Summer, Bloody Summer

The content of this podcast is based on medical fact and evidence based practice from credible authoritative sources, but is not a substitute for your institution's policies, procedures, common sense or good judgment. The views and opinions are those of Eric Bauer and Flight Bridge Ed in their entirety.

This is the Flight Bridge Ed podcast. Critical care and emergency medicine education for nurses and paramedics.

Everybody.

Eric, back with you today. I'm excited to have a good friend of mine, Peter Antivi, on the show. How are you doing, man?

Eric, great to be with you always.

How are you?

I'm good, I'm good. How's your summer going so far?

Summer's going great. I'm up here at my kids camp playing Camp Dr. Nice and got about 600 kids to look after and they get hurt, let's put it that way.

Well, I appreciate you taking the time. You know, we've wanted to talk about this for quite some time and there's definitely a lot of evidence, a lot of great evidence with a focus on pre hospital hemorrhage control, but really early blood product administration. And I know you really have been leading the way around the country in pushing this, especially in your area. And I think, I think I definitely see that it is making a difference across the United States. So I definitely wanted to talk about how you have went about implementing blood product administration, what you're using at your fire departments, your agencies, and then we'll expand the conversation into resuscitation and airway management. Perfect.

Well, first of all, I have to say that, you know, you can't really give me that much credit. I'm like the guy at the outside of the circus who's trying to tell people to come into the tent.

Okay, that's me.

And I wish I was.

Yeah, listen, I wish I was as.

Smart as those people, but I. It's funny, I had the opportunity at a conference a few weeks ago to, to moderate a panel and I called the panel the OGs of whole blood. And I had on that panel Don Jenkins from Texas, San Antonio area, John Holcomb, obviously, you know, he's in Alabama, but a very highly esteemed surgeon, Eric bank, who's EMS chief, HSD48. And he, he had the first civilian blood administration in a ground ambulance. So that was pretty cool. Randy Schaefer, another military person who really was the one who orchestrated the first blood in the air rescue and then into San Antonio.

And it was just.

We also had Holly o' Byrne, who's like the newest generation of wicked smart people. She's a lieutenant in Washington, D.C. and I can tell you they didn't record the session. I wish they would have, but it was almost very surreal. And the reason I wanted to mention this at the outset is because when you do, you know, the, the actual work and you look at how this all came about, you have to go back till, you know, the 2014, 2015 time frame where Phil Spinella, Don Jenkins, John Holcomb, they were trying to figure out how to get the military knowledge into the civilian population. And here we are now 2025, by 10 years later, and you still only have about 1% of ALS systems in this country carry whole blood. So when you look at the translation of the military medicine, or even bench research into civilian. Into the civilian medicine at scale, it takes a long time. But these folks, the reason that they're pushing so hard is because they've seen it. They watched our military personnel die in their arms, and they're not taking no for an answer. So just to kind of go back to your question, right around 2018 is when San Antonio fire, the ground service was up and running. And then they said, hey, come to San Antonio. We'll teach you how to do it. So of course I sent my team, they spent three days there, and basically, you know, R and D, everything ripped off and duplicated. San Antonio said, open arms, take what you need. And we did 20. It took from 2019 to July of 2022 until we ended up getting whole blood up and running in Palm Beach County. And that's because of all of the hurdles and all the legal stuff and the red tape and the purchasing and the contracting, etc. Then you have to fight the surgeons who didn't know what we were doing. But make a long story short, Eric, I could tell you that. And again, I'm giving all the credit to Chief Charlie Coyle, who really was there at the time leading the charge.

And now we have just so many.

People at Palm beach county who are really experts at whole blood. And now Since July of 2022 up to today, so we're July now. So it's exactly three years. We've given around 300 units of blood, which sounds like a lot, but when you look at the other systems, Washington, dc, Atlanta, I'll point those two out because they came out like guns a blazing. Why? Because they have a much higher violence rate, number one. And so Holly O' Byrne just put out on the Internet from D.C. that they've given now their 300th unit of blood within about a year, probably a year's time where it's taken us three years to give that same amount. Atlanta, within their first year had already given 400 units of whole blood.

So.

Now as far as just overall big picture, so people are listening, can understand that every system that we have seen so far that has rolled out whole blood has these exact same statistics in the same range. And I'll give you the range that if you are hemorrhaging, whether it's from medical, you know, OB trauma, and you have not gone into cardiac arrest yet, but you qualify for whole blood, meaning your vital signs are abnormal, whether it be heart rate, whether it be blood pressure, whether it be end Tidal, CO2, those are kind of the key ones. Shock index, your chance of survival, 24 hour survival, which again for most people probably know this. But if you make it after your trauma to 24 hours alive, you're probably going to live. And that's been shown in the military and so forth. But the 24 hour survival hovers around 90% for all those cases. If you, if you throw in the people who are in cardiac arrest and you roll up on the scene and you say, hey, hemorrhage, let's get an IO in, let's, you know, use the life flow and squeeze a unit of blood in there, the chances of those people making that to life are still very grim.

So we are now, I'm saying Lee, Matt Levy out of Hopkins is now trying to develop like the ultimate criteria, obviously, you know, witness shockable outcomes. We're trying to develop the Ustin criteria for whole blood and trauma so that you don't just lump in.

