By Division Chief Alex Lamb
Early administration of blood products in the prehospital setting offers a critical opportunity to improve outcomes for patients experiencing life-threatening hemorrhage.
Recognizing the potential benefits of early transfusion, Palm Beach Gardens Fire Rescue developed and implemented a whole blood program in April 2024. Through data-driven decision-making, collaboration with regional partners, assistance from a local fire department and support from department leadership and city administration, the department established a program that has delivered whole blood to 40 patients ranging in age from 1 to 94 years.
| READ MORE: Surrounded by data but lacking information: How to make fire service data work for your department
Our experience offers valuable lessons for EMS agencies considering the implementation of their own prehospital blood transfusion programs.
Recognizing an opportunity to improve patient outcomes
Severe hemorrhage remains a leading cause of preventable trauma-related death. For patients experiencing life-threatening blood loss, the ability to administer blood products before hospital arrival presents an important opportunity to improve resuscitation and reduce delays in definitive treatment.
In 2023, members of Palm Beach Gardens Fire Rescue (PBGFR) attended the Gathering of the Eagles EMS Conference in Hollywood, Florida. Among the topics discussed was the growing role of prehospital whole blood administration in the treatment of hemorrhaging patients.
The information presented challenged conventional approaches to prehospital fluid resuscitation and prompted an important question: Are we providing the most effective treatment for patients experiencing significant blood loss by administering crystalloid solutions alone?
One physician summarized the concept in a straightforward statement: “If they are losing something red, replace it with something red.”
That message resonated with our team. We returned to Palm Beach Gardens with a renewed interest in evaluating our existing practices and determining whether introducing prehospital whole blood could improve the care we delivered to critically ill and injured patients.
Building a program around data
Palm Beach Gardens Fire Rescue serves a population of approximately 64,547 residents across 59 square miles in northern Palm Beach County, Florida. With an annual operating budget of approximately $43.5 million and an annual call volume of roughly 15,000 calls, the department provides emergency services within a growing and medically diverse community.
We are fortunate to work with a progressive medical direction team that emphasizes evidence-based medicine, measurable outcomes, and continuous quality improvement. This commitment to data-driven decision-making provided the foundation for evaluating a prehospital blood program. A program such as this would not be possible without the vision, leadership and direction of Dr. Kenneth Scheppke, Dr. Peter Antevy and Dr. Richard Giroux.
Rather than relying solely on anecdotal evidence or emerging trends, we began with a retrospective review of our trauma patients from the preceding two years. Our objective was to identify how many patients might have benefited from the early administration of whole blood.
The review indicated that approximately 12 to 14 patients annually could potentially benefit from prehospital whole blood administration.
This finding provided the justification we needed to move forward. Armed with supporting data and emerging evidence from the EMS community, we presented the concept to department command staff and city administration.
Both were receptive to the proposal and supported moving forward with the research, funding and implementation necessary to establish the program.
Collaboration made the difference
One of our greatest advantages was our location in south Florida, where a prehospital whole blood coalition was already bringing together key stakeholders to advance prehospital transfusion capabilities.
The coalition, led by one of our medical directors, Dr. Antevy, includes representatives from fire-rescue agencies, healthcare facilities, trauma organizations and the military. This collaborative environment provided an opportunity to share knowledge, discuss operational challenges and learn from agencies that had already established successful programs.
Several south Florida fire-rescue agencies had implemented prehospital blood programs before us. Their willingness to share protocols, equipment recommendations, operational procedures and lessons learned helped us avoid unnecessary delays and common implementation challenges.
For agencies considering a similar initiative, collaboration with established programs can be invaluable. Developing a blood program does not need to be an isolated undertaking. Learning from organizations that have already navigated the process can significantly shorten the learning curve.
From concept to implementation
Developing our program required approximately six to eight months of planning and coordination. During that period, we developed clinical protocols, worked through contractual requirements with our blood supplier, coordinated with our legal department, identified the necessary equipment and supplies, and completed personnel training.
