Whole Blood Update (South Florida) - Dr. Jim Roach (9/13/2022)

Foreign.

Wendy's run up Davey Boulevard.

That's what, much like a truck. Yeah, that's what I was wondering.

So.

Okay, good.

Yeah, I found a shady spot, so this looks like as good a place as any to do this.

Yeah, Wendy's, like, you know, I think you should have some diversity, though, in your programs. So, you know, maybe some week maybe do Burger King and another week do. Yeah, that'll be good.

Yeah, Bolay. I like both. I'm a Bolay fan, so.

Yeah, is great.

All right, well, it's. It's 1102, so let's get started. And looks like we're getting a good corn going here. And welcome, everybody, to another Tuesday edition of the Florida EMS webinar. We have been talking about this topic for some time now, but we've really gotten to a point where a lot of good things are happening across the Tri county area. Thanks to several people who will be on this call today. And so Today we have Dr. Jim Roach from Broward Sheriff's Office and other agencies. Jim and Heath. Chief Heath Clark really initiated the whole blood program here in Broward county and have just done an incredible job. And many other people around the state are really looking towards his program. And Chief Charlie Coyle, who's on the call, you can see, you know, he and his team really made a big push, fought a couple of battles, and. And we are now live in Palm Beach County. So I asked him and.

Madonna from the trauma hospitals in Delray and St. Mary's in Palm beach county are going to give the Palm beach update for us today. Then I've asked Dr. Mark Peale to give us the Tulane blood registry Update. And then Dr. Pepe will give us the Eagles survey update at the end as well. So without any further ado, welcome, everybody. And Dr. Roach, thank you so much for starting us off. Just tell me next slide and I'll move your slides forward as you need them.

Absolutely. Dr. Antebi, thank you so much for putting this together and giving the opportunity to speak. This whole journey with whole blood has been quite an adventure thanks to what Paul and Dr. Holcomb and their influence on San Antonio. And we took the San Antonio protocols and basically learned from them and kind of just rip off and duplicate what they did, which was a total blessing for BSO and you know, to have all these things going on, it's just. It's fantastic.

Jim, did we lose you?

Did Jim drop off? Let's see that.

He just taking a bite of his Wendy's. I think we did drop.

Let'S see. I guess you don't get the best service out there in. In that area of the world. All right, let's give him another second. There you are.

Okay about that. Yeah, I got a phone call and it totally deleted. Shut me off. Anyway, so I wanted to say, is this the. What I did, this is the PowerPoint we had when we did some presentations, but I got rid of a lot of papers and stuff, and we're back down to pretty much just showing the folks that are considering whole blood, they can see this is the difference between whole blood and then component therapy. And you can see with the one unit of whole blood what you get versus that. You know, one to one to one component therapy. So it's not only is it everything, but it's also, don't forget the 6000 plus other proteins in whole blood that does things for the human body that we don't even necessarily know exactly what it does outside of the fact that it's just easier and more efficient. So, next slide.

All right, so now you can see that's the whole blood. And then you see behind there, just so you know, all the equipment that you need to get this going is, yeah, you get the whole blood. We get it from one blood. And that's where most of, I think all of the hospitals in Broward, in South Florida, Broward Health and definitely Memorial, use one blood. So it's very simple. At some point, if we can develop an exchange program, we'll talk about that at the end.

But.

But the blood box is what we use, and that keeps the blood cold at that 4 degrees Celsius for 24 hours. So just so you can see that. And then next slide.

Here is. This is the. So now you see, you see the blood box, you see the Quinn flow, which is our rapid warmer, and then the life flow. The life flow is huge. And since we got the life flow, we're able to give this blood. I mean, each squeeze is 10ml. So 50 squeezes is a unit of whole blood. And we've been able to get this in just, you know, minutes, three to five minutes, we can deliver a whole unit of blood. And that has been fantastic for, you know, in terms of our outcomes and what we've done. So that's the package, as you see there, for the equipment to get this done. And then next slide should be.

Then you see, not every. You don't have to have a freezer. It is helpful if you want to store extra blood. That. And it's timed and it's there's a quality sensor there you see at the top of that, that monitors the temperature of that freezer the entire time. So that's something. You can put extra blood in there, or if you have issues, you can just leave that there for extended periods. Okay, next, next slide.