Everybody into your whole blood program. You can separate it out. You could say, here are the penetrating traumas who are not in arrest. Here are the blunt traumas who are not in arrest. Here are the medicals, here are the obs. And then you can say that here are the folks who were in arrest. And what we're learning is that the people who are in arrest who had a compressible hemorrhage, let's say they had an extremity hanging off, they're bleeding from their arm, you put a tourniquet on where you could fill the tank back up and you can get the pulses back. And that's been shown to happen. So without sub segmenting the population, you're kind of doing whole blood a disservice. But I will tell you, even if you lump everyone together in the non arrest category to start and you get a 90% success rate, you're basically doubling survival from what we used to have. Or another way of saying it, you're having mortality. Having mortality. And I'm not so sure what anyone else has implemented recently, but there not many things that you can implement that'll. That'll double survival in trauma.

So.

And I'm sure that we'll talk about plasma in a little bit. But if an agency is the right agency, they have the right volume of trauma, which they can look back and say, show me the last 24 months, use these criteria. Let me figure out which patients could have received whole blood. You get a number. Let's say that number is 30, 40.

You can make a case that that patient should get whole blood.

Well, that's amazing. Can you highlight really quick for the listeners, what are you using as those treatment endpoints you talked about? Blood pressure, heart rate, shock index?

Yeah, that is a great question, Eric. And I'll tell you why. First, I'll start by saying that.

Many agencies are using their own kind of blend of vital signs. Why I think the vital signs are important is because imagine that you had such soft criteria that everybody got blood. Then what's going to happen is that your numbers, your denominator, if you will, of the total number of patients who receive blood will be large. And the total number of patients who receive blood may not be representative of the folks who really did need the blood. And there was a. There was an antibiotic trial done in the Netherlands a few years ago called the Fantasy trial that showed that antibiotics didn't help sepsis. But when you looked at the patient population, only 3% of them were in shock. So of course, antibiotics didn't help patients who didn't need antibiotics. Right. So here we have to be careful of the flip side of that, which is, hey, we gave a thousand units of blood this year and 99% of the people lived. Wow. Amazing. Yeah, but. But only like 100 of them needed blood. This is what the surgeons are worried about because they, they. And this is a real thing. When we see the patient in the field, they're dying, right? They're altered. Some of them are even braiding down. They're about to die. We give the blood, they come back to life, they wake up, they talk to us, they get to the er, to the trauma bay with normal vital signs, and the surgeon looks at us and says, why'd you give them blood? And we say, are you kidding me? So it turns out that the blood is turning them around so much that even the surgeons. And now the surgeons are getting upset because now their initial trauma Score, Right. The ISS that they get graded on when they say hospital A, sees the most severe trauma in the world because their initial trauma scores are, whatever, massively high. Now we're bringing all these people in that don't have those scores anymore and it makes it appear that those people are not as sick and therefore the hospital, again, I'm not sure if it's a reputation or just by the metrics, doesn't look or maybe payment. And so they're not happy about it, it turns out. So why I mentioned all this is that you have to have this locked in so that they're appropriate. B.

It doesn't create a massive overuse of a very precious resource. And then C, you have to make sure that you document, document, document, because you will be second guessed, maybe not every time, but every other time until they start to understand what we're really seeing. So with that being said, let me get into our criteria, which again, you don't have to use these criteria. We just kind of, you know, we ripped off and duplicated and then we kind of massaged it and changed things over time. So we have both adult and pediatric criteria for obvious reasons, because we're dealing with vital signs and they're age based in kids. But for adults, here's what it is. Any patient with evidence or suspicion of a massive hemorrhage, so they have to have that and one of the following. Either a systolic of less than 70.

That alone will do it. The next one is a criteria and it has to be two things, which is a systolic of less than 90 plus a heart rate of greater or equal to 110 beats per minute. That's the combo one.

Then we have a caveat for the elderly because for anyone who is on beta blockers and or calcium channel blockers, we actually give that consideration that the heart rate could be under 110, so blood pressure less than 90 and a heart rate less than 110. If you're on a beta blocker or a calcium channel blocker, bullet point number four is just EMS captain or flight crew discretion, which is massively important because as you know, Eric, you've been doing this for a long time and you've flown a lot and you've seen the worst of the worst is that you will see a patient and you'll know that they're about to die. But the last set of vitals was three minutes ago. You're trying to push the button. You can't do a manual, whatever it is, and you're like this guy's getting whole blood. You have to allow that. If you don't allow that, then okay. Now the other, the other thing to consider is end title. CO2.

Which is an end title of less than 25, is a very nice marker for severe hemorrhage. And the theory, and I haven't really haven't anyone to corroborate this theory, which is that, you know, if you have your full circulating blood volume, it's bringing back a certain amount of CO2 to the lungs that you're exhaling. If you decrease that blood volume by a liter or two, then you're bringing back less end tidal. So the end tidal reduction, just like.

In sepsis, an end tidal of less.

