What's the Whole Story About Whole Blood Transfusion?

This is the East TramaCat. Welcome to our next edition of the TraumaCast. I'm Carrie Valdez from Spectrum Health in Grand Rapids, Michigan. Before I introduce our guests, I'd like to say thank you to Humanetics for their generous, unrestricted educational grant and support of the East Online Education Committee.

Now on to our trauma cast. We're recording on Wednesday before Thanksgiving, and as we do introductions, not only will you all let the audience know who you are and where you're from, but I'd also like to know your favorite holiday dish that you're going to enjoy tomorrow, even if that means it's the mashed potatoes from the cafeteria. As I highlighted in our last episode, the online education committee members interested in hosting the Trauma Cast will be joining.

Today, Lauren Dudas, a trauma surgeon from West Virginia University, will be our host. Lauren has invited expert guests in whole blood transfusion, a topic that frankly I don't know much about and I'm really looking forward to learning from. As our new host, Lauren, we're going to start with you for introduction.

Please let us know who you are, what to do, and what are you going to be enjoying tomorrow. All right, I'm Lauren Dudas. I'm a trauma and acute care surgeon from West Virginia University. I hope that I'll be enjoying some of the greenby casserole tomorrow. I think I could do the whole thing by myself. I actually already made my green bean casserole sitting in the fridge waiting to go to the oven. The old school like French's onion like can of green beans. Yeah, I'm ready.

Um Don Jenkins returns as one of our favorite guests. Don, in uh in case there is anyone out there who doesn't know you, would you please introduce yourself, let us know what you're up to, and what are you gonna enjoy tomorrow?

Yep, uh my name is Don Jenkins. I'm a trauma critical care surgeon from UT Health in uh San Antonio. Had the uh great opportunity to uh be the president of East for a year, about a decade ago, and since That time we've invested a lot of energy and mileage into establishing a whole blood. as a as a thing. In terms of tomorrow, it's gotta be the stuffing. Uh stuffing and gravy. Just there's no replacement

So is your family like uh stick the stuffing inside the bird or or do you think uh stuffing in a pot? Absolutely. Great. And Dean Grabo, welcome to the Tramacast. Uh if you would please introduce yourself and let us know a bit about you and what are you doing here? Thanks, Carrie. My name is Dan Gribo. I'm a pharma surgeon, acute care surgeon from West Virginia. I'm partners with Lawrence.

It's great to be here. So thank you for that. I'm looking forward to some smoked turkey tomorrow. Uh since we moved to West Virginia we found uh a farm up the road from us who provides us with smoked turkeys, which is a delicious treat uh we found here in West Virginia. I didn't get that as in L.A., huh? No, not in Los Angeles. That sounds amazing. Dan, what did you do in the military?

I was a navy trauma surgeon. I was I ran a navy trauma training center at LA County, uh for about five years before I got out and I deployed to Kandahar as the chief of trauma. That was one of my uh deployments. Well some rotations and uh deployments on aircraft carriers. And Donna, what was your service?

So I spent a little little over 24 years in the uh United States uh Air Force, uh learned to speak army in the war. Uh and uh we did this little thing uh where we uh set up a trauma system uh for all the disparate units across uh two countries. Uh for the for the war. The estimate is somewhere in the neighborhood of uh over 10,000 uh soldiers probably alive today uh who wouldn't otherwise be based upon the change in mortality from pre-system to post-system.

uh just a matter of getting the right uh individual to the right resources, which is uh one would think that our Department of Defense would have that little uh thing uh like in a in a playbook but nope. No, they did not. Well, thank you everybody for joining us and uh for taking some time out of the holiday week. We have a really great panel. Lauren, I'm gonna turn the trauma cast over to you.

All right. Don, can you start us out by explaining what is whole blood? So uh whole blood is the uh unit of uh blood. The donor, you know, sits in the chair and donates. It's got a little tiny bit of preservative in it, but they don't separate it into its component parts. It just goes uh from uh the donor to the fridge and then it undergoes uh all the same testing uh the you know red blood cells would undergo.

uh when we draw whole blood, draw exclusively low uh antibody titern, uh O-positive whole blood, as our main uh donation type and unit. the majority of the people in this country are O uh blood type. The uh negatives, the R H negatives uh comprise uh about seven percent of the population and that's scattered amongst the A's, the B's, and the O's. So uh therefore most everyone, more more than 90% of the population is RH positive.