All right, so this is the criteria, and basically this is shock index. So when you get, you know, if you're looking at the ratio of the systolic blood pressure and heart rate, but systolic. Systolic blood pressure less than 70. If this is a no, is it just. That alone is a criteria. Systolic blood pressure less than 90 or heart rate greater than 110. And that's where you're starting to see a shock index above 0.9. And that's where your mortality increases. Age over 65, we go with a shock index of 1. So just when systolic blood pressure and heart rate are the same over 65, they get blood and then the end tidal CO2 really reflecting as we. As we look at that for sepsis, that patients in shock. So all of those are indications for giving the whole blood. And then next slide. So here's our data. And before I go into the data, I just want to say it's important to have the equipment, it's important to have the purpose for why you want to do this, the purpose for the whole blood.

And.

And I remember my niece Taylor, when she passed away, and I always think about what the fire rescue personnel had in those first 30 minutes to resuscitate her. And, you know, that's the thing. We want to give this therapy so that they can resuscitate in those first 30 minutes. We know it's not the golden hour, it's the golden 30 minutes. And in addition to the equipment and the purpose, you create a culture around your organization. Chief Clark and I have incredible people. We have. Steve Gravanic is our lieutenant. That guy is a legend. He constantly pushes whole blood. Every time there's a case that could have been whole blood, he goes back and educates the personnel. We have EMS captains Kensie Santill, Tom Kencey, Dean Meadows. These three guys. This is their. It's almost like become their life's mission to make sure this works without this kind of support around Chief Clark and I, and of course the fire chief and the sheriff. Do we have administrative support, but boots on the ground. These guys love it. They live it and they push it, and it's incredible. So this is our data here. You can see this data. We actually have given it 74 times now is the official count through 2020, since 2021. But this, from this data here, you can see we had. This is 60 patients with a 70% survival, 42 patients survived. And these are patients we're giving to. We're giving these patients. These are in hemorrhagic shock or sometimes in cardiac arrest. So. And then it's actually broken down by unit. We give it on air rescue. And also, I should mention the air rescue guys. That's another component of this. The air rescue people, they're masters of the equipment. They understand this. And I would put those air rescue guys against anybody. I mean, they really are phenomenal. So. So they also are a component of this. But we give it out air rescue and then our EMS, 17 ground units, we've given it two times so far for medical GI bleeds. And those cases, they intercept when that ambulance is on the way to the hospital, they'll intercept en route and jump on the rescue and give the whole blood. So it's fascinating. The next slide, I have just three cases. I wanted to just give you an idea. Out of the 74 cases, one of the first cases that we had was in April of 2021. This was a motorcyclist on Alligator Alley. And he complete amputation of his left leg. He was exsanguinating. They put up tourniquets. He was in shock. They gave him a unit of blood, and by the time he was. They gave unit of blood and plasma. By the time he was getting to the hospital, his vital signs had normalized. He was talking about motorcycles. And now he still got more blood while he was at the. At the trauma center at Kendall. But the folks at Kendall reached out to me and they said, you really did save this gentleman's life. And what you do with the whole blood. They're very.

Pleasant in that regard. And that actually started our. It sort of gave us like the spark, you know, we had one win. And then we said, man, this actually does save lives. And that's where people really started getting on board. Then we had this case in December of 2021. It was a boating injury. This gentleman actually came to Eagles with his family. He was out spear fishing, and a boat ran over him, and he had penetrating injury from his head, neck, torso, his extremities. He eviscerated. His intestines were actually outside of his abdomen, and he's in the ocean. First thing I thought was, how does this guy not get bit by a shark or something? His friend was with him, with a spear, guarding him as they swam back, guarding him so that shark didn't attack him. And anyway, they get to the shore and again he's in hemorrhagic shock, mental status deteriorating. And Dean Meadows, actually our captain, he gave him whole blood and Dean describes it, he goes, man, he went from looking like he was about to die and by the time he got to the hospital he was already turning the corner. And it's just amazing. So the guy I remember, the patient actually said, he goes, I don't know what you're giving me, but keep giving me that. So it's pretty awesome. The next case I wanted to talk about is happened in February 2022. This was a very incredible case. This guy was hitting an oxygen tank with a hammer. He was trying to remove the top valve and the tank exploded. He lost his left arm and his left leg and he was again exsanguinating. Fire rescue personnel did an amazing job putting up tourniquets.