Than 25 portends a lactate of 4 or greater. That's what you know that the equivalent is. An end tidal of less than 25 is significant in hemorrhage, that you have severe hemorrhage enough that you do need whole blood. So there are some people who use it, some people who don't use it, but that's just to keep in mind. And that's it. That's, it's very simple. It's not that complicated. For pediatrics, it's the same thing, but it's basically, it's basically age based. And so we actually just put it in the app. And you know, if the vital sign is less than this number then, or the heart rate is greater than that number. And I'm happy to share that with you in a spreadsheet if you wanted to pass that around too. It's not information that we want to keep to ourselves. The one big thing, Eric, is that a lot of people will come out of the gate and they'll say only for adults. And you know as well as I do that even though they know it's right for kids, they just don't want to fight for it. And then when they do fight for it, the next protocol change happens in a year or two or three. And now you have, in those three years you had a 15 year old who died and a 17 year old who died and a 12 year old who died. And oh, it's only three or four kids, but that's three or four kids. There is zero reason. And Christine Leifer from Pittsburgh, who's a big scientist in this area, all the military data, there is absolutely no reason. And if, if anyone listening to this and they want to know how to get around it, you go to the trauma surgeon and they're going to say none for Pediatrics. And you're going to say, oh, okay, let me ask you a quick question. When we bring this kid to the trauma band or hemorrhaging, what are you going to do? And they're going to say, oh, we're going to give them, you know, O negative. Oh, you will. So you're going to do the same thing that you didn't want me to do. And then that shuts them up really quickly so they have no evidence around it. All the experts are agreeing now that pediatrics should be in these criteria. So I'm going to push as hard as I can to make sure that every protocol that has whole blood for adults has whole blood for kids.

And is that down to what age?

Any age.

Any age.

Any age.

I mean, now listen, I went back, listen, when we were doing this and people thought we were nuts back after San Antonio did it, I went to my hospital. I said, okay, Children's hospital.

Yeah.

Level one trauma center. Yeah. Can we see all the bad stuff? Yeah. How many kids under the age of five have ever received a whole blood transfusion in the trauma bay? You know what the answer was? Zero. So I called around to other hospitals where maybe there's more penetrating trauma. And, you know, they gave me like in St. Louis, it was like four. You know, there was a kid who got shot by the father by accident. Another kid who, whatever. There was a couple gunshot wounds in there, but there were like four and the youngest was like a year and a half. But I will tell you to everyone listening today, it's very, very, very, very unlikely that you're going to need a blood transfusion in an infant in a one year old and a two year old. And in fact, the youngest we've given so far is a 4 year old on i95. Best story ever in Palm Beach Gardens. I gotta give Ashley my email's Captain, huge kudos. This kid was in the, in the back seat, in a car seat. Traffic on 95. So they were stopped. This guy came in at a high speed. Boom. He, you know, completely wrecked the back of their car. This kid ended up from the back seat in his car seat. He was now touching the dashboard with his car in his car seat still. His femur snapped in half. This kid, when we get there, is altered unconscious. He becomes unconscious and then his heart rate starts to go from 120 to 110 to 100. It's down to 50. We have an IO in the first 10 cc's per kilo goes in. This kid, Eric literally wakes up Starts crying. Oh, my God, right? Like you get the chills. We package him up, get him halfway to the hospital, There he goes down again, starts to Brady, down again. Ashley says, another 10 per kilo. You know, and the nice thing about the. The life flow infuser is that every squeeze is 10 milliliters. And so it was very easy. This kid got 17 squeezes, very simple. He wakes up again. This time, he stays awake. He gets to the trauma bay, and the surgeon, a resident, right, Trained in training, looks at EMS cap, and he's like, you did what? Like, giving her attitude. So, of course I had to intervene. And I think I told her. I told her, people, please go educate that guy. Then what the hell he's talking about? Anyway, this kid ended up with external fixation, left the hospital a week later, perfectly normal. No head injury, no torso injury, no abdominal injury. All he had was a femur fracture. This kid would have been dead. Right.

Well, I think that's where. Where we have to remember the. You know, kids have a circulating blood volume of 75-80 ML per kilo. And, you know, when you start looking at a 25% loss based on that volume, it's a very small amount. So a small amount of loss causes a huge decompensation. And. And that. That's a great testament of the. The transfusion, how quickly that they respond.

Right? And they. And so you said it beautifully, that this is the physiology that's important. Kids are more resilient, but on a percentage level, they're losing a larger percentage. But, you know, most of us in ems, urban, suburban, for the most part, we're going to get to the scene within 15 minutes. There's a great talk by Dr. Shackelford. Obviously, she was the chair of the joint of the jts. She was in Zermatt, which is a very beautiful place in. In Switzerland, if you ever have a chance to go. I've never been still saving up. So she was in Zermatt giving a talk. You got to look it up. It's a YouTube talk, and she. She outlines the. The physiology. And this, what you just mentioned, you probably have to shorten it a little bit for kids, but she says there is a magic number for blood transfusion, by which if you get the blood in from the time of the incident, you will save the life. And that number is 35 minutes. It's clear as day. And you look at her data from the military. So here's a nice thing. We in Palm beach county, really, in all of my agencies, you know, we have a six to eight minute, you know, time to arrival on the scene. So usually the blood is going into my Systems between minutes 16 and 21. We know that data for a fact.

When you look at the data that.

