One of the Most Useful Tools on the Ambulance Is Blood

One of the Most Useful Tools on the Ambulance Is Blood

Blood transfusions given at a trauma scene or during transport to a hospital-known as prehospital blood-can help patients most in need.

Of the roughly 15,000 EMS agencies nationwide, the National Highway Traffic Safety Administration estimates that only 2% to 3% carry blood products that could help patients during the most critical minutes after injury. (Photo by Gorodenkoff/Getty Images)

Emergency responders across the country are exploring a tool once reserved almost exclusively for hospitals and battlefields: blood.

Retired Army trauma nurse Randi Schaefer tells NCSL's "Our American States" podcast that the push for prehospital blood-blood products administered at the injury scene or during transport to a care facility-grew directly out of military experience in Iraq and Syria.

"On my first deployment in Baghdad, we would run out of product on the shelves and there's nowhere to get blood resupplied," Schaefer says. "So, we would turn to each other, take it out of our arms and put it directly into our patients. That's what's known as a walking blood bank."

It can work in a pinch, but it's not a sustainable practice. It evolved so that medics had blood supply with them. When Schaefer returned to the U.S., she began working with a Texas program to ensure that emergency medical vehicles had blood products on board and first responders were trained to use them.

Known as prehospital blood programs, they allow trained emergency medical responders to administer blood transfusions at the scene of a crash or medical emergency rather than waiting until patients reach a hospital. Advocates say the practice could save thousands of lives every year, particularly among traffic crash victims who die from blood loss before receiving definitive care in a treatment setting.

"We have approximately 40,000 highway fatalities every year in the United States, which is just way too high," says Jonathan Morrison, administrator of the National Highway Traffic Safety Administration. "When you take a look beneath the surface … we found that of those fatalities, 43% were alive when first responders got to the scene." That finding, drawn from an NHTSA analysis of traffic deaths between 2019 and 2023, has helped fuel interest in bringing blood directly to patients during the most critical minutes after injury. But the change isn't easy to make because the new procedures would require funding and equipment and the training of EMS workers whose certification requirements vary by state and county.

"One of the real issues is if you're bleeding out, how can you be stabilized appropriately?" Morrison says. "Currently, the standard would be to provide a patient with saline, which can help with hydration and whatnot, but you've got to get back to the hospital before you're able to have actual blood product applied to you."

With prehospital blood transfusions, he says, responders can begin lifesaving treatment immediately. "The first responder would have training and equipment and blood product to apply to you on the scene itself."

According to NHTSA research, about 37% of severely bleeding trauma patients could be saved with prehospital blood. Yet the practice remains rare. Of the roughly 15,000 EMS agencies nationwide, Morrison says only 2% to 3% currently carry blood products.

"That's a pretty major aspect where we think there's room for improvement," he says.

From Battlefields to Ambulances

Shaefer says that during her deployment, she learned a great deal about deploying blood in the field.

"What worked in Iraq may not work in Syria," she says. "It really gave me a strategic perspective on how to implement these prehospital blood programs to make them work for the operating environment."

After retiring from the military, Schaefer helped launch one of the nation's first multiagency, regional whole blood programs in South Texas, supplying blood products to civilian ambulances and medical helicopters. Since then, she has assisted about 80 EMS agencies nationwide.

"In 2016, there were approximately four 911 ground EMS agencies carrying blood products," she says. "Now we're up to 350-plus, which sounds like a great number, but it still represents a very, very small percentage of these agencies."

What States Can Do

Expanding prehospital blood programs often requires legislative action, particularly around who is legally allowed to administer blood.

"EMS licenses are not federally regulated. It's often left to the state level," Schaefer says. "In many states, paramedics are allowed to maintain a blood transfusion, but they cannot initiate a transfusion independently. It's that one word that's tripping up some states."

Several years ago, she says, about 11 states prohibited paramedics from initiating transfusions in the field. "Now we're down to four states where we still have some work to do."

Funding is another major obstacle. Blood products require specialized storage, training and quality assurance, all of which cost money.

"Most EMS agencies are finding money for equipment, training and blood products in their own budgets, or they're doing fundraising to pay for this," Morrison with the NHTSA says. "But for programs to be sustainable, you've got to figure out long-term solutions."

At the federal level, the NHTSA has partnered with other agencies to jump-start programs. "Just this last year, we worked to establish a $30 million fund to support demonstration projects," Morrison says, adding that another $50 million was approved through federal transportation grants in late 2025.

States, however, play a central role in removing regulatory barriers and providing startup funds. Aneesa Turbovsky, who tracks EMS legislation for NCSL, says lawmakers tend to have the biggest impact in three areas: scope of practice, that is, authorizing paramedics to use blood; blood supply coordination; and funding.

She points to examples including Texas, which appropriated $10 million to expand a regional whole-blood pilot statewide, and Massachusetts, which funded a mobile blood transfusion program without mandating a statewide rollout.

Beyond Car Crashes

While traffic injuries remain a major focus, Schaefer says prehospital blood is proving useful in a range of emergencies, including maternal hemorrhage, gastrointestinal bleeding and pediatric cases.

"Trauma still remains the leading cause of death for people ages 1 to 44, and we haven't moved the needle on that in decades," she said. "Time matters. Every minute matters in getting that initial blood transfusion going."

She describes the case of a 6-year-old girl who was minutes from death after she began hemorrhaging at home following a routine tonsillectomy. After receiving whole blood from first responders, "she started waking up and didn't require more blood products or surgery when she got to the hospital."

Stories like that, Schaefer says, show why the practice has gained momentum. "While it was born on the battlefield, it has great implications for all kinds of patients here in the U.S."

Still, she warns that without sustained funding, growth will remain uneven. "EMS agencies are right now taking it out of their operating budget, and they run on shoestring budgets," she says. "This is a lifesaving intervention, and it does require a small amount of money to get things started."

For Morrison, the path forward depends heavily on state and local leadership.

His federal agency is "looking to serve as a resource," he says, "but really encourage legislators and staff to engage with their state EMS agencies and help move this forward."