And packing the wound. And this gentleman actually went into cardiac arrest. They resuscitated him with whole blood plasma using the life flow and they actually got his pulses back en route to the hospital and ultimately he got more blood, obviously went to the or and he was discharged from the hospital neurologically intact. So these are the stories and we got more stories. Candice just text me said we had another win and that's true. We're getting a lot of these wins. The momentum is there. So I feel like more than ever I'm confident in this therapy. I know this is the right thing to be doing in the pre hospital and I'm grateful for the team effort and everything that's happening in Palm beach county and Dade county and Dr. Pepe's efforts in leading this whole thing. So yeah, thank you all for putting this together.

Wow, Jim, that's incredible. I'd love to hear the stories. I'm going to throw in another story before we pitch it over to Charlie. In Daily Fire, we had a patient, a lady got hit by a scooter, no helmet, she broke some cervical vertebrae, et cetera, some brain bleeds. But EMS 17 happened to be passing by. We went with our TBI protocol. We gave her whole blood. She got admitted on August 12, she just got discharged on August 30. Neurologically normal. Neurologically normal. Incredible. So I mean all the stars aligned for that, for that girl. 20 something year old girl.

Awesome.

I want to, I want to pitch, I want to keep moving and pitch it over to Chief Coyle and Madonna from the hospital side. We just got started, and again, Chief Clark and yourself have been doing this on the. On the Broward side. Charlie. And a number of individuals in Palm beach county been doing on the Palm beach side. So, Chief Coyle, take it away and give us part of your experience and some of the good, you know, the good, the bad, and the ugly, if you will. And then we'll pitch it over to Madonna from the hospital side as well.