Came out of the refill trial out of the uk, which was the first study that was they don't use whole blood in pre hospital. The average time to whole blood was 52 minutes. 52 minutes. And then those patients got like a liter or two of saline before that made it even worse. So if you're in a system that sees a large volume of trauma and again, you could do the math and you can get there within 30. If you can get the blood out within 35 minutes, you could do a calculation by how many lives you can promise your community you will save next year. It's a simple math equation because you're going to see the same number of trauma patients every year and you're going to double the survival and you're going to get a 90% survival from all patients who didn't go into cardiac arrest.

If you have the volume and you have the know how and you have the money and you have the hospital and you have the surgeon to agree with it, then you ought to do it. If not, I wouldn't do it, let's put it that way.

So obviously we can go a lot of different directions with this podcast. You know, I get a lot of questions on the implementation of a blood program and you know, I think most places start out with patch red blood cells. They might then add plasma. You know, I probably see more plasma placard blood cell administration. So can you just really quickly talk about that piece and then, and then oftentimes they segue. Once the program is up and running, it's proven getting the whole blood on board what your thoughts are?

Yeah, that's a great question. I will tell you this. Most programs that have been carrying whole and carrying blood products, let's put it that way, have for many years have used pack cells. And you know, that was the thing. And why is that? Because someone many years ago after, after the second World War decided that, and there was a reason for this, but they took the whole blood which they were using in the military for years, you know, go back to Vietnam, they gave 200,000 units of whole blood. Someone then decided that we're going to cut this whole blood into its three parts, plasma, platelets and packed red cells. They split it up, they can make triple the money. And if you have, remember this is right around the time where the treatment for leukemia was just coming out. And so if you're a leukemia patient and now they're giving you all the chemo, well, they're killing all of your cell lines. But today you need platelets, and tomorrow you need PAC cells. So there was a need for breaking up this whole blood into component parts. And that made sense, but it never made sense in trauma. So no one ever said, hey, you know what? Let's keep the whole blood for trauma, and let's keep the component therapy for the medical people who need it. So what they forced the trauma people to do is to give the trauma patient it back in parts. So you have a nurse. Imagine a nurse sitting at the bedside. Someone comes in with a cooler, and there's plasma, there's FFP, and there's PRBCs. And someone says, okay, let's go ahead and give the massive transfusion protocol. And now you only have, let's say, one or two lines. Hey, which one do we get first? Okay, give the packed red cells first. So now you're literally with a piece of paper, and you write the three things down, and you're giving a one and another one and another one, and you're. You're documenting just like you were in kindergarten, right? That's how it's done. And then, like, 30, 40 minutes into it when, like, the shit's hitting the fan and everything's going crazy, all of a sudden, they're. They're like, what unit are we on? It's just. It's a. It's a cluster of epic proportions. This is when the Don Jenkins, Phil Spinella's, John Holcomb's, and those guys came and said, what are we doing? And really, it's Jenkins when he was in the Mayo Clinic, who said, screw it. I'm doing it, and I don't care what you say. And he just made it happen. Like, he literally just. If you ever met Don, he's most humble human being. He's a powerhouse. This guy just said, we're gonna do it. And then, you know, then he moves to San Antonio, and the rest is history. So I would say today, everyone who's starting a blood transfusion program is going to go for whole blood. But here's the problem, that there is a problem with the amount of product that's available. So if you're in business as a whole blood. As a blood product distributor, and someone says, you could take this one unit from Eric, that he gave you his arm and you gave him two movie tickets, you can cut it into three parts, make three times the money, or you could sell it to that lowly EMS program for dirt cheap. What are you going to do? Oh, well, suddenly, I'm so sorry, ems, we don't really have any more product for you.

And that's, that is a real problem, which we can discuss later. There's definitely ways of getting around that. We are now in Broward, in my Broward, in Palm beach county, the same distributor that's providing me blood in Palm beach, the same distributor is providing us blood in Broward County. They've told my other agencies, sorry, we're done. So now the state is getting involved. So there is a big issue with blood product and they don't want to give away the cheaper product to us, especially because we have. It's in the sunshine. Every, all the contracts are discoverable. They're in the open. They, they initially didn't want anyone to see the charge. The price they were charging us, which was initially 600 bucks a unit, now they moved up to 650 a unit and they were charging the hospitals just a ton more money for the same exact product.

That is a huge cost.

Huge. It is, it is. So now moving on to. There are agencies using PRBCs. So take new Orleans for example. When they first got their program running, they were told, sorry, all we have is PRBCs. They say, we'll take it. They also didn't have money for a warmer. They said, screw it, we'll just use the life flow. We'll, we'll transfuse quickly, cold packed cells. Their data looks spectacular, let me tell you. So but when you, when you look at the contents of whole blood versus PRBCs, whole blood has all the proteins, you know, and whole blood has about 8,000 different proteins, clotting factors, it's got the plasma. So whole blood is definitely better. And the unit of whole blood doesn't have a lot of citrate in it. Citrate is put into the whole blood unit to make it not clot, but it also sucks up calcium. So when you give someone whole blood, they're already hypocalcemic from the trauma. Now you're making them more hypocalcemic from the blood transfusion. When you use it. When you look at PAC red cell unit, it has four times the amount of citrate. Now whole blood has 500cc's PAC cells has 250. So you have to give two units of PAX cells to equal one volume unit of whole blood. So now you're giving two units of PAX cells one, which is basically 16 times the amount of whole blood citrate. So if you're going to give packed red cells, you really need to focus in on how much calcium to give. So in New Orleans, they do a 2, 2 and 2, 2 units of PAC cells, 2 grams of TXA and then 2 grams of calcium.