One of the most time-consuming components was establishing the contractual relationship with the blood supplier and navigating the associated legal review and approval process.
Funding also required careful consideration. Because we were implementing the program in the middle of the budget year, we needed to identify a funding source outside our normal budget cycle.
We applied for and received a $35,000 grant from a local charitable organization. This generous contribution covered most of the program’s first-year operating expenses and allowed us to move forward without waiting for the next budget cycle.
In April 2024, Palm Beach Gardens Fire Rescue officially launched its prehospital whole blood program.
Under the initial operational model, each of our two EMS supervisor vehicles carries one unit of whole blood. This approach allows our supervisors to bring blood products to qualifying patients in the field while maintaining a manageable deployment model for the department.
Our protocols authorize blood administration for patients experiencing hemorrhagic trauma or medical emergencies involving significant blood loss.
The program was designed to provide an additional resuscitation option for patients who may otherwise deteriorate while awaiting arrival at a hospital capable of providing definitive treatment.
Real patients, real-world experience
Since the program’s inception, Palm Beach Gardens Fire Rescue has administered whole blood on 40 occasions: 26 administrations involving trauma patients and 14 involving medical patients.
The patients have ranged in age from 1 to 94 years, demonstrating the broad spectrum of emergencies in which prehospital blood products may be considered.
Of those 40 patients, all but four were transported to the point of surgical intervention or other definitive care. While these experiences are encouraging, transport and survival outcomes alone do not establish the independent effect of prehospital transfusion. Continued outcome tracking and review remain essential to understanding the program’s impact.
Two calls in particular illustrate the challenges faced by prehospital providers caring for patients with significant hemorrhage.
A life-threatening postpartum hemorrhage
In one particularly memorable case, our crews responded to a 29-year-old woman who had recently delivered a baby at home and was experiencing uncontrolled bleeding. The patient was deteriorating rapidly and repeatedly lost consciousness whenever she attempted to sit upright. Before our arrival, the attending midwife had administered approximately two liters of normal saline.
Despite those efforts, the patient’s initial shock index was 1.48, indicating significant hemodynamic instability in the context of her ongoing hemorrhage.
This case highlighted the importance of recognizing severe blood loss early and having access to resuscitation options beyond crystalloid administration. For patients experiencing postpartum hemorrhage in the prehospital setting, the ability to initiate blood product resuscitation may be particularly valuable when definitive obstetric care is still some distance away.
A pediatric motor vehicle collision
Another memorable case involved a 4-year-old patient injured in a motor vehicle collision. The child, who was suffering from multi-system trauma, became hypotensive at the scene and received a weight-appropriate bolus of whole blood. During transport, the patient became unresponsive and hypotensive, prompting administration of a second bolus. Upon arrival at the trauma center, the child was awake and crying.
For EMS clinicians, pediatric trauma can be particularly challenging because children may compensate physiologically before showing signs of significant deterioration. These cases reinforce the importance of early recognition, continuous reassessment, and having appropriate resuscitation options available when a patient’s condition changes.
Although individual cases cannot establish the effectiveness of a particular treatment, they illustrate the clinical challenges that led us to pursue the program and the importance of evaluating available treatment options for patients at risk of hemorrhagic shock.
Tips for replicating a prehospital blood program
For agencies considering prehospital blood administration, our experience has reinforced several important principles.
1. Understand your regulatory environment: Before beginning implementation, research your state and local requirements governing prehospital blood administration. Regulations, scope-of-practice requirements, and approval processes vary by jurisdiction. Not all states permit paramedics to administer blood products in the prehospital setting, so agencies must understand the applicable requirements before proceeding.
The Association for the Advancement of Blood & Biotherapies (formerly the American Association of Blood Banks) provides standards and resources relevant to prehospital transfusion planning. A useful starting point is the AABB’s Emergency Prehospital Blood Transfusion resources.
Agencies should also consult the National Prehospital Blood Transfusion Coalition and engage their medical directors, legal advisors, blood suppliers and receiving hospitals early in the planning process.
