient, obviously, and you mentioned that there could be blunt trauma, and that's really the biggest population that we have given blood to thus far is the MVAs. It's either blunt trauma, we can get to the traumatic arrest, which unfortunately the outcomes are. In our system, we have not had any survivors and we've given over 200 units total. So that's that one. The penetrating traumas actually do pretty well in our system. In other systems they may have different outcomes, but the knife and gun club, right? So look at New Orleans data, look at Washington DC's data. Looking at the San Antonio data, interestingly, their outcomes for penetrating were lower than the rest of ours. But again, there are some variables in there that we can discuss later.

There are a lot of people, especially the surgeons, if the surgeons are not on board, they're going to nitpick every time you give blood to a patient and they're going to start to Monday morning quarterback whether that patient really needed the blood or not. So, and I'm happy to share my protocol and you can link it if you would like. Protocol needs to include and blood pressures are typically what you'll see. Shock index is great. Some people use a modified shock index which use the map, so definitely use that. Also I would include in the protocol an end tidal value of less than 25. And why is that? Because if you think of the volume of circulating blood, if you decrease that volume of circulating blood from let's say, you know, 5 to 3.5, then it would seem reasonable that the amount of CO2 that is coming back around is less. It just, it's just a matter of volume. Right. And so a CO2 and this has been studied of less than 25 is a marker for hemorrhagic shock in the right patient.

And sorry, so a high shock index or hypotension end tidal. Are these ands or kind of any of the above?

That's a good question. We have the following. We have a systolic blood pressure below a certain threshold is all you need.

As a one with a mechanism.

Right? With a mechanism. If you have a systolic blood pressure that's higher but you have tachycardia, that's an and right. Now in the older population, we loosen up those vital sign parameters. We make it a little easier for you to give it to the 65 year old fall than the 35 year old fall with the same exact vital signs. And we also have a stipulation in there for people who aren't beta blockers.

Calcium channel as well.

No. So it's basically because the heart rate is going to be modified. That's kind of Right. So and then we have the end title is also listed in there. And again, I've looked at a lot of different protocols. Our protocol is pretty stringent. Some protocols are very loose and I worry about that a little bit and I think it needs to be studied a little bit better than. Because if you're a program and some programs right out of the gate were giving tons of blood right off the start. And I'm thinking to myself, why is that? Is it because the parameters are so wide open? So for example, I'm gonna give you the extreme situation here, you have somebody who has a cut finger.

Okay, right, I know what you're talking about.

And they had like they have one little, one little drop of blood, but they happen to be tachycardic. And you said ah, tachycardia, gave him blood. Look, look at that. We saved a life. Right, so. Right. So yeah, how are you going to know really what is the save rate that was really attributed to the blood? And the only way to do that is really to study this over time and to look at each case individually. And I think that if we pull all this information and we've started a registry thanks to the folks in Tulane, that over time it'll become much more clear that is it shock index, that's more important. Is it attack a cardia, Is it hypotension, is it end tidal? What is the most important parameter? We don't know that yet.

Right. But I think it's important to that we need to start considering these parameters in the context of a mechanism. And I don't know if we covered it or not. This applies to blunt and penetrating, Correct?

Same thing. Does this apply in our protocol to.

Is there any difference for the medical patient? Pph, GI bleed, varicose or a hemorrhage? Or hemorrhage.

Hemorrhage is a hemorrhage. The one thing there is a difference is our pediatric population. Obviously. Yeah, those vital signs are different. And so we have gone through every single age and we've attached the vital sign parameters for that age and we've plugged those in. And so when a patient is two years old then they have to fit these vital sign criteria. Those are all predetermined. I'm happy to share all of that with you.

Wonderful. Okay. We've been presented with a actively hemorrhaging medical blunt penetrating trauma patient who has some altered vital signs. Maybe they're uptunded, maybe they're tachycardic, hypotensive, end tidal. What we just talked about pre hospitally like you mentioned before, what we do is. Well I would say there's not a lot we do that's fast, but this is one of them and there are some very time critical interventions that we give. So I suspect when it comes to blood administration it's a Goldilocks effects too late and it's too late too early or is when do we give it?

