Sunday’s mass shooting in Sutherland Springs highlights the critical need for first responders to treat major blood loss in trauma patients. For anyone gravely injured – whether during combat, in a mass casualty event, or in a car accident – every minute counts.
Starting in January, rescue helicopters in South Texas will carry cold-stored whole blood for treating patients with major blood loss on their way to a hospital, said Dr. Donald Jenkins, deputy director of military health at the Institute of Trauma and Surgery at UT Health San Antonio.
The benefit? Jenkins said recent research he oversaw shows it saves lives. “Every minute that a massive transfusion is delayed for those patients who have lost half or more of their blood volume, mortality goes up by five percent,” Jenkins said.
Since the 1970s, standard practice has been to give trauma patients what is known as “component therapy,” meaning stored whole blood is divided into plasma, platelets, and red blood cells to be given separately, usually after arrival at a trauma center.
The shift from using whole blood to blood components happened gradually in order to maximize blood banks’ limited resources. Thanks to separation techniques, donations could be stretched to serve more patients, according to the U.S. National Library of Medicine.
“Component blood products are carried on [rescue] helicopters in South Texas, but that is not standard elsewhere,” said Elizabeth Waltman, chief operating officer of blood operations at the ?South Texas Blood and Tissue Center. “Helicopters started carrying packed red cells and plasma two years ago, and those component blood products are on almost all helicopters [in South Texas] now.”
Whole blood is rarely used for transfusions and has not been widely utilized for the past 50 years. Why? Limited resources and cost.
Jenkins, however, knows firsthand the benefits of using whole blood in military medicine. This sparked the former Air Force physician’s interest in revisiting its use for civilians.
Last year, the San Antonio Medical Foundation awarded a local research team, led by Jenkins, a $200,000 grant to assess the benefits of cold-stored whole blood in treating trauma patients prior to arrival at the hospital. The team included scientists from the Southwest Texas Regional Advisory Council (STRAC) and the Blood and Tissue Center.
Jenkins used data from battlefield trauma cases in Iraq and Afghanistan from 2003 to 2007 to assess outcomes for more than 500 soldiers with life-threatening injuries who received whole blood transfusions. Those patients showed improved 48-hour and 30-day survival rates compared with massively hemorrhaging patients who only received stored red blood cells, he said.
Earlier this year, Jenkins presented that data to the Blood and Tissue Center Foundation board, which supported the practice of giving cold-stored whole blood transfusions to patients en route to hospitals. The American Association of Blood Banks, the global nonprofit overseeing transfusion standards, also reviewed the team’s results and approved the practice in October.
The July issue of the Journal of Trauma and Acute Care Surgery showed a five percent per minute increase in odds of mortality in a study of trauma patients who did not receive blood products prior to arriving at a hospital. The data highlighted the benefits of transfusing blood as soon as possible.
Despite the benefits, Jenkins said he knows of only three cities that use cold-stored whole blood for trauma patients during transit to the hospital: Bergen, Norway, for the past two years; Rochester, Minnesota, as of six weeks ago; and, now, San Antonio.
Military physicians’ combat experience in treating trauma on the battlefield has historically led to major changes in blood transfusion practices, such as transfusing whole blood to help patients survive blood loss, which was common until the Vietnam War ended in 1975.
“As medicine became more specialized starting in the late 1960s, doctors began to treat cancer patients with only platelets and anemia patients with only red blood cells,” Jenkins said. “This evolution in medical practice happened over time so that the knowledge to collect, maintain, store, and transfuse whole blood was lost.”
When Jenkins deployed to Iraq and Afghanistan in 2001, he rediscovered the benefits of using whole blood in combat and created the Joint Trauma System. He was the trauma medical director at Wilford Hall Medical Center’s Level I trauma center when the terrorist attacks of Sept. 11, 2001, occurred.
“I set up the in-theater trauma system and incorporated a whole blood protocol using an old edition of a military handbook of whole blood transfusion procedures,” Jenkins said.
After he retired from active duty in 2008, Jenkins was the trauma medical director of the Mayo Clinic’s Level I trauma center in Rochester, Minnesota, for eight years where he used his work on whole blood transfusions to help launch its use there. Once he returned to San Antonio in 2016, he applied for and was awarded the $200,000 foundation grant to revisit the lost practice of using whole blood.
The whole blood project’s first phase looked at improved outcomes for trauma patients receiving whole blood. The second phase is focused on the processes needed to maintain and use cold-storage whole blood during a patient’s transit to a hospital.
The next steps for the South Texas Blood and Tissue Center are to determine inventory levels for the donor base and develop the logistics involved in processing, maintaining, shipping, tracking, and storing the whole blood supply. The South Texas Blood and Tissue Center will be the repository for whole blood with cold-stored whole blood ready for use on helicopters in January, Waltman said.
“We’ve been looking at the donor base needed to support this, because we still need to provide blood components to those patients who need them,” Waltman said. “All blood donated now is separated into components, so with the roll out of this new initiative, we’ll identify and test specific donors who will donate only cold stored whole blood.”
STRAC has purchased equipment for holding cold stored whole blood on helicopters and oversees first-responder training on appropriate transfusion techniques. The new procedures to maintain cold-stored whole blood on helicopters are in the final stages of development, validation, and training, according to Randi Schaefer, STRAC’s division director for research.
Blood transfusions can be costly for hospitals, as each unit of red blood cells costs about $210, not accounting for overhead and transportation costs. A decade ago the concept of adopting cold-stored whole blood for patients in transit to a trauma center was hotly contested due to a lack of hard data, Jenkins said.
That dynamic has changed as more research, such as this study on improved survival rates for soldiers receiving blood before arriving at a hospital and this study supporting the need to incorporate military combat trauma lessons into civilian trauma practices have been published.
“Helicopter agencies are getting on board with this because we now have evidence-based medicine showing that this is the right thing to do,” Schaefer said. “Trauma affects everybody.”