Uh and that's how we can uh get away with uh uh doing that. So I guess my my first question is why did we go to separating the components? Why didn't we just stick with whole blood from the get So the history of uh components uh separation

dates back into the late sixties, early seventies. Uh we started to uh poison patients with chemotherapy agents, uh harming their bone marrow, causing thrombocytopenia. And so the hematologists and the blood bankers got together How to separate platelets and what a combination of temperature and agitation or no agitation, uh, would provide the biggest bump in the platelet count for the longest duration of time. uh in these uh uh chemotherapy thrombocytopenic uh patients

And so that's when the breaking uh things down into the components uh started. We also uh began to uh treat uh hemophiliacs, and they don't need necessarily whole blood because they're bleeding and uh unfortunately we literally threw the baby out with the bathwater. and went all on full component and got rid of uh whole blood altogether. The first sixty or so years of transfusion in this country was exclusively with whole blood.

And uh sadly we're now two generations away from uh experience uh and knowledge of this. because we just haven't been able to uh uh get access to uh whole blood or train uh too but uh dan and i have uh uh have a shared experience in terms of uh the only source of platelets in the combat zone is walking around

in the veins of the other soldiers uh and marines. And so to administer a a life-saving uh blood transfusion that involves platelets required uh the use of whole blood. So by necessity picked that back up. We saw remarkable abilities. of whole blood to resuscitate a badly injured, bleeding, hypotensive patient and decided we need to bring that back home. How do hospitals get blood? How do they pay for it?

Why wouldn't everyone jump on board with this? Why would we stick with components? Is there a financial underlying drive to how this whole system gets laid out. It does make the blood bank uh team a little uh a little crazy uh because it's nearly a dual inventory that they have to maintain and you could envision how a bag of red stuff Could get mixed up with another bag of red stuff, thinking that it's red cells when it's actually whole blood, or vice versa.

Uh and so we had uh we created some special like you can see it from the from the end of the room uh tags to put on uh the whole blood units so to easily easily denote them. Same thing is happening with our cold platelet program because a platelet is a platelet is a platelet. And so we have to specifically designate them so that it's easy to be seen.

Uh when we started uh the cost of the whole blood unit uh was more than the three-part component uh transfusion, uh and our waste sat at about 11% because we set these limits on ourselves as to who could get it and how much they could get and where they could get. Once we lifted all the restrictions, the waste is now less than one point.

We haven't lost a unit of whole blood this entire calendar year. It's all been transfused to to our patients. And because the of the decrease in waste, the cost is now uh less than the three components. uh put together uh to get the whole blood. So there is some financial advantage uh to it uh once you figure out your management.

I think we're still at because of our restrictions, we're still at not showing so much of a financial advantage at this point in time. We're just still trying to figure out how much we need and we certainly hit the uh hit the wall recently where we're starting to use less blood. Uh showing some so to say wastage. And because of that, we're uh starting to show that we're maybe losing some uh based on money. We're still showing that we're spending more for the whole blood than we should.

And so but uh our group is not so much focusing on that. We have a good group, uh the blood bank is very committed to growing the program, realizing that trauma, especially in this area, is is certainly cyclical with the weather and uh we're in the downtime. And they they certainly saw the heavy usage over the summer months. Um and they know that we'll increase our purchasing of the whole blood during the the summer.

As we've transitioned back into whole blood a lot of our literature has come from military setting and now we're trying to generalize that to the civilian sector. Can you talk a little bit about how some of the military settings might differ from some of the things we do? Sure. And I think uh Don kind of alluded to uh some of that what we had in in theater was

Certainly, uh prior to cold stored whole blood and the cold stored platelet concept, the components were stored cold, but we didn't have platelets. So certainly when we went to think about one to one to one resuscitation. We only had two of those components, the uh packed cells and the plasma. able to give a massive transfusion scenario in theory, but we didn't have the platelet.

So to say. But what we did have in in our soldiers, our marines, our airmen, and our sailors walking around was fresh hold blood. So the concept was is activate a walking blood bank, rapidly collect.

pre screened donors from your your unit, your combat unit from continental United States who would been pre screened, we know who they are, uh, what their blood type was, and we can send out a message over the loudspeaker, so to say, and get the uh donors to come to the medical treatment facility and donate fresh whole blood so we're able to give our bleeding trauma patients fresh whole blood and give them the components all in one resuscitation bag. So

And with that we saw tremendous resuscitation capacity with the threshold blood transfusions in the military. I had completely forgotten about the big voice uh this loud speaker system. Anybody that used to watch man. uh you'd be familiar with that uh speaker they had up on the telephone pole that they would call out uh announcements, but at the end they never said that is all.