Yeah, I think that with whole blood administration the when I would abut that question up to when do you do it in the sequence of things that you're going to do from the ATLS perspective.

Sure.

And so the important thing is as fast as possible, but it has to be before the airway. And that's the key part there. It's resuscitate before you intubate. And that's something that ATLS is now on board with because now they call it X, A, B, C, D, E. What is the X for? Exsanguination.

Kind of like your march, right?

And we've seen a number of cases. This is the cruelest thing where. So I'll give you a great case. We had a police officer. Him and his partner, they were on a traffic stop. I forget what it was, but all of a sudden they were being attacked by a dog. It's a pit bull. One officer, unfortunately, shoots the dog to save his partner's life. The bullet goes through the dog, it ricochets and comes right back into his partner's groin. And now this is around one or two o' clock in the morning. My agency gets called out. By the time my EMS captain gets there. So this is. The officer is in a Suburban. That's how we kind of. It's like a battalion by battalion thing. By the time he gets there, the guy is unconscious, still breathing on his own for now, but, you know, starting to. He's not looking so good. Very diaphoretic, pale. And my medic, who was already on scene, is getting ready to intubate. Now, listen, this guy's still alive, right? But if you think about the cardiac output status of this person right now, not that good. If you go ahead and you paralyze, the patient's gonna die. Then throw some positive pressure into them, they're dead right on the spot, 100%. So EMA's captain says, Stop. We drill the IO, we squeeze in, we have the life flow, and I'll get to the speed of administration. Very important. In a minute, we squeeze in a bag, a 500cc bag of whole blood, literally in like three minutes. The guy wakes up and he says, give me more. That's what he said. That's the first thing he said. And by the way, we have a number of patients who have said, whatever you gave me, just give me more.

Of that or that.

And that guy did not need to be intubated. That guy did not need an airway. He needed oxygen. I got a second unit, gets to the emergency department, to the trauma bay. Obviously. We had, you know, the C LOCs, we had the pressure bandage. We had, you know, pressure on the groin. That Was done very nicely. Gets up to the or, the surgeon's a good friend of mine. Right. We go to dinner every couple months and he tells me a story later and he says, you wouldn't believe. I get into that patient's groin. He's like there was nothing to fix. He says basically like all the bleeding had pretty much stopped already and this guy didn't have to get intubated and he didn't really need much in the way of OR at all. He didn't need any blood in the hospital and the surgeon's job was a lot easier. So that speed of when to give it, I really think it has to be given within 15 minutes. There's studies in the military that show the exact same thing. That's really the ideal window of blood administration is within 15 minutes.

And I think I've read some stuff out there. Maybe you could correct me that, what every minute delay or something is a 10% ish.

11. 11%. That was the New Orleans data. Du Chesney and Dr. Marino and Mark Peel. Correct.

So what is it for every minute.

Delay there's an 11% reduction in survival.

Okay. So obviously that would go in line of there is a too late is too late. What about that patient arrest? Yeah.

What we've noticed with our data and there have been a few patients not in our system, but there have been a few patients in other systems like here and there that once a cardiac arrest has occurred, they were able to get them back. But that seems to be the problem. Once they go into cardiac arrest, then you're really behind the eight ball. And it's very difficult to get those patients back. And those survival statistics of the post arrest blood transfusions, still very low, I'm sure.

Yeah. That asystolic traumatic patient, no matter how much blood you give them, they're not going to come back.

Correct.

And like you mentioned, that golden hour that's been sort of thrown out the window, you could live right next to. You could be in the trauma center. And it's.