Are they using chloride or gluconate?

So that's the problem.

That's a good question. They're using chloride. But there is a risk of extravagantization, as you know. So there are some people now, including Dr. Jenkins and Dr. Holcomb, who are saying if you're only giving one unit, you probably don't need calcium. We decided to do the following. You do get a gram of calcium chloride after one unit in Palm Beach County. But we dump the brista jet, the 10, the 10 MLS or the one grammar into 100 bag of saline and we just run it wide open over two minutes. And that kind of helps us prevent this, someone squirting it into a vein and then ending up causing significant extravagation injury, that type of thing.

So that's the difference between whole blood and packed red cells. Definitely whole blood wins that one. And then there's plasma, which.

Maybe we'll say to talk about the plasma because that's definitely valuable. It doesn't have platelets in it, it doesn't have packed red cells in it, but it does have all of the clotting factors which does have significant benefit.

And there's a new type of plasma coming out on the market, which we can talk about next year, which is really going to change the game for everybody if the price is right. So I'll stop there. Okay.

Yeah. So let's talk about the plasma later. Or maybe we can do a part two. I want to really focus on where you've seen this from an application standpoint. We've really seen a big focus in the, in the industry. I know we have really tried to champion this over the last five or six years. The whole resuscitative sequence innovation mindset. Right. Not. Not thinking about rapid sequence, but resuscitative sequence. And then I've come up with the acronym factors for that post innovation.

Period, where we're seeing a lot of, you know, post intubation, hypotension and hypoxia. Right. And is it, Is it. Why is that happening? And there's definitely. If you're listening and you haven't listened to that podcast, go back and listen to that podcast. But I Know that there's some good data out there on that resuscitation phase. And so I want to talk about your experience with giving whole blood or blood products in general when you have somebody that maybe is an extremist. They're declining, blood pressures are low. Right. We're in a resuscitation phase. And you determine, hey, this patient probably would benefit from advanced airway management.

Yeah. This is so important, Eric, and I'm so glad you're bringing it up. And I just paused by saying that I was in ATLs. I was doing my ATLs refresher the other day, and they still haven't gone to the new atls, which I guess is being released any day now, supposedly. And I'm sitting in there and they, the surgeon, the front of the room is saying stuff like, remember, you take the airway, it's always the airway first. And I raised my hand. I'm like, isn't it X, A, B, C, D, E? Now he's like, yeah, yeah, but that PowerPoint's not out yet. Like.

He knew the answer. He knows, but he's forced to teach what this darn class is teaching us. So here, here's the. I'll start with the data and then I'll work backwards. And again, I got to give a lot of credit to Dr. Meg Marino.

Tom Dransfield out in Colorado, out in New Orleans as well.

Juan Du Chesney, who was. He's not in New Orleans anymore, but he was a surgeon there. And they actually put a paper out that was very important. I have the data here in front of me, so I can kind of, I can, I can say it the right way here, but this was a paper that was. When was it published? 2024. And it's called faster refill in an urban EMS system saves lives. And they, they looked at usual care, which is a patient in New Orleans on Bourbon Street. They get stabbed, they get rushed to the hospital, which is only, you know, eight, nine minutes away. And then they get into the trauma bay and they get blood. That's. That's usual care Group, that 149 patients in that group. And then they, then they had the other patients in the advanced resuscitative care bundle. Arc. Arc. Those are the patients who got blood in EMS on scene 60, one of those patients. Now, it turns out if you compare the two groups, the shock index was much worse in the pre hospital transfusion group. So they were a sicker bunch. Right. So already the scales are tilted towards the trauma, like giving blood in the trauma bay.

The shock index in the emergency department in the pre hospital transfusion group, in the arc group was lower than in the usual care group. So already the shock index was near normal. And for those people who know the shock index, you just take your heart rate. You know.

Most people's, I should say you take your.

Heart rate and you divide it by your blood pressure. So heart rate 60, your systolic blood pressure is, let's say 120. 60 over 120 is 0.5. 0.5 is considered normal. As you start to go up, meaning that your blood pressure goes down or your heart rate goes up, you can start to see that that number is going to start to get higher once you have a shock index of greater than 1. So let's say heart rate's 100, your systolic pressure is 100. That's not good. Now your heart rate's 120 and your blood pressure is 100. Now you're at 1.2. Once you start to get up higher and higher, your chance of mortality goes way up. So already you saw in this New Orleans study that the shock index was almost near normal.

The EMS intubation rate is the key here. In the usual care group, 12% got intubated, 12%. In the pre hospital transfusion group, 1.6% got intubated. So it was basically almost tenfold reduction in intubation. Now that's part one of the physiology. Now you're a physiology guru and I know that you talked about on your last podcast, but when you have somebody breathing, their cardiac output is minimum minimal at best. And, and then you come and you paralyze them. Now they don't have that negative pressure breath to create that vacuum to pull blood into their rv, which was, that's what's keeping them alive. You are. Now once you give the paralytic and then you throw positive pressure on board, their cardiac output goes to zero and they go into cardiac arrest. Scott Weingart showed this. Our good friend Jeff Jarvis showed this. Other studies that have come after them, one from India has shown this that if you are not optimized from a blood pressure perspective, and then you go and you try to paralyze someone and you throw on the positive pressure, they will have peri intubation arrest. And what they really needed was perfusion to their brain to wake back up again.