You talk about a your fresh whole blood in a walking blood bank with service members who were pre-screened, but they're pre-screened for their blood type. How did you all ensure that it was safe? I mean, right now the Red Cross Do you just say that we just have to accept that this is a risk and we're trying to save your life right now? Pre deployment, the uh soldiers are all tested for a number of things before you can leave to go to the combat zone to include infectious diseases.

if they follow the rules of engagement, they can't get an infectious disease. That's a incredibly important point because that's why it works in the military, right? So we can pre screen test, ensure safety once they, you know, get on a plane, get on a boat, whatever, get over into theater. And that's why we can theoretically ensure safety for the deployment theater, uh, but you can't necessarily say

Okay, uh there's a big explosion in Morgantown, West Virginia. Let's activate a walking blood bank. But we pre screened half the population in Morgantown, let's just activate the walking blood bank. There's no uh safety mechanism for that. That's why it won't work in the civilian world for the most part. Were sent from Iraq and Afghanistan to Germany. We're in the laboratory up there. They screened all of the donors' blood.

We knew who donated what unit to which individual, such that if there were a positive infectious disease test in Germany on that donor's blood, that we could track down that casual. Through the system. uh be it uh in the uh national capital region out in

uh San Diego or in San Antonio uh and address uh any uh transfusion transmissible disease issues at that stage. To the best of my knowledge, there were three individuals out of uh about 10,000 units of whole blood administered who ended up with a a potentially transfusion transmissible disease. in all of those cases those uh individuals got blood at multiple locations from multiple sources it was never able to be tracked back to a

a ultra fresh walking pole blood bank uh donor. You mentioned earlier about low titer. For those of us who aren't familiar with the lingo pole blood, can you explain what you mean and is there at a universally accepted level?

Yeah, so checking antibody levels in in blood uh is uh little tricky, mysterious business. uh because there is no set method uh for doing it. Different uh blood banks, different laboratories do it in different ways. It usually is a dilutional uh event. Uh and uh one to two fifty six is uh considered to be uh a safe level of uh antibodies in those uh specimens.

Uh the folks in Pittsburgh uh really went overboard to protect their patients. Uh they got that down to one in fifty, uh, which is uh really no uh no you know, practically no antibodies of any kind. Again, we've never seen We didn't do tigering on the whole blood in the in the in the combat zone. Uh we haven't seen uh any transfusion uh reactions uh to date.

uh in the whole blood program in Rochester, uh, Minnesota, in Pittsburgh, in San Antonio, Bergen, Norway, the Israeli Defense Forces in Israel. Uh just haven't seen any transfusion reactions uh to date.

I do want to talk quite a bit about um getting a program started. In 2016, we were lucky enough to host Dr. Philip Spinella and Alan Murdoch on the same topic. Can you guys talk about what you think are benefits to whole blood or what we've learned about in the past four years? So one of the things that I would uh say

And these are magic words uh when it comes down to uh your question, Lauren, about getting a program started. Uh what that when you uh talk to your blood bank team and you mention the word donor exposure. That's like uh and they just buckle at their knees uh when you say, well you know if we gave the patient a unit of whole blood, that would be a single donor exposure versus giving them one to one to one, which would be three donor exposure.

It's kind of like part of their oath that they take when they when when they turn into blood bankers uh is uh is to uh promise to limit donor exposure. And so when you use those magical words that really that really makes a difference. And if you think about it, I mean that's pretty it's it's kinda surgeon proof in a way. You bleed whole blood, you replace whole blood. I mean that's I don't know. Um I'd even say anesthesia proof.

Yeah. Yeah, that's like that's the green bean casserole right there. Yeah. Yeah. I think that's one of the keys. It certainly gives us the opportunity to ensure that we've achieved that one to one to one resuscitation ratios right off the bat. And I think we all struggle whether we're uh cognizant of it or not when we're in the trauma bay or like uh Lauren said with anesthesia when we're in the operating room.

the plasma, the yellows kind of seem to fall off and it's a high a amount of reds. And I think the the whole blood certainly helps us fix that problem right off the bat. So I think that's some something we can certainly hang our hat on when we

try and discuss this with our our colleagues around the around the trauma bay table, around the operating room table, uh and try and encourage them to at least think about it and look at it. One thing that we've talked about a number of times And trauma cast and it seems like it it a lot of MMs is the use of tag because there's one-to-one to one.

And then tag-based resuscitation. Do you think if if we did whole blood resuscitation, we would just eliminate the need for tag to be part of our transfusion plan? So I think that in the early resuscitation scheme.

You got a patient that meets your criteria to be transfused. Uh most of us are just gonna react and do the transfusions. I think subsequent rounds of transfusion. uh probably should be targeted by TEG. Uh number one. Number two, uh the relatively limited amount of whole blood available at any one institution and the restrictions that uh the blood bank potentially places on uh the clinicians in terms of what they could use. I've I've seen places where, uh for instance mayo c up in Rochester

They collect a whole blood unit a couple of three times a week. There are days at a time, they have none. They we had an artificial limit of four units of whole blood per patient when we first started our program because they weren't sure what the inventory management was going to look like. Subsequently we've lifted all those restrictions and uh got thirty six units of whole blood sitting in our blood bank uh as of this morning. The uh

uh army program uh does not participate with the civilian blood bank uh team here in San Antonio. They draw their own blood from their own active duty and retired population. Uh they uh had used a different preservative that had the shelf life of twenty-one days.

