With blood on hand, paramedics can save more people en route to the hospital

An early transfusion can save someone’s life, but it’s not a widespread practice.

By Michael MarksDecember 1, 2023 2:58 pm,

Whether someone lives or dies after a traumatic injury can often be a function of time. The odds of surviving massive blood loss go down with each minute that ticks by without treatment.

A lot of people die this way. In the U.S., traumatic injuries kill more people under the age of 45 than anything else, according to a new series by the Dallas Morning News and the San Antonio Express-News: ‘Bleeding Out’ looked into the causes and solutions for trauma-related deaths.

Lauren Caruba, an investigative reporter for the Dallas Morning News who wrote the series, spoke to the Texas Standard about its key takeaways.

This transcript has been edited lightly for clarity:

Texas Standard: I understand you spent more than two years looking into how people in Texas and across the country were treated for traumatic injuries. How did you get into this?

Lauren Caruba: So how I started reporting this series is actually kind of interesting. My reporting began all the way back in 2019, actually, when I was the medical reporter at the San Antonio Express-News.

And they have a really innovative blood program down there where they have blood out in the field for paramedics to administer to injured patients and patients with other major bleeding – so think, you know, ambulances and helicopters across the region.

And so I started reporting on that program down there, but brought the project with me to the Dallas Morning News. And the two papers worked together to publish this series, which is about the solution to what they are doing down in San Antonio, which is patients bleeding to death before they can be treated and bleeding to death of injuries they could have otherwise survived.

You know, I was struck by this statistic: Traumatic injuries kill more people under the age of 45 than anything else. But I was remembering seeing reports from health officials in the U.S. that cardiovascular disease, cancers, respiratory disease, diabetes, that sort of thing, all of these kill hundreds of thousands of people every year.

Could you explain how you came to the conclusion that these traumatic injuries are killing so many people? 

Yes. So the thing to keep in mind here is that we are talking about, you know, children and people up through the age of 45. So we are talking about a really young demographic, actually.

And the reason why traumatic injuries – so think people who are injured in car crashes, shootings, falls, any type of accident; you are adding all of those different categories of deaths together. So that can include homicides, suicides, car crashes, pedestrian fatalities.

So when you add all of that together, you have a public health crisis that is much bigger than just traffic or guns. It’s anything that causes this major disruption, this major injury to your body.

Smiley N. Pool / Dallas Morning News

And this trauma doesn’t have an even impact across the population either, right? 

That’s correct. It disproportionately affects young people, which is why it’s actually the leading cause of years of potential life loss. This is something that health researchers look at, and it – far and away more so than heart disease or cancers – steals years of productive life from people, cuts lives short.

Well, let’s zoom in on Texas. How does the Lone Star State stack up when it comes to the mortality rate of people who have one of these severe injuries?

So in our series, we actually did this analysis where we kind of looked at not overall mortality rates, but basically the proportions of patients who die from their injuries before ever reaching a hospital. And we did this national analysis to kind of figure out which patients are dying before they get to a hospital, because many, many of these massive blood loss deaths happen before someone ever gets to a hospital.

And what we found in our analysis is that where you live can often determine whether you live after a major injury, because time is such a factor. And our level one and two trauma centers, which treat the most injured patients, are not evenly distributed across the country. We found that access is much better on the East Coast versus Western states and things of that nature.

So we found that Texas was the 17th worst. So kind of like, you know, I guess that would be the bottom quartile or something to that effect. And we are such a big state that, you know, it’s one of the reasons why – if you’re in a big city like Dallas or San Antonio or Houston, you might be able to get to the hospital very quickly. But, you know, as soon as you go out into the more rural counties, that becomes a very different situation.

Time is critical. The studies have shown that basically the peak to death for severe hemorrhage is around 30 minutes, which is often before a lot of patients can even get to the hospital, let alone get into surgery and get the treatment that they need.

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Well, what about the general guidelines that first responders use when they’re trying to treat people who are severely bleeding?

So what we found is that there is wide variation in the treatment that bleeding patients receive across the country. So there are, of course, standards for paramedics to use and EMTs to use. But what we found is that basically the resources that those local paramedics have have much to do with the type of treatment that you receive.

In some cities such as San Antonio, Austin, New Orleans and a growing number of cities, paramedics are armed with blood and blood products. So basically they can administer blood to you on the way to the hospital. But the vast majority of paramedics across the country do not have blood products.

And so if you are lucky enough to be in San Antonio when you get in a car crash and you’re bleeding severely and you need blood, you’ll get blood on the way to the hospital. If the same thing were to happen in Fort Worth, unless you were picked up by an air ambulance company, that’s very much likely not the case.

So really, all you would get in that scenario is saline, which is just salt water, and some drugs that might help slow but not stop the bleeding altogether. So what we found is that you can have very, very different standards of care across the country, just depending on where you are.

Smiley N. Pool / Dallas Morning News

Well, why is there this disparity? I mean, you mentioned San Antonio and what they’re doing. There must be some sort of challenge associated with keeping blood on hand in like an ambulance or helicopter, or am I missing something there? 

Yes, there are some some challenges. One of the big things is cost. Blood products are costly. So a bag of whole blood, which is just the same as the blood in your body, it goes for around $500 a pop.

And there’s some interesting kind of regulatory issues, kind of insurance issues, where basically EMS providers – so like, you know, paramedics – they are not reimbursed in the same way that hospitals are; their services are not itemized. So when they transfuse blood outside of a hospital, the reimbursements that they get back from, like CMS, so Medicare and Medicaid, and other private insurers just don’t cover the costs of something like that.

There’s also, you know, of course, logistical issues. You have to keep the blood from spoiling. You have to keep it at the right temperature. It also has a limited shelf life. However, there are programs – like in San Antonio, Austin, New Orleans, Seattle – that have found ways around these barriers, and they have built these systems where they’ll have the blood out in the fields for a certain amount of time. Then they’ll send it to the hospital where it can be used on all of the different patients that come through the hospital. So very little goes to waste.

And this is something that military medics have done for years, you know: pre-hospital, in-the-field transfusions. This is not something that’s insurmountable. Like, it can be hard to get a blood program off the ground. But then once you do, from all of the paramedics that I’ve talked to you, it makes a huge difference for patients.

Sometimes when you’re dealing with medical situations, one of the big obstacles is concern about liability. Did that come up in your reporting when you were asking questions?

Not so much, actually, because … giving blood to a bleeding patient is something that it’s a basic tenet of trauma medicine and just medicine in general.

You know, the first kind of early transfusions, when they had figured out blood typing, it was like, World War I. And throughout all of the wars of the 1900s, like hundreds of thousands of units of blood were used to treat injured soldiers and, you know, wounded troops.

This is something that is is very well studied. And using Type O blood to revive a hemorrhaging patient is just a basic standard of medicine. So that’s not something that came up as much because really the big difference here is like not giving the blood itself, but whether you give the blood in a hospital environment, where it’s typically administered, versus giving it out in the field.

I see. And type O because it can be administered to a lot of different blood types, right? 

That’s correct. The most universal blood type is Type O-. But what we found in our reporting is that you can actually give certain kinds of Type O+ blood to any recipient as well, so long as they do this additional test for antibodies. So basically, if the antibodies in Type O are low enough, it won’t cause any harm to the recipient.

So we see a combination of Type O positive and O negative blood given in these emergency situations before they can know the patient’s blood type.

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