So I'll just relay one case and I'll pitch it back over to you. But one of our very first cases was a police Officer whose partner was being attacked by a dog. So to save his partner, he shoots the dog. And I love dogs. And that part of the story is not so happy for me. But he shoots the dog. The bullet ricochets off of the concrete wall behind them, and it goes right into his partner's groin. Puts a hole the size of like a. Like a small water bottle in the guy's groin. This guy's bleeding out.

Our ambulance crew gets there, they put, you know, pressure dressings. They're putting their knee in the guy's groin. This guy's unconscious. He's out. They're about to intubate the guy. EMS captain gets there and says, wait. He drills the IO, squeezes one unit of blood into him with a life flow. The cop literally wakes up, he looks around and he says, give me more.

And literally. That story still persists in our agency because it was almost surreal that the guy literally woke up and started talking and he says, whatever you're doing, give me more of that. We've since had a number of patients tell us the same exact thing. So what Mark and the others showed in this study.

It isn't just a fluke. Every single agency that has rolled out whole blood, who has taught their crews altered mental status with hemorrhage, that's not because of a TBI does not get intubated first. They get X first. So the X exanguination replace the blood before you go to abc, and that's the resuscitate before you intubate. And that's the. The acronym that you developed that. I mean, the fact that in 2025, in. In June, I was taught by a surgeon in an ATLS course. Not that it's concerning to me. What can I say?

Yeah, well, and I think that is the big thing is teaching the crews to be. Again, no TBI.

Recognizing mechanism hemorrhage. I want to come back to the shock index here for a second. But recognizing those things and then. And having a guideline where you know it. So what if they don't have whole blood? Let's say they have plasma packed red blood cells. Same thing. A unit of plasma using a unit of factory blood cells. See what happens. Or would you go two packed red blood cells? I mean, I know that's four times the citrate, but.

Yeah. So based on the data that's coming out of New Orleans, I can speak to that. So that's two units of PAC cells.

But I will tell you what we're doing in Palm beach county because that could speak to that. And we have some information. We haven't, we haven't published this yet, but about a year ago, we said to our distributor, hey, you guys have plasma? He said, that's basically like a throwaway substance. Like, nobody wants plasma. So we said, cool. How much would you charge us for it? They said, 60 bucks. We're like, we're taking it because in Palm beach county, we have 10 battalions and seven of them have whole blood. And we're like, you know what? At least we'll. We'll backfill those with plasma. And we did. So we have a lot of patients who, who have true trauma who need red cells. We don't have whole blood, and they get plasma. But the beauty of the plasma is that it's helping to stop it, stop the bleed very effectively. Just a quick second on the type of plasma we're carrying. When you go and put out your arm and they're getting your plasma, what they'll often do is freeze it. And that's what they call fresh frozen plasma. It's fresh. Someone just gave it, they froze it. And then when you give it back, you got to thaw it out. Then there's something called cold liquid plasma, which is. It's not ever frozen. It came from somebody recently, they cooled it, and you're using it. So that's a better. It's better because the proteins are better. They're. They're healthier, if you will.

And it's. And it's dirt cheap. So I would say that in agencies that cannot get whole blood, or let's, let's put it this way, if you know that one day you're going to get whole blood, tomorrow you start with plasma. Why, no one's going to be upset if you waste it. It only costs 60 bucks. And this is the training wheels to whole blood. Once you have the cooler and the life flow and the warmer and the, and your protocol set up, it's the same exact protocol. You have all that. Then you just throw the plasma in the cooler and you say, have a, have a good day. And by the way, it's type A plasma, not O positive. And we can talk about that at different time. But type A plasma is what you would buy. Cold liquid, their next year is coming out with something called spray dried, which is going to be. If it's reasonably priced, everybody will carry it and everybody will use it. Instead of normal saline or lr. You'll never use those ever again in trauma ever again.

So I, I will say today I'LL put myself on record on July 2, 2025, that we should never, ever be using normal saline or LR in trauma patients or TBI patients, ever. If you have plasma, that's the big if. So.

You know, just imagine how much a bag of saline costs and then you're going to be replacing it with a $60 bag of plasma or a X number of hundreds of dollars of spray dry plasma. There's going to be a cost and it's going to be cost prohibitive to some people. But you could do a math equation by looking at your last 12 months, looking at how many patients could have used it, and then go to your fire chief and say, I predict I'm going to need 100 bags of plasma at 60 bucks a pop. I need six grand in the budget because I want to use this plasma instead of a saline. So precious resource costs money.

But as we move on, our children, and our children's children will have laughed that we even carried normal saline and LR and we even dared to give it to a trauma patient. So in the order to answer your question, whole blood, two packed units of red cells, plasma is the order that I would say.

Is like the hierarchy, if you will, of blood products.