Uh they were wasting a lot of blood sending it uh from San Antonio to the combat zone because by the time it would get to where it was going, they had about five days to use it. So they changed the preservative, got the shelf life date out today thirty-five. Uh there's been a decrease in the uh need to send uh because the uh shelf life is just longer, therefore there's also In waste. But uh even at BMC, uh Brook Hardy Medical Center, uh, they have a limit of I think it's four or six.

uh units uh per patient and they will only allow it to be uh transfused while the patient is in the trauma area. Once they leave the trauma area then it's components Uh these are all artificial rules of engagement. Uh I don't uh necessarily uh agree with them. I don't disagree that you have to um have an active uh uh blood management. uh scheme in place so that you can manage your inventory appropriately. Uh it would be just as wasteful to use

A two-week old uh unit of whole blood while throwing three units of red blood cells that are gonna outdate by the end of the day in the trash. And so I do think that we want to use uh every drop of uh the gift. that the donors have uh provided. Uh and uh so I'm I'm willing to work with the uh blood bank team uh on those things. Once they get confidence uh and the and experience, uh th they have really loosened things up quite a lot. In fact, there's way more to that story I can add.

So do you work with your blood bank on a daily basis and decide, you know, who is gonna get what kind of units or is it based on need and the trauma surgeon just says what they want? More than daily. But who makes a call? Is it the blood decides which patient based on certain criteria gets whole blood versus components or is it the trauma surgeon gets to make the call, this one's getting whole blood, this one's okay with just

So um the way that we uh do things is that we have a highest tier trauma team activation. Uh Blood Bank Response. We don't have a satellite blood bank fridge up and running yet in our trauma area, but that'll happen in about two weeks. that that refrigerator will be stocked only with whole blood. When the blood bank comes, they bring two coolers with four units of whole blood. Uh so the surgeons don't even get a choice. They they're gonna give whole blood to a bleeding trunk.

Once the patient gets to the OR, NGO suite, ICU, then the call is made by the resuscitating team, be that anesthesia or the surgeons. Um and it's it it's taken a turn for the surreal, quite honestly, in the past seven months. Uh, there are blood shortages everywhere in this country.

Uh back in July timeframe uh when COVID was really peaking in New York City, uh New York Red Cross had an unfilled order for a thousand units of red blood cells that no one in the country And so we are managing on a half a day's worth of inventory at our regional blood bank. Three days makes them a little uncomfortable. They really like to be four days worth of uh worth of uh average use uh rate of uh inventory. We're we're we're counting on donations made today to transfuse tomorrow.

Uh and uh there's a combination of things uh that has gone uh into this. Uh some of it is the uh people don't want to get near other people. Uh they were told if you're not essential, stay at home. to have the the mayor come on TV and tell blood donors that they were essential and that they needed to leave their home and and go and and uh donate blood. Between April and the end of the calendar year, we had over a thousand blood drives canceled in the San Antonio area.

These would be usually held at businesses and schools, but because of COVID, they did not want people to and then they just canceled. And we just put out another emergency plea earlier this week. uh because it is a horrible problem and everyone's facing it. So when we make the call to transfuse Uh it's almost 100% of the time we get a call from a blood bank pathologist to say why.

Are you sure? Why two? We're just going to send you one. Well, we don't think since the patient doesn't have that vital sign abnormality. use anything right now. That I'm I'm very unfamiliar with this territory quite.

Dan, are you experiencing the same thing in uh West Virginia? Are you having the same kind of blood shortages that uh Don talks about? No, but I think what's really interesting if we could, you know, kind of talk about this uh in a similar in this in the same topic is uh the differences in a mature whole blood system like Don has in San Antonio and

Well, we're just starting out in West Virginia and you know, we're a rural rural system, you know, uh, you know, only forty percent of the traumas, but you know, a good sixty some percent of the trauma deaths are in the rural system. So We uh are are a big voice in the trauma world, although maybe not so loud, but we're still there. Uh we're certainly not mature like uh like what Don has in San Antonio, but we started out and when we started out we

Brought on in. You know, he came in and helped us. He came in as our guest, uh, visiting professor. He was involved in, you know, webcasts with us to speak with our blood bank, give us guidance. Um And we were actually and to that the COVID point, we were actually supposed to start our whole blood uh system in March.