Yeah. Thank you so much, Dr. Antevi, and thank you so much, Dr. Roach. We got so much from your team. I can't tell you how many phone calls I've had with you, Chief Clark, your lieutenants, your EMS captains, Candace, down in the hospital system. You know, Broward has just been so pivotal for us to be able to open the gateway to. To potentially save some lives. So I want to just give you a quick demographics on Palm beach county for those not familiar. Palm Beach County Fire Rescue, we're just completing our 50th fire station. So we have 50 fire stations. We cover approximately 1800 square feet, or square miles, I should say. We have two helicopters owned by the healthcare district that are staffed by our paramedics as well as our nurses. We have eight EMS captains on shift per day, and then we transport to 20 hospitals. Two of those hospitals are level one trauma facilities. And I think that's important because our approach was a little different. We started with the trauma facilities, and that's where all the headaches came in, like Dr. Antevi said at the beginning. And it wasn't bad headaches, it was just all of the trauma surgeons variants of opinions of fire rescue doing this prior to the patient arriving. However, once we started, everyone was very crystal clear on what patients were going to be receiving blood, and I'm going to share some of those cases with you. So currently now our inventory is we have one unit on each of our helicopters. So we have two units at the Tomahawk, which is two helicopters, and we have one. One of the units on our EMS captains. It's EMS 23. We ran the data centrally located so we can get that EMS captain up and down the turnpike if needed. It also works at various pickoffs points as needed. So so far we've had very good luck with this mantra, I guess you could say, of what we think is going to work. But essentially we only have five cases enrolled, but I want to share the cases with you. So case number one was A. And by the way, the first four cases were all under the age of 20. Case number one young man involved in a single, you know, a single motor vehicle collision struck a pole. By the time they got him out of the vehicle and put him in the back of the truck, unfortunately, he was already in asystole. They went ahead and gave the blood. We had no luck on resuscitating this young man, but everything went smooth. Blood was administered. We, we have the same setup that BSO is using. We used the warrior, we used the life flow. Blood was in three minutes, no problem. Second case, very interesting though. This young man was involved in a motor vehicle collision and was ejected from the vehicle. He was unresponsive, had lacerations all up and down his body and was combated. When the crews got there, they put him in the back of the rescue truck. They started to work on his airway. They secured the airway and they noticed his vital signs. Vital signs were 80 over 40. For his blood pressure, his heart rate was 140. They transferred him over to the helicopter for a four minute flight to the level one trauma center. During that time, they administered the blood and the vital signs. Upon arrival four minutes later, blood pressure 136 over 70, heart rate 102. The trauma surgeon did an immediate FAST scan, took him directly to the OR, where they found out several lacerations on his liver. According to the trauma surgeon, they were all coagulated at the time of operating. So he highly attributes this save to whole blood. Case number three, again, this was a traumatic arrest. Came from out west. You know, it seems like everything that we did just was gonna be futile care at that point. The crews did a great job though. They did bilateral finger thoracostomies, et cetera. No luck. But case four was very interesting as well. And I think there's some very important points here. And I'm gonna turn it over to Madonna to explain case number four because it did go to her hospital. But this patient was young. As a matter of fact. I'll just give you the age because it's easier. He was 15 years old. He was shot six times, was put in the back of the rescue truck, was pale, diaphoretic. They went ahead and administered fluid because our EMS captain was intercepting them because the trauma hawk was out on an inter facility call. His initial systolic blood pressure was 70 and he barely had any palpable pulses. They administered 500 of normal saline. They got his blood pressure up to 80 over 50, but his heart rate remained at 140. The EMS captain actually had one EMS captain in training was great. It was the Perfect storm for success. One of the EMS captains got up by the airway and set up for a dsi. Because of the mentation of the patient at that time, they administered a unit of whole blood, which his blood pressure went up to 110 over 70. His heart rate went to 110. But the impressive part to me was his mentation. He went from being in the. I'm almost getting ready to get intubated to alert, oriented. Could tell you his date of birth can tell you everything that happened. And it really saved us an airway. So I think that saving of the airway after talking with Dr. Peel is very paramount. You know, I don't know what that looks like in the future. Do we slow down on taking the airway and focus in on getting the blood and do, you know, BLS airway until we get the blood in? I don't know. I don't have enough data. We do have one more case that we administered last night, but again, it was an ejection. Patient was in cardiac arrest. Cruz did an excellent job, but unfortunately, the patient did not survive. So I'm going to go ahead and turn it over to Madonna because she's working on our registry. She's our Candace of Palm Beach County. She's the guru. She's anything you need, trauma related, that is the person to go to. But before I turn it over, I just want to thank Dr. Roach, Dr. Clark, Dr. Pepe, our medical directors, you know, Strack, Dr. Winkler, and all the people out of Strack. Amazing. And New Orleans, we've got to tour all facilities and we really rip off and duplicated everything that they've done. So with no further ado, I'm going to go ahead and give it to Madonna.

Thanks, Chief. Appreciate you. That was awesome. Madonna Stotzenberg, the trauma coordinator for St. Mary's and Del Rey. Madonna, are you there?

Doc, she said she can't unmute. Maybe she muted on your end.

Oh, that's a good question. Yeah, let me. Let me see if I can unmute her. He.

I don't have the ability, Madonna, to do that.

Darn it. You want to try to hang up and call back in? Unless someone else has another idea in the meantime.

Basically, her notes, though, she wanted to talk about that fourth case, and that was that shooting. That patient had a hemo pneumothorax, had rib fractures, got a chest tube. They pulled out 700cc's of blood out of his chest. And ultimately his chest tube was taken out yesterday. And it looks like he's on the way to get released. That other case that we spoke about, too, the 20 year old that was in the car accident with the liver lacerations, he's already at home. So it does appear these two young men are going to be released home to their families. And we largely attribute to that to the work with Madonna and her team at the trauma centers. You know, it takes a village to get this done. And we're very thankful for the relationship that we have with them, even when we got to go down the dark roads.

Thank you, Chief. Appreciate that. Madonna, I made you an attendee. Did that help? I'm not sure if she's still on the call.

