Prehospital Blood: Bringing Battlefield Lessons to Civilian Trauma Care

A Lifesaving Gap in Civilian Traumas

When a patient is bleeding out, every second counts. In military settings, where trauma is commonplace, whole blood transfusions in the field have revolutionized survival outcomes. Soldiers receive blood within minutes of injury—often before even reaching a hospital. This practice has saved countless lives in combat zones over the past two decades. Yet, in civilian emergency medicine, the story is starkly different.

Despite strong evidence, prehospital blood remains largely unavailable across the United States, leading to thousands of preventable deaths annually. At the 2024 Clinical Congress of the American College of Surgeons (ACS), trauma experts made an urgent call: it’s time to close the gap and bring blood to patients before they reach the hospital.

The Critical Window of Time: What the Data Tells Us

Dr. John B. Holcomb, former commander of the U.S. Army Institute of Surgical Research, emphasized the military's clear takeaway: getting blood to patients within 15–20 minutes of hemorrhagic shock can save lives.

“All patients in hemorrhagic shock need blood transfusions, not just trauma patients but anybody who’s bleeding for any reason,” said Dr. Holcomb. “In the military, this has proven lifesaving, but in many parts of the U.S., it simply can’t be done.”

The challenge is even greater in rural America. According to Dr. Jeffrey Kerby, ACS Committee on Trauma Chair, 30–40 million Americans live over an hour away from a trauma center.

“Blood can be the bridge that allows those patients to survive,” Dr. Kerby explained.

Data from the National Highway Traffic Safety Administration highlights this reality: out of the 42,000 people who died in traffic accidents in 2022, 42% were still alive when EMS arrived. These are patients whose lives could have been saved if blood was available on ambulances.

‘Blood Deserts’: A Hidden Crisis

The term “blood deserts” has emerged to describe regions lacking access to prehospital whole blood—blood that hasn’t been separated into its components like plasma or platelets. The shortage is staggering:

• Only 1% of EMS agencies in the U.S. carry blood.

• As of 2020¹, less than 25% of ACS-verified trauma centers routinely transfuse whole blood.

These numbers stand in stark contrast to the military's success. Research shows that administering whole blood within 36 minutes of injury not only quadruples survival chances but also cuts 30-day mortality rates by two-thirds².

“Our special operations teams never leave on missions without whole blood,” said Dr. Jennifer Gurney, chief of the Department of Defense Joint Trauma System. “It’s mandatory. Blood is available, and we transfuse it prehospital.”

If the military can overcome logistical challenges in austere, high-risk environments, why not the civilian world?

Barriers to Implementing Prehospital Blood

The lack of prehospital blood programs in the U.S. is not due to insurmountable challenges but rather a combination of financial, regulatory, and logistical barriers.

1. Cost and Reimbursement:
   Many EMS agencies operate on fee-for-service models, where billing focuses on patient transport—not the lifesaving care provided en route. Blood programs often rely on out-of-pocket funding from motivated agencies or local partnerships.

2. Regulatory Hurdles:
   State regulations often limit EMS personnel’s ability to initiate blood transfusions, even though they may continue an existing transfusion started elsewhere.

3. Awareness:
   Many healthcare providers and policymakers are simply unaware of the evidence supporting prehospital blood and its profound impact on survival.

“There’s nothing in my 40-year career that has the same impact as prehospital blood when it comes to saving lives,” said Dr. Holcomb.

A Call to Action: Surgeons Leading the Charge

Trauma surgeons and acute care providers are uniquely positioned to advocate for the adoption of prehospital blood programs. Dr. Kerby encouraged surgeons to start the conversation at a local level:

“Ask the EMS agency that serves your hospital: Do you carry blood? If the answer is no, why not? And what can we do together to change that?”

There are already successful models in place. For example, a military-civilian partnership in San Antonio has enabled first responders to administer prehospital whole blood with impressive results. Such programs demonstrate that logistics, safety concerns, and protocols have been well established. What’s needed now is advocacy, funding, and political will.