But because of donor shortages, we got delayed. Though the Red Cross is our supplier, we couldn't could not get whole blood until August. Uh so we were on about a five, six month delay before we were actually able to start our whole blood program. Um so what's what what we have going on is we allotted for six units a week that we purchased. We have a strict limit that uh we only give it to adults, priority one or highest tier traumas. They get two units max.

uh that they're allowed to uh be transfused based on strict criteria. Uh they have to show physiologic signs of uh hemorrhage uh as well as uh identifia identifiable source of hemorrhage. Um And then from there it's uh after those two units are exhausted, there's no more units of whole blood for the trauma patient. They go on to component resuscitation, either a massive transfusion activation or a tech direct resuscitation. uh directed by the trauma attending. So a very strict uh

as far as what we have. Now, when we first started it, we were still in our trauma season. And if uh Don remembers trauma you know, when trauma season was in Afghanistan, you know, it was certainly in the warm weather months and they shut it down in the cold weather months. Well it's just like in Afghanistan here. Uh cold weather slows it down. Um

And it's not a war zone, it's just that everyone's inside, no one's crashing their ATVs and whatnot. So trauma season has slowed down here significantly. But when we first started in August, we ran out of whole blood in the first two weeks. Um and we actually had to increase and purchase more whole blood, uh just to get through

uh based on our new protocols. Um and now we're actually not wasting it, we're giving it back. Uh we have an excess of whole blood here. Uh we're giving it back because our trauma volumes are back to normal. They're not down. They're just back to normal for the time of the year. Uh so Lauren Lauren knows that once you know the first frost hit so to say or the w the cold weather hits.

uh the holiday season it's people stay inside. Uh they don't go outside, they don't crash and whatnot. But once the warm weather hits and boating season starts and ATV season starts and the outdoors start We're at max capacity and we need the whole blood. So we're gonna have a cyclical use of our whole blood. Uh different, but uh very interesting to hear.

I think a well established cold blood system like Don has in San Antonio and what they're going through and then what we're starting with here. you know, starting out and then seeing the cyclical nature of uh rural trauma as well as, you know, time of the year type thing too.

So Dan, can you talk a little bit about how uh you got the whole blood program started or some of the barriers you encountered? So that's that's a great point. It wasn't so much um convince them of the value of cold blood. In fact I was I sit on the blood utilization committee like a lot of trauma surgeons and Q care surgeons.

On it, you know, we represent we're the ones that get, hey, there was this massive transfusion that didn't have the right numbers. Can you look at it? Right. That's what our job is. Um, but part of that was just uh the um the head of the blood banking uh head of the blood bank came to me and said, Hey, what do you think about whole blood? I think they can get it for us.

I said that's a great idea. He goes, Well that's great. I wanna get it. I think I'm I'm gonna get uh six units. I'll give some to the helicopter, some to trauma, some to the cardiac and uh program. I said, wait a second, that's you know, within a day there's me no whole blood for trauma. So

Let's figure out a plan, you know, a protocol, who gets the whole blood and all that. So that I didn't know how to do. I knew how it was done in a military world, uh, but I didn't know how it was done in a civilian world. So that's when I called Don. I said,

how do you set this up? Uh we have a willing supplier, we have a a great group who's interested in bringing it here, but then how do you order it? How much do you get for your your program? Uh so that was the biggest thing is just figuring out Who to bring in and that was easy for me because I know Don from our uh actually Don and I are from the same hometown area. Uh we went to the same school.

Might know some of the we're probably related some way down the road, I guess. Uh you're not from West Virginia though, right? No, we're from northeastern Pennsylvania. Even better. Yeah. Uh we're probably cousins. Uh but we both both went to the University of Scranton and uh we were did our trauma fellowship uh Penn, so we're uh we're all family up there anyway. Both military too, right?

So anyway, um you know, I called him, I said, Can you help me? And uh without a you know, there was no hesitancy there. Yeah, he, you know, got on the plane and showed up here and taught us how to do it. So that was the easy part getting them here. But then telling the blood bank, you know, we need six units for trauma and we're gonna tell you

how we're gonna do it. So based on what Don had developed in in Minnesota and as well in San Antonio, we put together our criteria for usage, who was gonna get it, adults. Priority one traumas, sh signs of hemorrhage, as well as physiologic response or a response of hemorrhage.

Um, and then we limited it though based on what the blood bank could supply us uh with. Uh they said they could get us four to six units and we wanted to make sure that we supplied trauma first. Interestingly, we got um You know, a six month period to look at that, to say, for six months we're gonna look at it and say, This is what we need uh for trauma. And then based on that we can give information to the system.

on how to then resuscitate patients with whole blood within the system and then help the blood bank decide how to buy for or purchase for the helicopters and the other disciplines within the system that wanna use whole blood. So that was how we did

So then what's ideal? Is ideal we transition to entirely whole blood transfusion is ideal that you both mentioned you start with whole blood and then we go to tag and do component product transfusion. There's no restrictions on any of the resources that you need. What would you like to have? Well I think Don's gonna have a much better answer than I am because he's much m better studied on I think what's ideal for us is understanding that