Okay. Yeah, yeah. And obviously the PROMET trial showed promise with, with plasma. I guess the other, the other, the other big thing is, is we could talk about this for hours, is how do you, I think a lot of this stuff from an implementation standpoint comes down to forward thinking medical direction like yourself, forward thinking and administration. Right. If you don't have those two ingredients, even a forward thinking medical director with administration, that is not forward thinking, you're going to hit roadblocks. So, you know, I think that's, that's also the big thing is we have to continue to change with the times. We have to continue to learn from our peers. We have to share results. We have to share, you know, these programs that you've already rebuilt. I love that you were able to take everything from San Antonio, take it, bring it into your system, apply it, put it into real time. You know, NAEMSP and all the colleagues you work with, you guys are communicating, you're always sharing information. And I think that's how we can really make a positive change. And I often hear that from different people is, well, hey, you know, we've, we've always done it this way. There's, there's no reason to change this. And that's just not, that's just irresponsible almost.

It is, you're exactly right. With the two pieces, I would add a third piece in there, which is what state you live in. Right. Unfortunately, some people live in states where their hands are tied. I get calls all the time and they're like, you know, we can't do it because the state doesn't want to do it. My medical director does want to do it, my fire chief wants to do it, but the state is locking me down. And if you don't have like there's a guy named Scott Branny in Colorado. This guy is military guy, great guy, he's at the state level. He is making it happen statewide. So it is a statewide issue. He's just going to make it happen statewide. Then you have other states.

There'S a big vacuum up at the state and no one up at the state has ever been in the back of an ambulance in the last 10 years. And they just don't want to touch that spot.

Then there's a fourth variable which is very interesting to me, which is a group of individuals out there who for some reason are putting like a stick in the wheel of whole blood, even though they have nothing, they have no data to prove it. And.

So there's a financial.

Conflict of interest here for some people. And I want people to be aware of this, which is if you are a system where you're called out in the helicopter to bring the whole blood, and you have, let's say 30 runs a year, 30 flights a year for whole blood runs and tomorrow those 30 runs go away. You can do the math on that. And so I've been following very closely certain places around the country where pretty smart doctors are coming up against whole blood. They're writing papers that are completely trash papers and everyone's calling them out. But.

Now that there's such a huge wave of not only people, but data, and of course those people are going to say, we want the randomized controlled trial.

That's their way of getting around it. Or they'll point to the refill trial from the UK, but they won't mention there was a 52 minute until the patient got blood.

So people have to be very attuned to what's happening. They have to be able to go and make the case. And so what I would propose to people is the following, is that there are entities. San Antonio is the leader, right? They, they invite people. They do summits every year. That's number one. I'm part of a group that's led by people like Randy Schaefer, Mark Peel, Wandu Chesney, Tom Dransfield and many others who we created something called the Spark Academy and the arc. The SPARK is advanced resuscitated Bundle. And basically it's a four hour class that we put on at conferences all over the country. And it's meant for people to come in and learn from the people who are doing it right. We have military folks, we have Navy seals who are with us. We have surgeons, we have everybody there.

Other people like Matt Levy, Hopkins, they just put together an online training. So now that we're in, if you look at that bell curve of adoption, you have the early adopters. The early adopters are typically innovators who also have a component of being maybe a more high performer, ocd, very attuned to process detail training, education. So those first 250 or so agencies who initiated whole blood already are probably a different type of service. Now what's happening is we're getting into the middle of the bell curve, which is, you know, hey, I heard you were doing whole blood. That sounds pretty cool. I heard, you know the Flight Bridgette podcast, and I want to do it and they go back to their agency and there's crickets. So they don't really have that much information. They don't have support. So we want to be that support. San Antonio wants to be the support. Matt Levy wants to be that support. The folks.

Led by John Kramer want to be that support. So there's been this coalescence now of massive amount of education, education that will come to you. Randy Schaefer now is a consultant. And everyone who calls me, I say, you call her. You pay her money and she will get your blood program up the right way. She will talk to the blood banker, she will get your policies together, she will make everything run smoothly. Because here's what we're worried about. That, that middle of the bell curve type of population comes in. They don't have their temperature monitors. Correct. They don't have the right coolers. It's all Mickey Mouse training. Nothing's right. The FDA comes in and inspects and they shut the whole state down. They say, this is Mickey Mouse. You guys don't know what you're doing. So if I had it my way, and I hate regulation, right? I'm in Florida. We're a delegated practice state. But I do think that if you're an agency wanting to start up a whole blood program, there should be somebody who knows what they're doing to come in and say, check, check, check, check, check. You look like you know what you're doing. You have all the things in place.

Good.

Go ahead and start. We give you the blessing.

There is value to that because the blood bankers don't like or didn't like ems, and now they're starting to kind of understand us, and we're understanding them, but because we're so kind of cowboyish appearing.

One mistake, one extra death, one transfusion reaction that wasn't treated correctly, and they're going to come in and say, you're done, and they're going to ruin it for the rest of us. So just, that's an overview of where we've been, where we're going, and that there's resources out there for people listening here today that don't cost money. They just need a network and a phone call to say, hey, Pete, can you help me out? And I have a whole folder, PowerPoints.

Numbers I give people.

And say you call those people and they'll help you out.

Amazing stuff. Well, we will definitely put your, your email in the show notes and your contact information, as always. I, I know you're, you're very accessible and you always are responsive to people. So, yeah, it's always appreciated. Well, do you have anything else to hit on before we wrap it up, give you your day back?