While waiting for Madonna to try to get on, I saw Chief Clark pop in, and I want to get. I wanted to give him a couple of seconds before I let Chief. Dr. Peel come in. Chief Clark, are you there?

Hey, Doc, can you guys hear me?

Yeah. If you want to go ahead and make a couple of comments and thank you for all the work you've done on this. Really appreciate it.

It's. It's a pleasure. It's a passion project, as it were. Charlie, I'm glad everything's working out up there. If there's anything else we could do, let us know. Dr. Roach, with your leadership, this is what's, you know, what we're doing. We've got another county on board. My understanding is down south they're looking at doing it. It's wonderful to see this expanding for anybody in South Florida, you should be expecting an email from me in the near future. In terms of our plans on how to try to increase blood supply and reduce cost, because we need to continue expanding this. It's not going to be enough to be on a couple helicopters and two ground units. We got to do more in order to really be effective and really change lives. That's really all I got. It's really magical. One other thing I will mention, Dr. Roach mentioned Dean Meadows. Dean Meadows told me he was actually very close to retiring until he actually administered blood. And it changed everything for him as a. As a practitioner because he said in 25 years of providing care to trauma patients, he never felt like he truly ever made a difference until that moment. It's. It's really magical stuff. It's wonderful. So thanks for letting us on, Doc. Continue evangelizing on this. And if anybody needs any information from us, it's. I'm pretty easy to reach. It's heathclarksheriff.org.

Amazing.

Thank you so much, Chief, for The commentary, I don't see. I don't see Madonna on yet, but I do see a couple folks from. From Miami. I see Chief hall, I saw Dr. Clift. So either of you want to come on and just either make a couple comments about where you are in Miami Dade, we'd love to see you coming on board at City of Miami, etcetera, or anything we can do for you guys down there. You want to unmute?

Sure.

I have a question. We've been talking already about a trial on our air rescue units, but my questions are in reference to ground units. In our case, our transport times are so fast, and when, like Chief Coyle, you mentioned, you put them on your EMS captain units. But my question is.

Do you delay transport in order to wait for the.

And if so, what's the threshold there of, you know, as far as how long you should be delaying transport in order to wait for the blood?

Chief Clark, take that one. Yeah, yeah.

I was gonna say, when it comes down to two things, it's gonna be proximity of where your ground is and the wherewithal of your officer on scene that that's taking care of the patient. To ask the question of where that officer is. I don't know how familiar with my county, but essentially the first time we did it was a textbook of what we want to happen. They were northeast of the trauma facility off of Federal.

They recognized they had a blood candidate. They asked the EMS captain where it was. He happened to be south and west of them. He took a main thoroughfare to Federal, stopped on the corner, basically hopped out of his truck with the cooler with the blood in it and the K flow, stood on the corner of the road with his thumb out. They rolled up, he hopped the truck, and they took off. The truck come to a stop, I don't think stop. So I really. I mean, you're talking about going down 45 miles an hour, back down to five, right back up to 45. They gave blood and route. That patient did very well. And we've done this, I think, four times now. One time intra agency, I'm sorry, extra agency with Davey, which worked out fantastic. So it's proximity and knowing your routes and your zones and that. That really comes down to the practitioners out in the field, but it works really well.

Awesome. Let me and Chief hall, hopefully that was. Answered your question. But we only have a few more minutes, and I wanted to bring in Dr. Peel. And number one, he could probably also add some color to that last comment. But then. But mainly I have asked him to come on here to talk about the registry. Many of you know, I mean, I know Mark very well. Many of us have come to, you know, admire him. He's a creator of the life flow. But Mark, talk to us about the, the two lane registry with Dr. Duchesne. Paul's been involved in that. I know Madonna and so forth. Give us an update if you can. Thanks for joining. Jeffy, can.

Can you hear me okay?

Yeah.

This has been really inspiring. Thanks for inviting me.

Just.

I think you mentioned my disclosure, but I have, I do have a conflict in that I'm one of the inventors in the lifeload. But we created it for this very purpose, what these guys are describing. And the New Orleans Group now has 80 cases. They are soon to be presented at the Western Trauma association meeting and then published. And they're interested in adding additional data from other agencies to their registry. So to double and triple those numbers readily, it would take some of the folks in Florida. There's a Virginia group that's going down that path. It takes creating a data use agreement which is ready from Tulane and an IRB approval at your hospital. So Madonna.