The person who comes in to the trauma bay or the h emergency room, and I think we'll find this out too with our follow-up to our initial whole blood for trauma program, is that they come in uncross matched with signs of hemorrhage. uh an unidentifiable source they get whole blood. Probably in a limited quantity. One to two units or sorry two units and then they go on to component resuscitation or tech directed resuscitation based on that until

surgical control or angiographic control is uh achieved. I think that's where we're gonna start for now. Um But more importantly than that, I think we have to understand what, you know, certain systems are like. We're not the urban center or the center with a short transport time. or less than a half an hour. The average transport time to West Virginia, our university hospital, is upwards of two hours. So

we have all these satellite hospitals, these partners' hospitals, critical access hospitals, the helicopters. We need to get this whole blood to them on the helicopters first before we uh go saying we're gonna give unlimited numbers of whole blood within our s in our hospital first. They may need you we may need to distribute it out to the uh outlying hospitals to get that initial two units of whole blood out there first, uh before they get it before we go

I don't say crazy, but uh be very aggressive giving it to, you know, four to eight units of whole blood to a trauma patient in the hospital. It might be better to have it four to eight units to some critical access hospitals. out in the um surrounding areas or on the helicopters first. I think we can touch more patients that way. So I really think it depends on the system and the the hospital itself as to how they how you devise your system for whole blood.

So let me add a comment uh in there about that uh Dan. Each uh state regulates their own EMS and there are somewhere in a neighborhood of about thirty states. uh that don't allow ground EM To administer blood products. Take an exception from state legislature, you know, State Department of Health. uh to make a change in those rules of engagement. Uh so when we were in uh when I was in Rochester, Minnesota, we put whole blood on the helicopter.

But we couldn't put it on the Mayo owned Gold Cross ambulances because of Minnesota statute. Uh which uh they're still working on changing. Here in San Antonio we're one of the lucky states

uh where if the medical director says you can do it, you can do it. And so exactly as you as you cite Uh we we did a little retrospective review of tr transfusion at our trauma center and looked exclusively at the massive transfusion patient population that initiated massive transfusion on arrival to the trauma.

uh over a thirty-two month uh block of time uh hundred twenty five got emergency transfusion in the in the trauma bay, 125 got massive transfusion over that thirty-two month block of time. Uh those getting emergency transfusion on arrival had a death rate of 40%. Those getting their blood volume replaced in a massive transfusion on arrival had a death rate of 75%.

So it was pretty easy to take that story forward and say, Hey guys, we gotta put this where the patients need it. We we gotta get it out of the blood bank and we gotta get it on the streets. And so it started out small. Uh we started out with uh one helicopter. You put a little schedule together like for the next week and the week after that. Uh another helicopter here, another helicopter there.

uh until we have now two units of uh pollut on thirteen different helicopters uh in South Texas. That's five different uh helicopter EMSAs. Uh we've got uh uh one unit of pole blood on nine EMS supervisor rigs in San Antonio proper. Uh I've got one unit of whole blood on sixteen other EMS rigs not associated necessarily with uh San Antonio. Thirteen of them are county level uh in rural counties uh uh out there.

And I've got whole blood in a single uh level three critical access hospital. We had it in two, but they just couldn't find uh they didn't have the sweet spot to to use it and it was going to wait. So far in the hospital, our average our our average patient getting emergency transfusion with whole blood gets a mean of three and a half units of uh of whole blood.

My gut told me we probably needed twenty units on the shelf at the hospital. That has now been exceeded. We're sitting at an inventory of thirty six. Of whole blood at the uh at the hospital. We're transfusing whole blood. The mean number per month has crept up from the single digits to about 27 a month now. uh are getting whole blood transfusion or going through a little over one hundred and fifty units a month.

of of of whole blood. In total, we've transfused nearly 700 patients with a little over 2300 units of whole blood since the program inception two years ago. As of August Have 55 non-trauma uses that we have written up. Most of those are GI bleed, ruptured, AAA, or obstetric hemorrhage. We've got a peripartum hemorrhage protocol with whole blood.

Disorder, women. We're up to 15 women have gotten whole blood transfusion. Again, no transfusion reactions, very low uh consumption of blood products in that patient population. The only way you can do that is to have an active donor program. At the beginning of the calendar year, we had about 3,000 of these pre-tested low antibody titer O-positive men donors. Uh we've got uh right at about eight thousand of these uh folks today. Uh and so they show up by appointment uh on call as needed.

Uh there's about a hundred and seventy units of whole blood currently in the system. across the hospitals and the the EMS agencies and at South Texas blood and t. And in fact, uh unbeknownst to us, but we figured it out in short order, when we were getting into some real tight spots with components.