This is an important topic because this is the one big thing that if you live in a big city, you will hear this from the surgeon, which is worried right down the street. New Orleans just completely disproved that. What they did was they looked at how much time, how many minutes it took after you arrived at the trauma bay to actually get blood infused into you. I don't know the exact number, but something like 19 minutes. So if you take the 19 minutes and then you add the additional pre hospital time that you're on scene. And for a lot of agencies, that's in my part of town here where I live, our scene time to the hospital is about 18 minutes. So you end up having an issue if you're over 30 minutes and you're expecting it to happen at the hospital. So that whole story of we're right next to the hospital, that does not hold any water.

You and I, our systems are tremendously different. But the same thing would ring true here, which is just fascinating. Same, same, but different.

Yeah.

So there we go. We know who to give it to, we know when to give it, how do we give it. So you've mentioned IO, can this be given iv, does size matter?

Yeah, absolutely. So the very interesting part about this whole thing is that if you think about the gauge of the IV that you're going to give, we all know that the IO is a 15. Most people are probably going to put an 18 or, you know, 16, 14, whatever in that patient. There's a device that was created and I don't have any conflicts. I wish I did, but he's become a good friend of mine. Mark Peel, called the Life Flow. And there's a couple cool things about this device. Number one is every time you squeeze it, it's 10ml, so you know how much you're giving it, especially if it's a kid. The second thing is that you could really almost invert that unit of blood within, let's say, three to four minutes, depending on the size of the gauge of the iv. Something that they don't talk about enough is that let's say you only have a 22 gauge or a 20 gauge, right? And you're trying to squeeze this in and you're going to blow the vein. What they did, which is really brilliant from a mechanical engineering perspective, is that along the tubing they added a piece which is about, I don't know, like maybe like 10 inches long, where it basically absorbs all of that additional pressure so that no matter what gauge IV you have downstream, it's not going to give that IV so much pressure that you're going to blow the vein. So whether you get an IO, whether you get an iv, the one thing that all of us would agree upon is that you have to get it in quickly. And this is really a hand driven device. I think that's the one piece of equipment that you really need to have in the EMS environment. We also have added a warmer. A lot of people in the United States are using a device called the Q and Flow, which is called quality inflow. And a very simple machine hook it up and basically, as the blood goes across this little, like, aluminum. I think it's an aluminum type structure that's inside. It comes out of body temperature.

Okay.

And it happens within a second or two.

That's the idea. You just don't want to give cold fluids to a hypothermic patient.

It is but. Here's the but in New Orleans, because they had some budgetary issues and they didn't have a warmer. And by the way, New Orleans, also because of their distributor, they can only get packed red cells. So New Orleans is using cold packed red cells, and they found no difference. So take that with a grain of salt.

Sure.

So I'm not really sure what that really means, but in the ideal situation, we all know that cold temperatures are bad for trauma patients.

Okay? So we want to give this fast. So it's obviously a bolus versus a drip. We want to give it through. Ideally, the biggest. What I'm hearing the biggest size catheter you can then. But I heard this old adage, you know, 22 in the hand is better than a 16 in the garbage. So I suspect same thing here. If that's all you can get, we can make it work. We want to warm it up, but how do we get it to the patient? What does that cold chain management look like? You know, does every ambulance have it? Is it only a specialty team that has it? Do you put it with supervisors? Obviously, every system is going to be different, But I'm just curious how you actually get it patient side.

Now you're talking logistics. And I suck at logistics, let me tell you right now. So that's why I don't. I'm not the logistics guy. But I will tell you that if you have people who are really good at logistics, and it turns out that in fire departments, that's what they're. They're logistics. So these things don't bother them. But there is a chain, a cold chain storage thing that has to happen. Number one, there also has to be a documentation chain that has to be very accurate. Because if you think about it, usually the blood distributor sells to the hospital, and then the hospital gives to the patient. Very simple. So if you're a blood banker, you know exactly where that blood has been. You know exactly the temperature it's been stored at. You're the one who sent it downstairs. And when it was given, they took out the scanner at the hospital, the whole chain of custody, they scanned it. Everybody knows what's Going on here. What happened is pretty funny. We have a guy in a Toyota Prius who drives in.