2. Start the contracting process early: Establishing a contract with a blood supplier can be one of the most time-consuming parts of the implementation process. The contract must address the operational and logistical requirements associated with supplying, storing, transporting and replacing blood products. Legal review and approval can add considerable time to the process. Starting these discussions early helps identify potential obstacles before they affect the implementation timeline.
3. Determine which blood products best meet your needs: Work closely with your medical director to determine which blood products are appropriate for your agency and the patient populations you serve. Options may include whole blood, packed red blood cells, plasma or a combination of blood components.
Agencies should also define the clinical circumstances in which these products may be administered. Will the program focus exclusively on traumatic hemorrhage, or will it include medical emergencies such as gastrointestinal bleeding and postpartum hemorrhage? Are there additional indications that warrant consideration? These decisions should be guided by current evidence, medical direction, applicable regulations, local patient needs and the capabilities of receiving facilities.
Clearly defined protocols establish a consistent clinical framework for patient selection, administration, monitoring, and quality assurance.
4. Do not reinvent the wheel: Other agencies have already navigated many of the challenges associated with establishing prehospital blood programs. We relied heavily on the experience and resources of south Florida agencies that had implemented programs before us. Whenever possible, connect with established programs to discuss protocols, equipment, training, logistics and quality assurance practices.
If regional interoperability is a priority, consider standardizing equipment across participating agencies. Using compatible infusion devices, blood warmers, disposable heating components and coolers can simplify operations when multiple agencies respond to the same incident.
5. Develop a sustainable funding strategy: Prehospital blood programs require ongoing financial support, not simply an initial investment.
Whole blood has a limited shelf life under routine storage and distribution arrangements. In our program, the relatively short usable period of approximately 18 days creates additional logistical and financial considerations.
Actual shelf life and handling requirements depend on the blood product, storage conditions and supplier protocols.
Agencies should account for product costs, storage and transport equipment, disposables, training, replacement inventory and any associated supplier or service fees.
Grant funding and blood exchange arrangements may help offset expenses, but agencies must understand the full operating costs and identify a sustainable funding source.
A program that is financially viable in its first year must also be supportable in subsequent budget cycles.
6. Track outcomes and share your successes: Data collection and quality assurance are essential to maintaining a successful program.
Track the number of administrations, clinical indications, patient demographics, relevant physiological measurements, transfusion-related complications, transport and hospital outcomes, and other measures identified by medical direction.
Where feasible, compare outcomes with appropriate historical or regional data while recognizing the limitations of small patient populations and retrospective comparisons.
Reviewing these data allows an agency to identify opportunities for improvement, evaluate protocol adherence and better understand the role of prehospital transfusion in patient care.
Equally important is communicating the program’s results to command staff, city administration, medical direction, funding partners and the community.
Meaningful outcome data and well-documented case reviews help demonstrate the program’s value, support evidence-based improvements, and strengthen the case for continued funding when budget priorities are evaluated.
Looking ahead
Our experience implementing prehospital whole blood administration has reinforced the importance of remaining open to evolving evidence and continually evaluating the care we provide.
For agencies considering a similar program, the process may initially seem complex. Regulatory requirements, supplier contracts, equipment, training and funding all require careful planning. However, the experience of established programs demonstrates the value of collaboration and a methodical, data-driven approach.
At Palm Beach Gardens Fire Rescue, we believe that improving patient outcomes begins with asking difficult questions, evaluating the available evidence, and being willing to change when better approaches emerge.
Prehospital blood administration represents an important advancement in the resuscitation of selected patients experiencing life-threatening hemorrhage. By continuing to evaluate our results, share our experiences, and collaborate with our regional partners, we hope to contribute to the ongoing development of prehospital transfusion practices and help other EMS agencies determine whether a similar program could benefit the communities they serve.
ABOUT THE AUTHOR
Alex Lamb, BBA, EMT-P, RN, brings 35 years of experience across all facets of EMS. He has served with Palm Beach Gardens Fire Rescue for 29 years and currently holds the position of division chief of EMS, overseeing the department’s emergency medical services operations and programs.