If a patient in the medical ICU uh or our uh surgical ICU uh was uh in need of component uh therapy for whatever reason, uh oftentimes they would give them uh whole blood in lieu of the uh because they just didn't have the components to spare. uh as long as we needed uh all those components anyway. So the blood bank went from, you know, they didn't want us to give hardly anybody any to anybody

Uh and certainly not outside the trauma room to now just giving it out to medical patients. With transplant patient gets some uh whole blood uh not that long ago. And so putting together a manuscript uh there to look at that utilization.

uh of uh of whole blood for other than trauma and in lieu of components uh as a life-saving way of doing Uh in fact with the shortages that we've had in blood, uh what they've done is very smartly called upon special donors of the of that program is called brothers in arms Uh they have called on those brothers in arms donors to come in and donate blood.

just to be used as components. So they're going to separate it out because uh they don't have enough other donors uh to keep the inventory where it needs to be kept. We wouldn't have any of that uh happening if uh if it weren't for this uh program, quite honestly

So it's been it has been a game changer. Our uh main uh blood bank pathologist when I first met her, the very first trauma meeting we had, multidisciplinary meeting, we got down through the agenda and when uh we got to the the the line where it said blood bank and this woman behind me uh spoke up about blood bank issues, I drew the conclusion that this was our blood bank pathologist.

And I when the meeting was over, I I turned around and said, Hey, uh, would you entertain a conversation about whole blood? And her answer was, yes, of course. Would I go I'll talk about that with you. Everyone knows it's bad for patients. So that's where we started.

in August of two thousand sixteen and now she's given whole blood out to uh the world. Uh and uh as of uh our child multidisciplinary meeting, uh well we held a special meeting uh uh uh uh Principles in the in the region because of blood shortages throughout all the hospital.

two days ago, uh she was the first one to speak up and said, I love whole blood. You mentioned a little bit about within your your own system, how you manage whole blood, but who kind of oversees all that? Are you the one personally keeping track of all that or is the blood bank managing?

So we have a medical command center that uh does all the trauma paging and dispatching, uh, et cetera. So twice a day uh they update uh that that Excel spreadsheet grid so that we know it goes out in a group me app. uh uh platform uh uh at least twice a day. And every time uh an EMS agency either uses or trades in uh their whole blood for a new uh unit of whole blood.

uh the uh it gets updated so that we have the actual um expiration dates uh and we know where those units are. Uh not unlike uh Dan's story about running out of whole blood that's happened to us in the past. uh perfect storm of a fourth of July holiday, which happened to fall on a weekend and a bunch of people didn't show up and donate. Uh we had to call Some of the helicopters and EMS agencies to bring their whole blood back and drop it off at the hospital for us to use.

That's when we decided we needed to do this active management thing and uh thankfully haven't run out of whole blood uh since then. And so you can watch the inventory in real time and you know when you're getting in trouble. It's how they manage their expectations with their donors because they call them and ask them, can you come tomorrow? We don't want you to come and donate, you know, we don't want you to call. We'll call you when we need you.

uh sort of a thing. So it's a it's a very actively managed program and uh they hold, you know, some some press conference uh sort of stuff. Uh uh annually it makes the uh uh foundation the South Texas Blood and Tissue Foundation uh board happy to see uh success stories uh uh young mom who in a car crash during extrication loses pulses. uh gets a unit of whole blood from the ground EMS agency, gets a unit of whole blood in the back of the helicopter on her way to the hospital.

uh leaves the hospital about seventeen days later, uh having had her uh spleen embolized and uh her cervical spine uh fixed. And then she gets up with her uh two boys. Uh in front of that crowd. So you can do this but it takes an ac it it doesn't just happen. I'll I'll just I I'll just put it like that. And uh I wouldn't expect most uh trauma surgeons to have uh the working knowledge of the system

uh that I have. This has been by necessity uh that I've had to learn this stuff and learn to speak blood bank. uh lingo uh in order to be able to get this uh done. Uh I have heard other surgeons uh in group talk uh and a variety of uh platforms say you just tell your blood bank they gotta give it

It's like, mm, dude, that's no. This it's it's America. It's twenty twenty. That's that doesn't go that doesn't go anywhere. One thing you did mention about uh giving whole blood to young females, I think this was kind of a

educational opportunity when Dan, when you rolled it out at WBU, but can you talk about how it's safe in kind of childbearing age? Yeah, when uh when we had doc uh Don come out, uh he talked a lot about um women of childbearing age and whether or not they're, you know, so to say, eligible for whole blood, uh given the R H status.

possibly for future pregnancies, potential maternal fetal blood mixing, right? So Uh we talked a lot about that and understanding where uh Don and his group they just give the blood, understanding that the risk is extre exceedingly low. and read some of the other papers that they withhold whole blood uh to women of child bearing age. In fact there's a recent publication In the past year or so.