I like the siren.

Yeah. The guy basically shows up to one of our fire stations. He has no idea where he is, and I don't think he even knows what he's doing. But the guy comes from this distributor and he says here. And then he hands some papers to our medic or the captain. Now everything's on paper. Here we go. We're on paper now. And as you know, the blood has all these barcodes on it, and we don't have a barcode scanner. We need to. And the folks in Texas are doing it. So all that's going to catch up. Industry will catch up to this whole thing. But now one blood who's at our distributor. The only way that they know that the blood is at our station is when they get the paper back. Incredible, right? And so now we're completely on paper. Now that blood then goes into our fridge. So we have a fridge, you know, cheap Amazon fridge. You don't have to buy anything expensive that sits at the station. And then comes the cooler. So back in the day, all there was was a pelican credo. It's a credo cooler. It's about 600 bucks. And there was no temperature monitor in there, so we had to purchase something called the temp stick, which is Bluetooth. Because the blood folks, the one thing they want to know is that blood has been in temperature range, right? And so we put the temperature stick inside the credo. We put the blood in the credo. There's also a little dot that gets activated once the blood is at temperature. And if it ever leaves temperature, it actually changes color. So if the blood has changes color, that's how you know. But everybody wants to know that that unit of blood was kept at temperature. So now you have to have a way of sending those logs back to one blood to show. Hey, Warren. Compliance. There's a new company which is really taking over the market called Delta Development. They've made something called the Delta Ice 2L, I believe it's called, where it's on the. The cooler. They have their own app. You can give access to the blood distribution, folks. So everyone's in the loop. Slowly but surely, we're taking care of that. Now, that blood is now sitting in the back of our Suburban, which is with the EMS captain who controls one battalion. They get called out to specific call types, right? Or they can be called out by the treating medic on the scene, say, hey, I Need blood. And then the EMS captain goes out there, right? That blood now is being administered. And now it's again, more of a paperwork nightmare because now you have paper in triplicate. And a lot of these younger medics, they had no idea what a triplicate paper is.

And they're filling out all three pages. Perfect. Very, very funny stuff. But so all that has to be fixed again. The San Antonio folks have created an app. The people in Washington, D.C. holy cow. Dr. Vitberg and Holly O', Byrne, the lieutenant there, they have figured it out. They use ArcGIS and they have the whole thing all automated. So logistically speaking, you have to be able to track the blood. If you waste the blood, if you transfer the blood, if you give the blood, you have to have a way of documenting that entire path. And that has been in cold storage.

The entire time and then heated up patient side to give it in. So this is, you know, the more I, I hear from this, this is tremendously complex, which, to be honest with you, I was expecting. I wasn't expecting this to be a run of the mill thing, but the gears are turning within me. What does that training, that initial and ongoing training look like for these paramedics? There's a lot happening here just in terms of. Yeah, like you said, the logistics, but even backtracking the patient selection.

Yeah, you're right. We have done extensive training because we're fortunate the way we are structured. We have 30 EMS captains in this agency that has, let's say, 1600, 1700 people. So we're not training up that many people. Our EMS captains in Palm Beach County Fire Rescue are the cream of the crop. They're like the doctor. That's how good they are. They're better than doctors, in my opinion. They know how to do ultrasound. They do finger thoracostomy. They can do it. All right, so we brought them in. We had, you know, a training session that we did with them. And initially, you're right, it sounds complicated, it seems complicated. But once you do it, once you're like, this is just another medication. So honestly, people do get scared by these hurdles. You have to go over regulatory, financial, legal training, cqi, all this other stuff. But at the end of the day, all it is is another medication that you're just hooking up to an IV and administering. Think about that.

That's simple. So there's ongoing training, too.

It becomes that simple.

Yeah, I guess when you boil it.

Down, it honestly becomes that simple.

Yeah, when you boil it down, you're right. It is just on the medication there. Obviously there's an ongoing training as well with this or it's kind of once you've done it, you've done it.