Has been active in this happen at her hospitals. It's not super easy. I think she's probably smoothed the path now and knows how to do it better. But your hospital has to create a data use agreement so that the hospital level trauma outcomes data can be entered in their red CAP database. Then irb and then I did want to address that. The transport time. I'll just address that real quick. The two lane data has shown that they have not impacted transport times at all. In fact, it looks a little faster analyzing that data now. But their transport times remain under 10 minutes despite giving two units of blood en route. So I think the idea that short transport times mean you shouldn't resuscitate with blood is probably not true. And you have a method of giving it fast and warm. Anything else, Peter?

No, Mark, that was it. That was exactly what I was hoping you would say. And yeah, I see Jim giving the clap. I think we're all good in the clap. I mean, you guys are all brilliant and really appreciate it. I'm going to make a proposal here. You know, I would love to have heard from the hospitals and I know there's some hospitals maybe on today.

Jim and I are going to try and meet tomorrow. And I know Chief Clark and I, we've spoken about this before, but I think it's time to go and move towards a south Florida whole blood coalition where we have Palm Beach, Broward, Miami Dade, we get on a zoom. We get the hospitals involved. We not only share information, tactical information, like we did today, but then we also get the hospital folks involved, have surgeons talk to surgeons, have trauma coordinators talk to trauma coordinators. But more importantly, in Broward, where we have umpteen different departments, we don't need every single department to have their own setup. I believe we should look at the map, and we should. Just like the trauma centers are spread out, I think we should have blood spread out. In Davey, the case I relayed to you earlier, we happen to have blood because I believe it was Dean who was driving by and happened to pass by our trauma. But we need this everywhere in a coordinated, organized manner. But before I end, let me bring in Dr. Pepe. Dr. Pepe, you know, you're the one who has really brought a lot of this literature to the forefront. You've led us in so many different areas. What words of advice do you have? And then do you have any information on the outcomes from the survey?

Okay, yeah, I'll try to. Just have to whip through this. First of all, it's a congratulations to everybody. Once again, Florida is taking the lead in these great areas, and this is a good example of it. Just a couple things I wonder. We heard people today, Dr. Roach was mentioning that, you know, how the components are better if you have that one whole blood versus the components. And also if you're a nurse, I think one of the things Madonna might have told us is that you only want to give one thing or have to check the transfusion numbers. You know, on one thing, it's just so much easier. So that could drive things further. And I think what we're doing is driving the hospitals to also have the blood available as well. And I think that's really an important part. Charlie knows that very well. And I think one of the reasons why that's important is that.

Is that you just make sure that there's also a source there, let alone a continuity of care as we get in there. The other thing I was going to say was that the blood versus some of the other things we've been told to do in the past.

Actually protects the glycocalytes versus the fluids, you know, knocking it out. And I think that's why we can probably get away, even with an actively bleeding person with the blood. We may actually make some people worse. We may. But I think on balance, we're going to make things better for some people. And we see. And then the other thing is that people will criticize it, saying, well, you just have anecdotes so far. But these anecdotes are very good anecdotes. It'd be like saying let's no longer resuscitate people with asystly or pea because we only get 5% of them back. Okay, but you're going to probably be doing this here. And I think it's be more than 5%, quite frankly, because the healthy people who have a lot more resilience and then think about just. You want me to do the survey? I can give you about three or four quick tidbits. Is that okay? Peter, you're on meat. Peter.

Go ahead. It's okay. This is going to be really rudimentary. And by the way, there are cases of what Jim and doing I was talking to Chief Clark there, Dave. They have up to 80k 100 cases and there's a lot of good information. We'll be writing that up soon and we'll get this exported, you know, because we're doing great work done here. And then so the what I was going to tell you was the 50 cities that we look at, these are the metropolitan. It turns out that I was surprised. I thought 5 or 10% of them were doing it. Turns out one third of them are now doing it. And all this has been started within about 20, 21 was most of the start dates that we looked at. So that's interesting about.