Trauma game changer

whole bloodTheresa Hernandez was three weeks away from giving birth to her third child. As she got ready for bed, the last stop was the bathroom. She noticed that she was bleeding. 

“When I stood up, I felt pain. It felt like the baby was coming out,” she said. 

Her placenta had ruptured. 

“I lost a lot of blood, so I told my boyfriend to call an ambulance,” Hernandez said. 

After receiving whole blood in the ambulance and being transported to the hospital, doctors delivered her son by emergency C-section. The quick transfusion of whole blood to Hernandez—before ever entering the hospital­—is what initially saved her life and that of her son, said C.J. Winckler, M.D., assistant professor of emergency health sciences in the School of Health Professions and deputy medical director of the San Antonio Fire Department Emergency Medical Service. 

Because of lessons learned on the battlefields of Iraq and Afghanistan, South Texas patients are among the first in the nation to receive lifesaving whole blood transfusions before they reach the hospital. The effort, initiated by UT Health San Antonio faculty with military trauma experience, is part of a partnership under the Southwest Texas Regional Advisory Council, which oversees trauma and emergency health care projects and programs in 22 counties in South Texas, including the San Antonio area. 

“There is no place in the U.S. where an entire region of 22 counties, across 26,000 square miles, with more than 50 hospitals and 70 EMS and helicopter EMS agencies, has access to whole blood for injured and bleeding patients, except for South Texas,” said Donald Jenkins, M.D., professor of trauma and emergency surgery. He serves as vice chair for quality in the Department of Surgery at University Hospital and associate deputy director of UT Health San Antonio’s Military Health Institute.

San Antonio is the only city in the nation with a broad network to transport whole blood to trauma sites. The move to whole blood transfusions has transformed emergency response, with a 25 percent reduction in deaths due to hemorrhage in the region between January 2018 and January 2019, Dr. Jenkins said. But whole blood transfusion is not new.

Whole blood—blood that has not been separated into components—is the original transfusion fluid. It’s what’s running through our veins. From the early 1900s through World War II, if a soldier needed blood, it was transfused from another soldier. During the Vietnam War, whole blood was donated in the U.S., refrigerated and sent to Vietnam, where 10 million units were used. The practice was discontinued after Vietnam because of increased HIV and hepatitis C viruses in donors. “That was before we had testing for viruses in the blood,” Dr. Jenkins said. 

With a dwindling blood supply because of the viruses, and a shift toward specialized blood products for transfusions, it became standard practice to use blood components—red blood cells, platelets and plasma—instead of whole blood for transfusions at hospitals throughout the U.S. Generations of doctors were taught that using blood components was the best and most efficient way to transfuse blood. 

That changed as the U.S. became embroiled in the wars in Iraq and Afghanistan. There was a new type of warfare: improvised explosive devices. IEDs cause significant blast injuries that result in hemorrhage. Many blast victims bled to death before they reached a field hospital. To save lives, military physicians began researching factors that could lead to better survival. 

It takes 20 to 25 minutes to bleed to death, so time was identified as the most important factor for survival. If blast victims received a blood transfusion before ever reaching the field hospital, 10 percent of the victims could be saved, research concluded. But what would be the best products to use?

“When you take a pint of blood and separate it into parts, you have a much more diluted product than if they just drew blood, sealed the bag and put it in the fridge,” Dr. Jenkins said. Reconstituting the blood products also is challenging because of their different storage, testing and temperature requirements. On the battlefield, it was impossible. 

“Whole blood is what these patients need. They need oxygen from the red blood cells, clotting from the platelets and plasma to carry it through the body. These factors are all in whole blood, and refrigerated whole blood can be safely stored for 35 days,” he said.  

After retiring from the military in 2008, Dr. Jenkins and colleagues in Pennsylvania and Norway continued whole blood research in the civilian health care system. While at the Mayo Clinic in Rochester, Minnesota, he initiated a whole blood transfusion program for trauma patients in the hospital.

When he arrived in San Antonio in 2016, he studied three years of data from University Hospital—one of two Level 1 trauma centers in South Texas. Patients arriving at the trauma center in need of an emergency transfusion had a 40 percent death rate. For those with ongoing bleeding requiring a replacement of their entire volume of blood, the death rate rose to 76 percent. 

“It didn’t take too much convincing [to switch to whole blood],” he said. “All you had to do was show the numbers. After beginning a whole blood protocol at University Hospital, the death rate dropped to 13.8 percent.” 

He then worked to provide transfusions to patients before they reached the hospital. Whole blood transfusions are now possible on helicopters and in San Antonio Fire Department ambulances, and the program is spreading to other hospitals and ambulance companies in the region. Dr. Jenkins and others are now consulting nationally on the use of whole blood. 

Tiffany Kieschnick-Rivas knows the advantages of whole blood transfusions firsthand. She wouldn’t be alive without one. While driving home in January, she had a stroke. Her car swerved off the road, flipping down an embankment into a ravine with standing water. 

By the time she was rescued, she had no pulse and was not breathing.  

“Our paramedics gave her a unit of whole blood and she began to blink and move her arms and legs,” Dr. Winckler said. Two more units were transfused on the helicopter that brought her to University Hospital. “For just under four minutes, she was dead. But now she will live another 40, 50 or 60 years.” 

The mother of two sons said she’s grateful she received whole blood at the scene of her accident.

“I would not be here without it,” she said.

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