Yeah, I mean, this is something that we happen to train a lot of other people. And so the team that I have, and we'll be at EMS World this coming week and we do an entire live demonstration of the blood. And I put this on the Internet, I have some YouTube videos on it. But the team that we have, we do so much training and teaching that we have really become very adept at doing this and teaching others. And I can tell you the biggest benefit that we never even realized is that had people who are going to retire, they're like this EMS thing, I've been doing it for 25 years. These people do not want to retire anymore because it's trail. Seeing somebody coming back to life right in front of your face is something that is magical and it's like, it's almost like a dopamine hit and they want it over and over again. It's incredible.

Yeah, I find it interesting too. By the sounds of it, you're sort of tackling rural, urban, large services, small services. This seems to be able to be operationalized quite generally.

I do a webinar every Friday and my last webinar was a guy named Jeff Hayes. He's the deputy medical director at Wilkes county ems. It's a rural place in North Carolina. And he just gave a beautiful presentation about how they have put up a program, not two, three years, and they have so many saves and I just give them so much credit. And it's probably gotten some of the most views I've ever had on a YouTube presentation. Why? Because people out there are thinking there's no way I can do it. But it's not that hard if you get the right people around the table. So what they did, they went to their local trauma center and said, can you help us get the blood? Yeah, here you go, we'll give you the blood. Can you swap the blood back out? Which I didn't talk about. Very important. If you don't have a swap out program, you may see wastage rates of.

40% swap up being as you come to the expiry, you bring it back to the hospital so they could use it type deal?

Correct. So, for example, if the blood expires in 21 days at day 14, you bring it back to the hospital and they'll use it in the ICU and they'll use it for trauma patients. They'll use it for surgeries they'll find will be used. Here in South Florida, we still haven't figured out the expiration swap thing yet. It's almost done, but we have wastage, they don't have wastage. So they're in a rural town, they have essentially no waste, it's being paid for because the hospital they work with is actually providing them the blood. And like I mentioned earlier, even if you didn't have that and you got creative and you started testing your public safety, your nurses, your doctors, and you had a heroes in arms like San Antonio and you have the local people donating and now all that blood, whole blood is sitting there, EMS comes around, open up the cooler, put it in, and now you have that local hospital blood bank managing the entire program. Now the blood is not costing you any money, but again, you have to have all the other stuff done. This is not for agencies that, that can't afford it. You're going to have to go to your city commission, you're going to have to get grants, you're going to have to, hopefully the federal government here in America, they're now going to cms and CMS is going to give a little extra if you, if you are using a blood product is what we hope that they end up doing. But for now, just to let everyone, all of your listeners know in America, my town, we will bill you $800 for, you know, an ALS type transport. We will only collect half of that $400. And the blood, every time we give a patient blood is costing us $1,000, $600 for the blood or so, plus another $400 for all the accoutrements. Right. The life flow and the Q and flow and all the other stuff that you need. And so this is a losing proposition, but we're saving a whole lot of lives.

Yeah, we'll get to that in a moment. So lots of challenges by the sound of it. And you know, challenges aren't supposed to scare people, but just something to overcome. So how do you overcome, you know, patient consent, religious objections, the potential of giving whole blood to females of childbearing age?

Great questions. I think that you have to have in your protocol these items and I can share with you protocols that do have them. The New Orleans one is very good because you have, for example, Jehovah's Witness that, that population, they don't want blood. Right. We even had a medic who worked for us who was Jehovah's Witness. He didn't even want to administer the Blood.

Okay.

Right. So we do have that stipulation that if possible, try to get consent. Right. We haven't gotten to that point where we've had an issue with it, but that aspect of the protocol probably needs to be looked at. And you may want to go and talk to the folks in the community, the leaders, let's say, the Jehovah's Witness folks in the community talk about that. You definitely want to announce to the community what's going on. You should definitely have news stories, print newspaper, online stories that, hey, our community now has whole blood just so that the dialogue is there and people understand that that's a possibility. I definitely think that's, that's that. The other question you asked with respect to females of childbearing age, another very important consideration for those people who, who want to understand why that's a concern.

