In 2016, the number was zero. Now, it includes 152 emergency medical service agencies in 23 states, according to Dr. Randall Schaefer, a retired Army trauma nurse and steering committee member of the Prehospital Blood Transfusion Initiative Coalition.
It still amounts to only 1% of all the rescue services in the country, but the doctors leading the charge are not the type who give up easily.
“Through individual efforts we are making gains, but it’s really slow,” said Dr. Jeffrey Kerby, a former Air Force trauma surgeon who is now the head of trauma surgery at UAB and the chair of the American College of Surgeons Committee on Trauma.
“It would be accelerated to an incredible degree,” he added, if the insurance providers would reimburse for the use of blood in rescue vehicles.
“If we can just get them to focus on this one treatment, that will have such an impact on lives saved,” Kerby said.
He puts the number at about 40,000. Holcomb estimates it could save the lives of at least 60,000 people. “And that’s conservative,” he said.
A ‘magical’ treatment
Trauma is the No. 1 cause of death in the U.S. for people between the ages of 1 and 45. Numerous medical studies conclude that no other single intervention has a greater impact on survival than a patient getting blood prior to their arrival at a hospital.
Yet, the overwhelming majority of ambulances and rescue helicopters in the U.S. administer crystalloid, a version of saline water, to bleeding patients. Holcomb argues that crystalloid is not just a poor substitute for blood — it can do more harm than good.
“The data says this very clearly,” Holcomb said. “Not only is crystalline ineffective in a bleeding patient, it can cause severe complications.”
Whole blood transfusions were common until the 1970s when component parts — platelets, plasma, red blood cells — became the only readily available products. That was largely because blood banks could serve more patients, particularly those suffering from cancer, by breaking down the blood. Selling component parts could also be good for business.
Even today, whole blood is only available at 50% of the nation’s trauma hospitals.
But the experience of the former trauma surgeons on the battlefield showed them the value of whole blood transfusions. And when they returned home, they began pushing to make it more available in the individual communities where they settled, places like Katy, Texas, and at the Mayo Clinic in Rochester, Minnesota.
“There is a whole group of doctors, nurses and medics who’ve seen this with our own eyes,” Holcomb said. “They’ve seen patients come back from death’s doorstep, white, pale, bleeding to death. They give them whole blood and they see them come to life in front of you.”
Among the first places to have an integrated whole blood program was San Antonio, which has become a model for the rest of the nation.
The story of how it came to be begins in 2001 when Dr. Donald Jenkins was an Air Force trauma surgeon stationed on a desert island off the coast of Oman.
He was there to provide medical support for the U.S. air base. But his responsibilities changed dramatically when the U.S. invaded Afghanistan following the 9/11 attacks.
“We had to prepare to care for up to 50 simultaneous casualties,” Jenkins said.
He had read about using whole blood — as opposed to platelets or plasma — for trauma patients but had no training in it. “It was not a thing,” he said.
The arrival of the wounded soldiers posed a serious challenge. With few other options, Jenkins pulled out from his back pocket a “NATO emergency war surgery handbook,” which described how to administer whole blood, a section co-written by Holcomb.
“We did it literally on the fly in the desert with no experience, no guidance outside of that that had been written basically in World War II,” Jenkins said. But the results were “magical.”
Some 15 years later, Jenkins led the effort to get blood onto rescue vehicles in San Antonio. He did so by coming up with a novel approach to overcome the lack of insurance reimbursement.
The city or county that oversees the EMS system pays the upfront cost — about $500 — of getting a unit of blood and must put up the money to buy refrigeration units to keep it cold on board. But if it goes unused and has been properly maintained, they can exchange it for a brand-new bag of blood – universal donor type O – at no cost.
The system takes a similar approach to tackle another hurdle: where to get the blood in the first place. Blood donation centers signed on to a plan in which they provide blood to rescue services, and if it goes unused for two weeks, the blood can be returned. If it is deemed safe after testing, then it goes to the area trauma center.
“And we have another three weeks of shelf life to be able to use it,” said Jenkins, a trauma surgeon with University Health and professor at UT Health San Antonio, who noted that the rate of blood waste is under 1%.
Since its inception, Jenkins estimates that the program has saved the lives of at least 2,000 people.
One of those is a 12-year-old girl named Mayah Zamora. She was in the fourth grade at Robb Elementary in Uvalde when a mass shooter opened fire in her school in May 2022. Mayah suffered gunshot wounds to her chest, arm and hands, but she was one of the lucky ones. The rescue helicopter that flew her to University Hospital in San Antonio gave her blood on the way.
After 66 days and 20 surgeries, she left the hospital and returned to normal life. Without the whole blood transfusion in the helicopter, she would not have made it, her doctors said.
A prehospital blood transfusion also saved the life of a 6-year-old Florida girl last January.
About a week after she received a tonsillectomy, Izzy Niemczyk started spitting up blood. Then she fainted in her father’s arms. A clot had burst, and she was bleeding out. Her father, Neal Niemczyk, who was the district chief for the Palm Beach County Fire Department, checked her vitals and immediately called 911.
“Make sure they bring whole blood,” he told the 911 dispatcher, according to a recording reviewed by NBC News.
The county had launched the program in April 2022, and Niemczyk was intimately familiar with it.
Izzy received a transfusion in the ambulance, with both of her worried parents looking on.
“I am not kidding you when I tell you 30 seconds after that first pump, she went from being unconscious to being alert and looking around,” Niemczyk said. “That’s when I knew everything was gonna be fine.”
“It’s remarkable what it can do. It truly is,” he added. “I’m thankful that I live in Palm Beach County Fire rescue zone and that we were there that day.”