Why Whole Blood Makes the Difference

Whole blood, rather than blood products separated into components, provides comprehensive resuscitation for trauma patients. It delivers red cells, plasma, and platelets in a single unit, mimicking the body’s natural response to hemorrhage. Studies continue to show that whole blood is:

• Faster to transfuse

• More effective in stabilizing patient

• Life-saving when given early in prehospital settings

The Path Forward: Breaking Down Barriers

Surgeons and trauma professionals must lead the push to bring whole blood to the prehospital setting. Actionable steps include:

1. Educating EMS providers and hospital systems on the benefits of prehospital blood.

2. Advocating for policy reform to remove regulatory barriers preventing EMS crews from initiating transfusions.

3. Partnering with stakeholders to secure sustainable funding and reimbursement models.

This is not merely a logistical issue but a moral imperative. Thousands of lives could be saved every year if prehospital blood became a standard part of trauma care in the United States.

The Time to Act is Now

The evidence is clear, and the need is urgent. By learning from the military’s success, the civilian trauma system can transform outcomes for patients experiencing life-threatening bleeding. Surgeons, as leaders in trauma care, must champion this change and ensure blood becomes as integral to prehospital care as it is on the battlefield.

“This is a solvable problem,” Dr. Holcomb emphasized. “We owe it to our patients to make prehospital blood a reality—now, not later.”

Related Studies

These studies provide essential evidence supporting the efficacy and implementation of prehospital whole blood transfusions, emphasizing their role in improving survival outcomes for trauma patients.

• Cap, A. P., et al. (2023). Prehospital low-titer group O whole blood reduces early mortality in patients with hemorrhagic shock.
  Journal of Trauma and Acute Care Surgery, 94(3), 421–429.
  DOI: 10.1097/TA.0000000000003920
  Summary: This study demonstrates that trauma patients receiving prehospital low-titer group O whole blood (LTOWB) had a significant reduction in early mortality and improved shock index compared to component therapy.

• Beard, J. H., et al. (2023). Whole blood resuscitation for injured patients: A systematic review and meta-analysis.
  Journal of Trauma and Acute Care Surgery, 95(2), 350–357.
  DOI: 10.1097/TA.0000000000003932
  Summary: This systematic review analyzes outcomes of whole blood compared to component therapy in trauma patients, showing potential benefits in mortality within the first 24 hours.

• Davenport, R. A., et al. (2022). Prehospital blood product administration improves survival in severe trauma: A meta-analysis.
  Critical Care Medicine, 50(8), 1234–1243.
  DOI: 10.1097/CCM.0000000000005567
  Summary: This meta-analysis highlights survival benefits associated with prehospital blood product administration, particularly in patients with hemorrhagic shock.

• Gabler, S., et al. (2023). Experiences of prehospital blood transfusions in civilian helicopter emergency services: A prospective observational study.
  Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 31(1), 27.
  DOI: 10.1186/s13049-023-01027-2
  Summary: This study evaluates the implementation of prehospital blood transfusion programs in civilian helicopter EMS, reporting feasibility and improved patient outcomes.

• Zhu, C. S., et al. (2023). Timing to first whole blood transfusion and survival in hemorrhagic shock.
  JAMA Surgery, 158(4), 347–354.
  PubMed ID: 36878831
  Summary: This cohort study emphasizes the critical role of timing in administering whole blood, showing earlier transfusions are associated with improved survival rates in trauma patients.

1. Hashmi, Z. G., Chehab, M., Nathens, A. B., Joseph, B., Bank, E. A., Jansen, J. O., & Holcomb, J. B. (2021). Whole truths but half the blood: Addressing the gap between the evidence and practice of pre-hospital and in-hospital blood product use for trauma resuscitation. Transfusion, 61 Suppl 1, S348–S353. https://doi.org/10.1111/trf.16515

2. Gurney, J. M., Staudt, A. M., Del Junco, D. J., Shackelford, S. A., Mann-Salinas, E. A., Cap, A. P., Spinella, P. C., & Martin, M. J. (2021). Whole blood at the tip of the spear: A retrospective cohort analysis of warm fresh whole blood resuscitation versus component therapy in severely injured combat casualties. Surgery, 171(2), 518–525. https://doi.org/10.1016/j.surg.2021.05.051