Yeah.

Is because you have to remember we're giving this O positive blood if you're a woman who's getting O positive. The problem is, is that if you have a child that you're going to have in the future, sometime or another who's O positive and the mother has antibodies against that O positive blood, those antibodies cross the placenta and can kill the baby. So you have an O negative mother who received this low tyre O positive blood, not a big deal, except that her body is now making antibodies against that positive antigen. Those antibodies remain in her system.

And then years later she has a baby. The husband happens to be O positive, so now the baby, even though the mother may be negative, the father was positive, so now the baby is positive. So now you have a mother who has antibodies that were built up from the blood transfusion. Now those antibodies cross the placenta, get into the baby and then cause a pretty severe hemolytic anemia and can cause death. Therefore, if you have a mother who you know is Rh negative, it's very simple. And that mother got a blood transfusion, that mother needs to get treated to get rid of all those antibodies that were created. There's this Rhogam, which is the IM version. There's an IV version of RhoGam. I don't know what the brand name for that is, but it's not that complicated. It's just that if you're going to get low tatter O positive whole blood and you're a female of childbearing age, someone at some point has to give you Rhogam or the IV form of Rhogam to be sure that you won't have any problems later down the Line.

Wonderful. Later problem, worry about the saving life in front of you. We'll figure out that later.

Correct. Paper written by an ethicist recently. Great paper that basically said, what is the right thing to do here? I think they had interviewed some people and they asked women, hey, what would you want if it was you? And they say, well, I wouldn't want.

To be alive to even have the option to have a child.

Correct.

There you go. Okay. One thing that we haven't quite yet touched on, transfusion reactions.

Yeah.

Is that very common. How do you monitor for it? You're giving the blood.

Right. So I had never heard of a transfusion reaction in EMS until the webinar I did on Friday with Jeff.

Oh, okay.

Where they apparently have had two. You know, there are transfusion reactions people may get. And if people want to look up trali T R A L I, and it's basically an acute reaction to the administration of blood, they get significant pulmonary edema. It could be turned around rather quickly. But again, that is something that can happen and it's something that has to be addressed when it does happen, to my knowledge. And again, the patients who did have those true reactions, according to Jeff's webinar the other day, they both did fine. But there is a small risk there that needs to be appreciated.

And is it just monitoring temperatures or is there a little bit more to it? I'm not so familiar.

Oh, no. As far as the reaction itself.

Yeah. Or just even seen if. Seeing if it's happening.

Yeah. I mean, you will see some clinical issues with trolley. It's not quite a thing. They have significant respiratory distress, pulmonary edema, hypoxia, they need positive pressure, they need normal saline in that particular case, believe it or not. But yeah, it's. It's not something that's subtle, let's put it that way.

Fair enough, fair enough.

So you have to remember it's a. It's an immune reaction. Right. So it's an immune reaction like any other immune reaction. So it just has to be treated appropriately. The TRALI would be the big one. But again, we have not seen that yet, but we've only given a couple hundred units.

Very interesting. When it comes to the management of the trauma patient, there's a lot more to do as well. Like we've sort of covered, you know, I'm thinking applying a tourniquet, a pelvic minor hypothermia management, all of these other interventions that need to happen. But when it comes to blood administration, are there any adjuncts that you're going to include, I'm thinking here, calcium taxa as sort of a robust package.

