California Prehospital Blood Program Is Already Saving Lives

Prehospital blood administration is a concept promoted by the ACS Committee on Trauma (ACS COT).¹ 

It also has been approved by the Trauma Hemostasis & Oxygenation Research Network and Association for the Advancement of Blood & Biotherapies (formerly known as the American Association of Blood Banks), as well as recommended by the Committee on Tactical Combat Casualty Care and International Association of Emergency Medical Services Chiefs.²

The practice of administering prehospital blood stems from the reality that hemorrhage is the leading cause of mortality in both civilian and military trauma patients.³

Unfortunately, trauma is still the most common reason for death for individuals up to 44 years of age. To reach its goal of zero preventable deaths from injury, the National Academies of Sciences, Engineering, and Medicine (NASEM) is focusing on improving the treatment of life-threatening hemorrhage.³ As such, the delivery of blood to a hemorrhaging patient in the field initiates the resuscitation phase early and could potentially save up to 10,000 lives a year and benefit between 54,000 to 900,000 patients annually in the US.^1,3

This model, while not new to some parts of the US, has not been adopted in many states. Data from October 2023 showed that 24 states had adopted prehospital blood transfusion but accounted for less than 1% of 9-1-1 emergency medical services (EMS) agencies in the US.2 (For more information on the use of prehospital blood, read the March 2025 Bulletin article, “Improving Access to Prehospital Blood May Save 10,000 Lives a Year.”)

Use of warm, fresh whole blood has been studied extensively in the military and shown to decrease the mortality of traumatic hemorrhagic shock.¹ In the landmark study by Shackleford and colleagues, 24-hour and 30-day mortality was shown to be reduced in patients receiving prehospital transfusion within 15 minutes of the injury.⁴ Because it has been studied widely in the military, experts in prehospital blood administration advocated for it to be extrapolated to the civilian sector. Notably, initial studies from early civilian adopters demonstrated similar potential benefits as evidenced by the military studies.¹

Bringing Blood to the Field

Inspired by these results, the Ventura County Fire Department (VCFD) requested the Ventura County EMS (VCEMS) Agency seek approval from the California EMS Authority to implement a prehospital blood program. The VCFD then engaged with the Ventura County Medical Center (VCMC), Ventura’s west county trauma center, on the programmatic journey to bring blood to the field. It made sense to partner with VCMC because it has the only whole blood program in the county.

After the MOU was signed, there was another challenge related to starting the program due to the Palisades (Pacific Palisades) and Eaton (Altadena) fires in the Los Angeles area that erupted in January 2025. The fires burned 23,707 acres and 14,021 acres, respectively, resulting in the destruction of more than 16,000 structures and 28 deaths.⁷

Containing the fires and managing the aftermath required the use of resources from not only Los Angeles County, but also many other fire departments such as the Ventura County fire units. Following containment of the fires, training of 100 VCFD and sheriff’s department personnel occurred, and the pilot program was started on April 1, 2025.

Ventura County’s prehospital blood program currently involves four of five battalions, with the hope of increasing to all. The eventual goal is to create blanketed coverage, including aviation-unit helicopters used by the Ventura County Aviation Unit, which is a joint unit run by both the VCFD and the Ventura County Sheriff Department. To enable support of the program, monthly blood drives will be organized.

A press release was issued upon initiation of the program, and a press conference was held on April 9 to help ensure public awareness of the program.

Ventura County is located in southern California. It has a population of 823,000 and is situated approximately 70 miles northwest of Los Angeles, approximately 30 miles southeast of Santa Barbara, and just north of the Pacific Ocean.⁵ The county has two adult ACS-verified Level II trauma centers; one is located on the east side, and the other is on the west side of the county.

The chief proponent of the program from the VCFD is firefighter and paramedic Edward Campana who assembled stakeholders from VCEMS, VCMC, and our local blood supplier. Multiple meetings were held with all stakeholders to mirror the development of an established program in San Antonio, Texas. While the program in Ventura was evolving, programs also were being established in Los Angeles, San Bernardino, Riverside, and Sacramento counties, which collectively form the California Development and Rapid Operationalization of Prehospital Blood or “CAL-DROP Coalition.” The coalition was developed to foster collaboration and establish best practices for multiple regions across California looking to implement prehospital blood programs. The local EMS agency in each region is responsible for programmatic oversight and will report data prospectively to the California EMS Authority.⁶

The initial goal was to start the program in October 2024, but there were some unexpected challenges. VCEMS had to acquire approval from the California EMS Authority, which was granted in September 2024. Criteria for the administration of blood was created and agreed upon by all stakeholders (see Figure above). Funding for startup of the program came from VCFD in the amount of $122,215 for basic equipment.

