# Blood product initiation in the field by EMS



## MedicBender (Apr 19, 2012)

I had a call coming from a small community hospital, for a transfer to a level one hospital about 2 hours Away. Patient presented with esophageal varices, vomiting approx 4 hours ago at home with blood present. Patient came to ER and decision to transfer him to a larger hospital was made. On scene patient was alert, oriented. Vitals p110 sinus tach, BP 156/104, resp 20 non labored. 

The RN stated that they were sending typed and matched blood, to be administered if the varices ruptured en route.

I'm a Iowa paramedic specialist (fancy name for NREMT-P). I called my dispatch to see If this call required an Iowa CCP. Dispatch sent a CCP to meet us. The Iowa state protocols are very vague. I know I can transport blood products, but there is no cut and dry answer for initiation by a medic in the field. The state the same for an Iowa CCP. 

After discussion with the sending facility, the medical director, and dispatch, the Patient was sent with the CCP. 

Has anyone here had protocols for blood administration? 

We're you trained to administer blood products in medic school, or by your service? 

Would you consider this to be in a paramedics scope of practice, or something that requires additional training? 

Just curious to get some opinions on the matter. Hopefully we'll get more clarification from the medical director later. 

Thanks!


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## Veneficus (Apr 19, 2012)

MedicBender said:


> I had a call coming from a small community hospital, for a transfer to a level one hospital about 2 hours Away. Patient presented with esophageal varices, vomiting approx 4 hours ago at home with blood present. Patient came to ER and decision to transfer him to a larger hospital was made. On scene patient was alert, oriented. Vitals p110 sinus tach, BP 156/104, resp 20 non labored.
> 
> The RN stated that they were sending typed and matched blood, to be administered if the varices ruptured en route.
> 
> ...



When I went through paramedic school in my home state, the administration of blood products was taught because the state allowed paramedics to do whatever their local medical director would write orders for. (much like Texas)

Some years and politics later, the state specifically eliminated administration/initiation from the paramedic scope of practice, stating that a paramedic could transport an already hanging blood product.

The work around for it was to have the hospital start administration 15 minutes prior to transport at the lowest rate possible to keep the tubing from clotting and giving the medics additional "maintenence" blood. 

The initial administration of blood products is still part of the curriculum taught in the local schools.

I think it is absolutely within the capabilities (or absolutely should be) of a paramedic to administer blood products. But I don't get to make or change rules.


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## Akulahawk (Apr 19, 2012)

I was taught to monitor blood products, but not to initiate the blood transfusion. I think it's absolutely within a Paramedic's knowledge to be able to monitor and maintain blood products that are sent along with the patient by a sending facility... but I think it's outside their ability to initiate it on their own, if they're carrying their own supply. If the patient has an order for a transfusion that should be initiated if a given, defined situation occurs, _and_ the sending facility has provided the blood and verifies with the Paramedic that the blood is specifically for that patient prior to departure, I have no issue with Paramedics initiating the transfusion. 

Of course, if I can't verify that the blood is supposed to be for that particular patient...


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## kindofafireguy (Apr 19, 2012)

Akulahawk said:


> Of course, if I can't verify that the blood is supposed to be for that particular patient...



Forgive my ignorance, but wouldn't that be relatively simple? As in, shouldn't the patient (assuming this is a transfer) have a blood-type band, and the bag be labeled appropriately?

I don't have experience with transfers, though. It just seems like it be the same as verifying the right patient-right drug for normal pharmacological interventions.


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## Veneficus (Apr 19, 2012)

kindofafireguy said:


> Forgive my ignorance, but wouldn't that be relatively simple? As in, shouldn't the patient (assuming this is a transfer) have a blood-type band, and the bag be labeled appropriately?
> 
> I don't have experience with transfers, though. It just seems like it be the same as verifying the right patient-right drug for normal pharmacological interventions.



Because of the potential harm, it is reasonable to require extra verification procedures for initiating a blood infusion outside of emergent use of O neg.


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## kindofafireguy (Apr 19, 2012)

Gotcha. Makes sense.


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## DrankTheKoolaid (Apr 19, 2012)

We have the same in our protocols.  But the way you present it would be really pushing it as the infusion was not started prior to departure.  

We can continue hanging bags of blood PRN while in transit, which were checked by 2 licensed personnel prior to departure.  An for us training was in house as all P's have to be CCT trained because of the transfers we do from X hospital to X medical center


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## MedicBender (Apr 19, 2012)

We ended up sending the CCP with very specific orders from the ER doc. In the event of a rupture the CCP was to call the sending ER and they would help walk them through the set up. 

It was a rare situation, but one that I felt could have been handled differently. 

In my very limited experience with a varices rupture, it seems like airway control would take up most of the resources. 

The patient only had a 20ga in the right foot, which is bare minimum to run blood through. I don't feel it's sufficient for the amount of volume resuscitation that may be needed.