Yeah, yeah, one more thing. Said this I'm super excited about is. And this I have to give. And so listen, I want to tell the people out there who are. I think we have to grow many more EMS leaders. So if you're, if you're a lieutenant, an fto, an EMS chief, an EMS captain, a battalion chief, someone in EMS who is like a rising leader.

The magic happens when you network. So I'm going to brag upon Chief Charlie Coyle, who is just an amazing human being, was my EMS chief. Now he's moving up the ranks. So he's now not the EMS chief anymore, but I brought him to namsp, you know, to the national conferences. Now he's on the speaking circuit. And John Holcomb and him were having a tequila at a, at a bar one night with a bunch of people. So Charlie Coral is sitting next to John Holcomb. And Holcomb says, charlie, you guys have done an amazing job with your whole blood program. I got an idea for you. Charlie says what? He says, there's, there's data, a decade worth of data showing that plasma will fix the leak in the brain from a tbi, whereas saline will just leak out into the, into the tissue of the brain and cause edema. The plasma seals the hole and has Significant improvement in animals and some very small human studies. And Holcomb says to Charlie, are you interested in doing that study? And literally there are two margaritas in John's writing down on a napkin. And he says, yeah, we'll do it. Two months goes by. Remember we already had plasma on our trucks. Charlie writes the protocol. Holcomb gets on. He does a whole webinar for us and the team, which I posted on YouTube. We wrote the protocol, we trained up everybody. We implemented it like four months ago. Let me tell you.

The number of old people who fall who have a GCS less than 12. That's our inclusion criteria is enormous. We already have like 40 some odd cases.

And the funny part is that one of Holcomb's colleagues in Chicago has been working for three years to get a randomized controlled trial done on plasma for TBI in the hospital. Holcomb. So I, I get the guy on the, on a zoom. I said, hey, Doctor. Dr. Alam, John Holcomb sent me to you. Guy got on a zoom with me. He had no, he saw I was wearing my ems, you know, my, my, my polo. He starts, you know, saying, who's this clown? And I, and he, and, and I said, sir, is it true that you're doing an rct? He's like, yes, I've worked three years with the fda. They still haven't approved the study. And he says, tell me about yourself. And I said, well, I'm a lowly medical director here in South Florida. And about, I said, in about a month from now, we're starting plasma for TBI in ems. And the guy's like, you heard the record, stop. He said, wait a minute, you're actually starting? He said, how are you doing that? I said, well, it's Florida. And I spoke to John Holcomb and he told me to call you. And the guy's like, you don't understand. I've been forbidden for doing this for three years. And here you are starting in a month from now. So we've started. We have 47 cases. He still hasn't started the study yet. And it's going to take him three years to conclude the study. And if you ask Holcomb, Holcomb will tell you that that plasma in his study is going to happen way too late. It's happening already in the trauma day. So here we are in this very weird place in time where ems, once plasma becomes normal in ems, when that spray dried stuff gets out there and everyone's going to be using it for tbi. And other things. Can you imagine? This guy's study is not going to be out for three years. We're going to have thousands and thousands of patients getting plasma for tbi. And that study may come out and say it doesn't work, just like the refill trial came out. So.

For people who are listening, EMS data and EMS medicine is very, very, very different than hospital medicine. I keep pushing the NAMSP to move away from AHA Guidelines. We need to make our own set of guidelines. We're a different specialty. We are board certified in this specialty. We have EMS leaders who are amazingly wicked smart who need to rise to the occasion, who need to come to the NMSP conference, who need to make their names known, who need to get involved with research, who need to stop listening to what the hospitals are telling us and own it. Own it. We treat trauma, we treat cardiac arrest, we treat stroke, we treat pediatrics better than anybody else. And if you're going to come into this profession, you better own it. And you better, you know, fight like hell like Don Jenkins fights, like Hul fights, like Phil Spinella fights. Fight like hell to make just to get that one extra life in your community next year. That's what. That's what you're here for. That's what you serve the community for. It's not for a paycheck. And, you know, EMS is getting to the level now where.

They'Re finally understanding the value of ems. It takes people like you, Eric, with all you're doing, and I'm going to keep fighting to let the hospital folks know that EMS is where lives are saved and not in your shiny hospital room with air conditioning and a blood cooler that gets to the patient way too late. Thanks for. Thanks for coming to my TED Talk there. Sorry for the little rant there, but.

I had to say, amazing stuff.

Well, again, amazing stuff. Love it. If you have any questions, please reach out to him. I will put his contact information in the show notes. And we. We hope you have a great summer and enjoy the 600 kids.

And I'm gonna see you in Canada soon, right?

Yeah, couple months. It'll be here.

Oh, man, I can't wait. I can't wait. So excited. Thanks for everything you do. Thanks for your leadership. And.

There'S not a place to go around the country that people haven't been impacted by you and your entire team. So from my team to yours, thank you so much for everything you do.

And I appreciate it.

Have a great time.

All right. All right, guys, if you have any questions again, reach out eric.bauer@flightbridgeed.com and we'll talk to you soon.

This has been a production of the flightbridge Ed Podcast, leading the way in pre hospital critical care and emergency emergency medicine education.