One August afternoon in 2023, Angela Martin’s cousin called with alarming news. Martin’s 74-year-old aunt had been mauled by four dogs while out for a walk near her home in rural Purlear, North Carolina. She was bleeding heavily from bites on both legs and her right arm, where she’d tried to protect her face and neck. An ambulance was on its way.

“Tell them she’s on Eliquis!” said Martin, a nurse who lived an hour’s drive away in Winston-Salem. She knew the blood thinner could lead to life-threatening blood loss.

When the ambulance arrived, the medics evaluated Martin’s aunt and then did something few emergency medical services crews do: They gave her a blood transfusion to replace what she’d lost, stabilizing her sinking blood pressure.

The ambulance took her to the local high school, and from there a medical helicopter flew her to the nearest trauma center, in Winston-Salem. She needed more units of blood in the helicopter and at the hospital but eventually recovered fully.

“The whole situation would have been different if they hadn’t given her blood right away,” Martin said. “She very well might have died.”

More than 60,000 people in the U.S. bleed to death every year from traumatic events like car crashes or gunshot wounds, or other emergencies, including those related to pregnancy or gastrointestinal hemorrhaging. It’s a leading cause of preventable death after a traumatic event.

But many of those people likely wouldn’t have died if they had received a blood transfusion promptly, trauma specialists say. At a news conference last fall, members of the American College of Surgeons estimated that 10,000 lives could be saved annually if more patients received blood before they arrived at the hospital.

“I don’t think that people understand that ambulances don’t carry blood,” said Jeffrey Kerby, who is chair of the ACS Committee on Trauma and directs trauma and acute care surgery at the University of Alabama-Birmingham Heersink School of Medicine. “They just assume they have it.”

Of the more than 11,000 EMS agencies in the U.S. that provide ground transport to acute care hospitals, only about 1% carry blood, according to a 2024 study.

The term “blood deserts” generally refers to a problem in rural areas where the nearest trauma center is dozens of miles away. But heavy traffic and other factors in suburban and urban areas can turn those areas into blood deserts, too. In recent years, several EMS agencies throughout the country have established “pre-hospital blood programs” aimed at getting blood to injured people who might not survive the ambulance ride to the trauma center.

With blood loss, every minute counts. Blood helps move oxygen and nutrients to cells and keeps organs working. If the volume gets too low, it can no longer perform those essential functions.

If someone is catastrophically injured, sometimes nothing can save them. But in many serious bleeding situations, if emergency personnel can provide blood within 30 minutes, “it’s the best chance of survival for those patients,” said Leo Reardon, the Field Transfusion Paramedic Program director for the Canton, Massachusetts, fire department. “They’re in the early stages of shock where the blood will make the most difference.”

There are several roadblocks that prevent EMS agencies from providing blood. Several states don’t allow emergency services personnel to administer blood before they arrive at the hospital, said John Holcomb, a professor in the division of trauma and acute care surgery at UAB’s Heersink School.

“It’s mostly tradition,” Holcomb said. “They say: ‘It’s dangerous. You’re not qualified.’ But both of those things are not true.”

On the battlefields in the Middle East, operators of military medical facilities would maintain that only nurses and doctors could do blood transfusions, said Randall Schaefer, a U.S. Army trauma nurse who was deployed there and now consults with states on implementing pre-hospital blood programs.

But in combat situations, “we didn’t have that luxury,” Schaefer said. Medical staff sometimes relied on medics who carried units of blood in their backpacks. “Medics can absolutely make the right decisions about doing blood transfusions,” she said.

A quick response made a difference: Soldiers who received blood within minutes of being injured were four times as likely to survive, according to military research.

Civilian emergency services are now incorporating lessons learned by the military into their own operations.

But they face another significant hurdle: compensation. Ambulance service payments are based on how far vehicles travel and the level of services they provide, with some adjustments. But the fee schedule doesn’t cover blood products. If EMS responders carry blood on calls, it’s usually low-titer O whole blood, which is generally safe for anyone to receive, or blood components — liquid plasma and packed red blood cells. These products can cost from $80 to $600 on average, according to Schaefer’s study. And payments don’t cover the blood coolers, fluid warming equipment, and other gear needed to provide blood at the scene.

On Jan. 1, the Centers for Medicare & Medicaid Services began counting any administration of blood during ambulance pre-hospital transport as an “advanced life support, level 2” (ALS2) service, which will boost payment in some cases.

The higher reimbursement is welcome, but it’s not enough to cover the cost of providing blood to a patient, which can run to more than $1,000, Schaefer said. Agencies that run these programs are paying for them out of their own operating budgets or using grants or other sources.

Blood deserts exist in rural and urban areas. Last August, Herby Joseph was walking down the stairs at his cousin’s house in Brockton, Massachusetts, when he slipped and fell. The glass plate he was carrying shattered and sliced through the blood vessels in his right hand.

“I saw a flood of blood and called my cousin to call 911,” Joseph, 37, remembered.

The ambulance team arrived in just a few minutes, evaluated him, and called in the Canton-based Field Transfusion Paramedic Program team, which began administering a blood transfusion shortly thereafter. The program serves 30 towns in the Boston area. Since the transfusion program began last March, the team has responded to more than 40 calls, many of them related to car accidents along the ring of interstate highways surrounding the area, Reardon said.

Brockton has a Level 3 trauma center, but Joseph’s injuries required more intensive care. Boston Medical Center, the Level 1 trauma center where the EMS team was taking Joseph, is about 23 miles from Brockton, and depending on traffic it can take more than a half hour to get there.

Joseph was given more blood at the medical center, where he remained for nearly a week. He eventually underwent three surgeries to repair his hand and has now returned to his warehouse job.

Although Boston has several Level 1 trauma centers, the region south of the city is pretty much a trauma desert, said Crisanto Torres, one of the trauma surgeons who cared for Joseph.

Boston Medical Center partners with the Canton Fire Department to operate the field transfusion program. It’s an important service, Torres said.

“You can’t just put up a new Level 1 trauma center,” he said. “This is one way to blunt the inequity in access to care. It buys patients time.”

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By Michelle Andrews
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