Yes. I will start with the txa. Many people are familiar with the data on txa. The reason that it got a patchy start, and there's still some people who don't believe in it, is because when you look at the data, EXA only provides a very small benefit, like, let's say, 2%. In order to find a 2% benefit, you need to have studies that have tens of thousands of patients, and those studies did. Right. The problem is, is that the way TXA was being administered was initially a gram plus another gram. Right. So you give the first gram over 10 minutes and then you give the next gram over eight hours. Right. But it turns out that the further you are away from the initial bleed, once you start to go past three hours, it turns out that TXA may be harmful. So when you look at some of the more recent studies and some of the military data, and you look at TXA given within the first hour, that's where you see the greatest benefit. And then people said, maybe we shouldn't be giving one plus one, maybe we should be given two. And instead of giving it over 10 minutes, maybe we should get over just a couple of minutes, or maybe we should even push it, or maybe we should even give it intramuscular. So many of us think whether we're right or wrong, you know, this is kind of what the data is looking like. It should be 2 grams up front. So what we do is we put the 2 grams into a 50 bag, 60 drops, set wide open, and basically that just gets it in within a couple of minutes. So I think that most people have kind of hopped on that train, on the TXA train, because that's fair, done, it's cheap, it's easy, and there's really no downside to it. So it's only going to give you a small benefit. Maybe this new pattern, this new protocol, will give us a little bit bigger benefit. But we're not talking massive benefit now. Let's go to the calcium. This has been a very big question mark. Many people know that there's citrate in the blood bag to prevent the blood from clotting. It turns out that there's four times the amount of citrate in a packed red cell bag than there is in a whole blood bag. So if you give packed red cells and New Orleans is giving two units of packed red cells, and how much is a unit? So packed red cells are about 300 350. A unit of whole blood is 500.

Gotcha.

Let's say pack red cell, just for sake, we'll say it's 250. So that's why New Orleans gives two units of packed cells, which is the equivalent in volume of one unit of whole blood as a volume, but they're giving a much higher amount of citrate. So if you're going to be giving pack red cells, when you give that citrate that's in the packed red cells, you're going to drop the patient's calcium significantly more than just a unit of whole blood. That being said, there's a lot of data coming out really as we speak. There's studies going on right now, but most people believe now that you should be giving calcium early. And sure, more data is going to come out and we're going to know more about it. But what we decided to do, we just added this to our protocol, is a gram of calcium chloride. The problem with calcium chloride, as many people know, is that if, if it extravagates, you're going to cause yourself a big problem. So what we decided to do is we decided to actually give that calcium and we put it into a 50 bag. It's the same thing, 60 drop set. And we give it so that we actually dilute it and it doesn't cause a problem.

Gotcha.

Let me time out real quick. Let me hold on one second.

No problem.

So the calcium perspective, I see the world moving towards calcium. The other option is calcium gluconate. It's a 3 to 1, right? So for every gram you give of calcium gluconate of calcium chloride, Sorry, you have to give 3 of calcium gluconate. So then there are people who are saying now I gotta buy three of these things. How come I can't just give this one thing? So some people are only giving one of gluconate. It's a little hodgepodgey. Right now. I think the way to answer the question is to determine what's the calcium level in the field? What is the calcium level maybe after or even before you give the blood, what is the calcium level after you give the blood? Or what is the calcium level in the emergency department? All those things are gonna be hard to do in the field. So there are studies now looking at what is the original calcium concentration on arrival to the emergency department. Also consider that trauma in and of itself. Nice papers being written on this, and there's some old data on this that the trauma in and of itself causes Hypocalcemia and you had mentioned Goldilocks earlier, it turns out that hypocalcemia, bad, hypercalcemia, bad. So the calcium level has to be just right for the patient to have a good outcome, for the heart to be happy, for the vessels to be happy. So I'm not sure where all this is going to go, but we've decided on 1 gram calcium chloride, not too fast, over, let's say three to five minutes after, not before the unit of blood has been given.

There you go. And that's something I forgot to ask you earlier. How much blood are you giving? Are you titrating to effect? Are you just. It's. Here's your.

So it's either one unit or two. For the adult, it's either 10cc per kilo and then repeat 10ccs per kilo for the kid. And basically what we've noticed, we have majority of our patients have received one unit. We have about 15 cases that have received two units. Take this with a grain of salt. But all the patients who receive two units are all alive.