the group out of Philadelphia that uh uh published their paper. So yeah, we looked at a lot about a lot of that. We actually had our pharmacist and our blood banker call uh Don's blood bank team. and look at how they do it there. And we came up with ours, um, so anyone, any woman of childbearing age, and we gave anyone seventeen to forty five who received

our low titer O positive blood. Uh we actually get O O negative blood too sometimes. So we have to look at that. And they receive it. Um we we have a consult with them the next day. Um obviously wait waiting for them you know to

settle down, recover, recuperate a little bit, at least have a conversation with them. If they have a desire future pregnancy, we confirm, you know, blood types and all that. And then based on the amount of blood volume that they receive, we dose either rogue or Winro to them. uh and provide them with education for future pregnancies. And that was just our policy. It's echoing what he said.

It's not just the trauma surgeon making this decision, right? It's it's the entire team. We do things, we round as a multidisciplinary team. We're getting blood from the blood bankers. Everyone has to be comfortable with this, right? Um So if you know, I know as a lot of the trauma surgeons we were discussing this, we said, Well let's just do what San Antonio does, let's just do what uh another group does and if they don't uh

work this up then it's it's good enough for us. And, you know, that really wasn't sitting too well with the other people at the table. So the pharmacists and the Blood bankers really wanted to have a program in place uh for women of childbearing age. So uh we had uh we developed a consult team to go see them and talk to them. You know, it's led by the trauma surgeon obviously and they need to make that comment. happen and um if they

desire future pregnancies and they've received low tide or O positive blood, then they uh they get their Winrow or Rogram depending on how much uh blood volume they got. So that was our So when we looked at uh when we looked at this, if you look at the demographics of South Texas Uh the population is about seventy percent Hispanic and Africa.

American, meaning that the uh Caucasian uh group is sitting only uh in the twenty-five percent or so uh range. What we know uh and it's unclear why this occurred. I've not studied it, but people from Asia have a Rh negative preponderance of about 1%. In African Americans and in Hispanics it's it's about seven percent. In Caucasians it's about fifteen or sixteen percent.

Uh there are certain places, little pockets of uh of uh people in parts of Europe that are as high as uh forty percent RH negative rate. So when we looked at that 125 patients getting massive transfusion on arrival, 25 of them were women, and half were of childbearing potential, the death rate was uh fifty-five percent in that in that group. And as per the prediction, there were uh two uh I'm sorry, one RH negative woman out of the sixteen of childbearing potential.

Uh, which puts it right at seven percent. uh in that uh nearly 700 patients we've transfused whole blood to so far, uh we've had four or five uh RH negative uh uh people get uh O positive uh whole blood. Uh two of them were men, one was an older woman, one was a woman of childbearing potential. And we did precisely what Dan.

Uh it's that it follows a next day consult uh because as soon as they see uh that there's a disparity in the patient's blood type with what blood product they received and emergency.

uh that automatically rings a bell and uh they uh come to the bedside and uh s assess the patient talk with the clinical team uh the day after as Dan said when the d dust has uh settled. So so far so good uh as would turn out that woman uh oh childbearing potential who is R H negative got the O positive uh whole blood analyze to save your life.

She uh said that there was no way uh she was ever gonna have children anyway, so she didn't want to be growing. What do you guys think is on the horizon for

Full blood. From my standpoint, I think centers like ours are gonna try and grow to be centers like what Don has. I mean, he's got the system there that's mature. It's uh a tremendous amount of education and infrastructure and uh teamwork. And that's what we've been trying to just replicate on a smaller level here, to take all the lessons learned from the military uh system as well as a well established civil

and put it into practice to capture um our patient, right? And what do we have to learn from what Don's doing? He in his system is that really that that those rural trauma patients, the the patient that comes in

bleeding in the trauma bay for the most part is what we're looking at, but also that uh patient transported on a helicopter for the pre hospital blood as well as that critical access hospital. So if we can start growing uh this to all the a vast majority trauma centers, I think that's what the future is for whole blood. So uh I I I agree with uh what uh Dan uh said. I think that uh There is still some great potential in the transplant uh community.

Uh it may require a leuko-reduction of the whole blood in order to meet the needs of that patient population, but at this time we have given it to some of those transplant patients. I think uh OB is another growing uh area for uh uh for whole blood. Uh they have uh started that program up. Pittsburgh now, which is uh going well for them, uh as I understand through Mark Gazer. So uh uh yeah, I think that I think there's plenty still to do.

By the time this gets published, the holiday will be over. But but for us it's Wednesday and we're getting ready for some smoked turkey, some stuffing, some green bean casserole. I hope everyone has a safe and happy holiday. And that wraps up another edition of TraumaCast, brought to you by the East Online Education Committee of the Eastern Association for the Surgery of Trauma.

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