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## MedicBender (Apr 19, 2012)

Veneficus said:


> The work around for it was to have the hospital start administration 15 minutes prior to transport at the lowest rate possible to keep the tubing from clotting and giving the medics additional "maintenence" blood.



We thought about doing something like this, however they only had one line established and were unable to start another. The one line was running NS and another drug (ill have to go look up the name) that was incompatible with blood. Since his labs were within normal limits they didn't want to discontinue the drug and start the blood if they didn't have to.


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## Veneficus (Apr 19, 2012)

MedicBender said:


> We ended up sending the CCP with very specific orders from the ER doc. In the event of a rupture the CCP was to call the sending ER and they would help walk them through the set up.
> 
> It was a rare situation, but one that I felt could have been handled differently.
> 
> ...



A 20 isn't the minimum, it is the desired minimum. A handful of exeptions preclude this though.

In the event of a rupture, you will need blood. If you ever see one rupture, it will remove all doubt that will be most important.

Out of curiosity how far were you going and how much blood did they give you?


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## MedicBender (Apr 19, 2012)

The trip takes about 2 hours. There are 2 small hospitals on the way out there to divert if necessary, but there is an hour stretch where there is nothing. 

I'll have to double check on the blood, but I remember seeing 2 bags. By the time the blood arrived the CCP was there and had taken over the call, I was trying to coordinate with the medical director.


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## Veneficus (Apr 19, 2012)

MedicBender said:


> The trip takes about 2 hours. There are 2 small hospitals on the way out there to divert if necessary, but there is an hour stretch where there is nothing.
> 
> I'll have to double check on the blood, but I remember seeing 2 bags. By the time the blood arrived the CCP was there and had taken over the call, I was trying to coordinate with the medical director.



2 bags as in two bags full of units of blood or 2 unit of blood? 

because if it was 2 units, you probably wouldn't have nearly enough in the even of catastrophic rupture.


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## MedicBender (Apr 19, 2012)

Just heard back from the guys on the trip. The hospital sent 2 units with the crew.


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## Veneficus (Apr 19, 2012)

MedicBender said:


> Just heard back from the guys on the trip. The hospital sent 2 units with the crew.



they probably shouldn't have bothered


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## fast65 (Apr 19, 2012)

Our protocols allow us to monitor and continue a blood infusion, as well as begin an infusion if the sending facility sent blood for that patient with us. 

We carry blood y-sets on our ambulances, and as I said, we're allowed to start a blood infusion if the sending facility gives us blood for that specific patient. We're required to check and double check that the patient information matches the blood documentation. However, our protocols also state that we should have two IV's in place and that we should be running the blood through an 18g or larger.

I'm gonna agree with Vene though, 2 units isn't really going to do much in the event of a rupture. It's like the hospital that sent me with a hypertensive AAA patient the other day, and only gave me 2 units of blood, why bother. <_<


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## Veneficus (Apr 19, 2012)

fast65 said:


> I'm gonna agree with Vene though, 2 units isn't really going to do much in the event of a rupture. It's like the hospital that sent me with a hypertensive AAA patient the other day, and only gave me 2 units of blood, why bother. <_<



In a catastorphic rupture or rupture into the peritoneal space, short of a knife and a clamp, there is nothing the hospital can give you that would matter a damn for that.


...and that clamp is only going to be useful for about 20-40 minutes.


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## MedicBender (Apr 19, 2012)

fast65 said:


> Our protocols allow us to monitor and continue a blood infusion, as well as begin an infusion if the sending facility sent blood for that patient with us.
> 
> We carry blood y-sets on our ambulances, and as I said, we're allowed to start a blood infusion if the sending facility gives us blood for that specific patient. We're required to check and double check that the patient information matches the blood documentation. However, our protocols also state that we should have two IV's in place and that we should be running the blood through an 18g or larger.



Do they provide you with a drop rate? Or do you need patient specific orders to follow the protocol? 

Also, are you running this through a pump or gravity fed?


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## fast65 (Apr 19, 2012)

Veneficus said:


> In a catastorphic rupture or rupture into the peritoneal space, short of a knife and a clamp, there is nothing the hospital can give you that would matter a damn for that.
> 
> 
> ...and that clamp is only going to be useful for about 20-40 minutes.



Exactly.

My orders were to start it if her SBP dropped below 110, but really, I would imagine I would want her to be a least a little hypotensive if it started leaking. So I guess I would just be using the blood to titrate her pressure up?



MedicBender said:


> Do they provide you with a drop rate? Or do you need patient specific orders to follow the protocol?
> 
> Also, are you running this through a pump or gravity fed?



Sometimes they do, sometimes they don't, just depends who the doc is and if they write it on the transfer orders. Of course, if they don't, I'll ask them, but as far as my protocols go, it says "initiate the infusion slowly", so that's helpful. :unsure:

It's gravity fed if I'm starting the infusion en route, but if I'm just continuing it, they'll usually let me take the pump with me.


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## jwk (Apr 19, 2012)

All I'll say it that's a scary bad ER.