And so the question is going to become which patients need a unit versus which patients need two units. And again, I think that you have to keep evaluating your patient. Obviously, try to stop the bleed, use adjuncts. We're actually now looking at riboa in the field, obviously the junctional tourniquet. You talk about pelvic binders, you talk about stopping extremity hemorrhage. All those things are important. But, you know, if it's the extremity hemorrhage, it's pretty simple. If it's a blunt trauma, there's internal bleeding, retroperitoneal bleeding, et cetera. Those are harder because you could pool a whole lot of blood in the abdomen. And so the GI bleeders may need more blood. So I think mostly you'll need just one. And then a smaller segment will need two.

Interesting. So still lots of questions out there, which is great. That's how, that's how we move this forward.

But.

So you've been using this how long in your system and what have you found?

July 2022, we started. We've given over 200 units. We have just shy of a 90% survival if the patient received the blood before the cardiac arrest. All the patients, like I mentioned, who received their blood after the cardiac arrest did not make it. A few of them made it to the hospital. A few died in the operating room, A few died in the icu. But to have, and I was looking at the Washington, D.C. numbers, they've given, as of the most recent numbers, 110 units. And they just started a few months ago, by the way, maybe, maybe six months ago, they've given 110 units and they have a 90 plus survival and they publish every month. It's, I mean, these folks are the darling of the industry because they're just, they're so freaking smart and they're being very transparent. This PDF is available to anyone. They post it on the web and on the PDF they have all of their data and they have every case, case number, you know, 55, 36 year old who fell on glass and he tore his brachial artery and you know, they give you all the information. It's insane.

Fascinating.

It's clear as day, clear as day that all the haters out there, and there are haters out there, they're going to be overwhelmed by a tsunami of data and patients and people who want this thing. Because it's obvious that it works, that I predict within the next five years, everybody listening to this podcast will have a blood product. You may not have whole blood, but you will have liquid plasma. Freeze dried plasmas coming down the pike. We're actually just starting a study now for liquid plasma for TBI patients and the elderly. We're going to be doing at some point plasma for sepsis and plasma only costs 60 bucks. That's it.

Peanuts.

It's peanuts. It's peanuts. If it's going to. Listen, if you're in septic shock, you have a 40% mortality rate. What if plasma reduces that by half? You're not going to. Of course you're going to do it and you're going to pay the 60 bucks all day long.

Sure will.

And so blood products are here, they're here to stay, and they're going to change trauma care forever.

What a great statement to end this on. Before I cut you loose, is there anything else we want to cover that you think we've missed?

I want to thank you for bringing this to the forefront. You mentioned it several times, but there's a lot we don't know. I know we all sound very confident, but trust me, we're continuously looking at our data. We have a very, very significant CQI program. We have a big research team now. We're connected with other people. So the one message I will leave your audience is start a coalition. You know, you're in Ottawa, you should start the, you know, the Ottawa Whole Blood Coalition and then connect with other coalitions. So we started the Florida Blood Coalition. North Carolina has a coalition. Now there's a national coalition. And the reason I say that is because we've already done all this stuff. We have the SOGs, we have the protocols, we have the videos. We can tell you what to buy, we can tell you how much it costs, we can tell you who to talk to. We have the blood registry. We can tell you what metrics to look for at the trauma center. Don't do all that stuff over again. We'll just give it to you. It's called R and D. Rip off and duplicate. And we will help you.

Thank you. That wraps up our conversation about pre prehospital blood with Dr. Peter Antevi. Thanks again to Peter for sharing his expertise, guidance and real world experience. And thanks again to all of you for listening. We have tons of resources available on the website and I'd encourage you to take a look if you want to learn more about this. Criticallevels CA. Now, Dr. Antevi scratched the surface on TXA, but next week we're going to release a little micro episode covering everything else you need to know about TXA with Dr. Eric Vu. If you have any consternation or outstanding questions about txa, you'll definitely want to tune in to this one. It is short and sweet. In the meantime, we will see you there soon. Happy Holidays, Happy New Year and stay safe out there for critical levels. I'm Zach Ander.