A blood exchange rotational system was configured with VCMC. After determining the nuances of blood units available for the prehospital side and exchange with VCMC, a memorandum of understanding (MOU) was signed between VCFD and VCMC. VCEMS and VCFD reviewed historical EMS data to determine the optimal strategic deployment of blood in Ventura County.

On April 10, a Ventura County fire paramedic became the first ground paramedic to administer prehospital whole blood in California. Thus far, there have been four cases of prehospital whole blood administration in young adult males. The first was stabbed in the thigh and required a combination of Stop the Bleed packing techniques, tranexamic acid (TXA), and one unit of whole blood. The patient was treated nonoperatively after adequate control of the arterial bleeder.

The second patient was stabbed in the back and had a retroperitoneal bleed that also was treated with one unit of whole blood, TXA, and nonoperative management. The third patient had a devastating penetrating head injury with significant blood loss, was administered TXA and one unit of whole blood, and delivered to VCMC. Family wishes were honored. The fourth patient had a suspected gastrointestinal bleed from gallstone ileus, was administered one unit of whole blood, and underwent surgical management.

The program has a quality assurance process to review all cases for identifying any challenges such as inappropriate use of blood, transfusion adverse reactions, outcomes, and other metrics.

Efforts to create the Ventura County Prehospital Blood Program demonstrate how collaboration works in improving the quality of life for the injured patient and aligns with NASEM’s goal to attain zero preventable deaths after injury.

It is important to note that Ventura County leadership worked with the Joint Advocacy Committee of the ACS California chapters (Northern, Southern, and San Diego Imperial chapters), which was instrumental in sponsoring the Stop the Bleed Assembly Bill (AB) 2260 with Assemblymember Freddie Rodriguez (D).⁸

The legislation was the first statewide law of its kind to make bleeding control kits widely accessible in public buildings.⁸ During the past several years, joint efforts from both Ventura County trauma centers (VCMC and Los Robles Regional Medical Center) and VCEMS have brought ACS Stop the Bleed training to the community at large, including but not limited to, the summer 2024 Junior Lifeguards Program, where 900 kids (ages 10 to 18) were instructed on lifesaving skills.

Acknowledgment

The authors extend their sincere thanks to all stakeholders that contributed to this initiative, including VCEMS, VCMC Blood Bank Committee, VC Prehospital Services Committee, Vitalant Blood Services, and VCMC’s administration.

Disclaimer

The thoughts and opinions expressed in this column are solely those of the authors and do not necessarily reflect those of the ACS.

Dr. Thomas Duncan is the trauma medical director for Ventura County Medical Center in California. He also is an ACS Specialty Society Governor and member of the National Committee on Trauma.

References

1. Newman MS. Improving access to prehospital blood may save 10,000 lives a year. Bull Am Coll Surg. 2025:110(3):8-15.
2. Levy MJ, Garfinkel EM, May R, Cohn E, et al. Implementation of a prehospital whole blood program: Lessons learned. J Am Coll Emerg Physicians Open. 2024 Mar 21;5(2):e13142.
3. Schaefer RM, Bank EA, Krohmer JR, Haskell A, et al. Removing the barriers to prehospital blood: A roadmap to success. J Trauma Acute Care Surg. 2024:97(2):138-144.
4. Shackelford SA, del Junco DJ, Powell-Dunford N, Mazuchowski EL, et al. Association of prehospital blood product transfusion during medical evacuation of combat casualties in Afghanistan with acute and 30-day survival. JAMA. 2017;318(16):1581-1591.
5. World Population Review. Ventura County. Available at: https://worldpopulationreview.com/. Accessed May 8, 2025.
6. California Development and Rapid Operationalization of Prehospital Blood (CAL-DROP). Ensuring life-saving blood availability in prehospital settings. Los Angeles County Department of Health Services. Available at: https://dhs.lacounty.gov/harbor-ucla-medical-center/work-or-partner-with-us/la-drop/#1741391754882-595277b8-3ae0. Accessed May 8, 2025.
7. Phillips S. The Palisades and Eaton fires: Neighborhood data and potential housing market effects. UCLA Lewis Center for Regional Policy Studies. 2025. Available at: https://scholarship.org/uc/item/1kg4v5v1. Accessed May 8, 2025.
8. Maa J, Liepert AE, Doucet JJ, Fuchshuber P. California advocacy produces six lessons for surgeons across America. Bull Am Coll Surg. May 2023. Available at: https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/bulletin/2023/may-2023-volume-108-issue-5/california-advocacy-produces-six-lessons-for-surgeons-across-america/. Accessed May 19, 2025.