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## fast65 (Apr 20, 2012)

jwk said:


> All I'll say it that's a scary bad ER.



No comment


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## mycrofft (Apr 20, 2012)

20 ga for blood? We were taught minimum of 18, preferably 16, due to cell damage and haemolysis because of turbulence in smaller catheters and needles.


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## Veneficus (Apr 20, 2012)

mycrofft said:


> 20 ga for blood? We were taught minimum of 18, preferably 16, due to cell damage and haemolysis because of turbulence in smaller catheters and needles.



It is really agency/population specific, I have run it through 22 ga on infants and 26 ga on neonates.

While central access is prefered, sometimes early peripheral access is needed.

As my first ever rescue instructor said:

"The book tells you how to rescue somebody in a perfect world. If the world was perfect, nobody would need rescued."


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## Farmer2DO (Apr 20, 2012)

Veneficus said:


> While central access is prefered, sometimes early peripheral access is needed.




And if the patient only had a 20 g in the foot with a non-compatible medication running (I'm guessing octreotide), and they were concerned enough about rupture to send blood with the crew, I would say that central access would have been required.  In fact, I probably would have insisted before I left.


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## Veneficus (Apr 21, 2012)

Farmer2DO said:


> And if the patient only had a 20 g in the foot with a non-compatible medication running (I'm guessing octreotide), and they were concerned enough about rupture to send blood with the crew, I would say that central access would have been required.  In fact, I probably would have insisted before I left.



For sure.

But we could go on about what you get from community facilities for hours I'll bet.

Sometimes you just have to do what you have to.


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## Farmer2DO (Apr 23, 2012)

Veneficus said:


> For sure.
> 
> But we could go on about what you get from community facilities for hours I'll bet.
> 
> Sometimes you just have to do what you have to.



Which is sometimes holding the sending facility responsible.  I don't take dump jobs.  I'm all about being part of the solution, but that scenario was incredibly irresponsible.


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## Flight-LP (Apr 23, 2012)

Yes, additional access would have been necessary. RIC line, EJ, Subclavian, something.

2 units of blood for an emergent rupture is definitely equivalent to pissing in the wind. 

Was there consideration given to a more rapid method of transport with an appropriate specialty team? I.e. fancy way of saying perhaps this would have been a patient that could have benefited from air transport?


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## MedicBender (Apr 24, 2012)

I doubt they would have flown him. It's a state run hospital, they were sending him so far away in am effort to keep him in the state system. I've taken higher priority patients out of there by ground. Usually they stabilize and transfer when necessary. Not sure what happened with this guy


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## kindofafireguy (Apr 24, 2012)

Bureaucracy happened.


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## Flight-LP (Apr 24, 2012)

MedicBender said:


> I doubt they would have flown him. It's a state run hospital, they were sending him so far away in am effort to keep him in the state system. I've taken higher priority patients out of there by ground. Usually they stabilize and transfer when necessary. Not sure what happened with this guy



Sadly, I understand their dilemma. I am surprised they do not have a contingency in place for State facilities. Do they really send all populations and levels of care by ground with a standard crew?


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## Veneficus (Apr 24, 2012)

Flight-LP said:


> Sadly, I understand their dilemma. I am surprised they do not have a contingency in place for State facilities. Do they really send all populations and levels of care by ground with a standard crew?



There is a point where medicine prices itself out of the market.

A brief glimpse at a lesson that will be hard learned it not fixed.


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## MedicBender (Apr 24, 2012)

Flight-LP said:


> Sadly, I understand their dilemma. I am surprised they do not have a contingency in place for State facilities. Do they really send all populations and levels of care by ground with a standard crew?



Yes, I don't remember the last time they flew some one. They are sending them to the only level one hospital in the state. In town we have two level 2 hospitals. In the event its very critical, they may keep them in town and send them to a level 2. However I can think of one that I transferred downtown in the last 5 months. The rest go to the level 1 hospital. 

They will 99% of the time send them by regular paramedic truck. However they may send a CCP if it meets the requirements (over 3 meds running, biPAP, art line monitor)


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## jwk (Apr 24, 2012)

MedicBender said:


> Yes, I don't remember the last time they flew some one. They are sending them to the only level one hospital in the state. In town we have two level 2 hospitals. In the event its very critical, they may keep them in town and send them to a level 2. However I can think of one that I transferred downtown in the last 5 months. The rest go to the level 1 hospital.
> 
> They will 99% of the time send them by regular paramedic truck. However they may send a CCP if it meets the requirements (over 3 meds running, biPAP, art line monitor)



A Level II trauma center ought to be a lot more prepared/competent than what is being described here.  Just sayin...


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## MedicBender (Apr 24, 2012)

jwk said:


> A Level II trauma center ought to be a lot more prepared/competent than what is being described here.  Just sayin...



The issue is these hospitals are not part of the state program. In an effort to cut down on cost, the hospital tries to keep the patient in the state system. Sending them to one of the level IIs would take them out of this system.


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