On Jan. 30, 2019, Tiffany Kieschnick-Rivas was driving to the store when she had a stroke. Her Hyundai Sonata veered into a guardrail, flipped and landed in a ditch filled with water.
Within minutes of San Antonio Fire Department paramedics pulling her from the crumpled heap of metal, Kieschnick-Rivas, 37, was dead.
“She crashed,” recalled paramedic Jason Aguilar. “She had no pulse.” What they would later learn is that the woman’s spleen had ruptured and she was bleeding internally.
Today, however, Kieschnick-Rivas is telling her survival story thanks to a treatment plan the fire department and area medical partners implemented just three months before her wreck.
The EMS unit that rushed to the accident was equipped with whole blood, which is exactly what the name implies. It’s blood that contains all of its components and not just some of its main elements - platelets, plasma or red blood cells.
Instead of giving Kieschnick-Rivas a single blood component or the usual saline solution to replace lost fluids, paramedics gave her a whole blood transfusion at the crash site. Within five minutes her heart began beating again.
“She started trying to breathe on her own. She opened her eyes. This had never happened before,” Aguilar said.
As far as anyone knows, the young mother is the first blunt force trauma patient whose heart stopped beating and then was revived when ground crew paramedics transfused her with whole blood.
The San Antonio Fire Department has since expanded its whole blood program, and now carries it on eight EMS units strategically located around the city.
In January 2019, San Antonio Fire Department Paramedics Jason Aguilar (left) and Albert Garcia (right) transfused Tiffany Kieschnick-Rivas with whole blood shortly after her car crashed. The EMS team credits the availability of whole blood with saving her life.
The fire department’s deputy medical director, Dr. C.J. Winckler, an emergency medicine physician at University Hospital in San Antonio, said his team is still analyzing data to determine the impact whole blood has had on the survival of patients transfused by department paramedics. However, he’s confident results will show that in the first year of using whole blood, a significant number who otherwise wouldn’t have made it survived.
The Whole Blood Coalition
The San Antonio Fire Department is just one important thread in a tightly woven network of South Texas emergency medical providers who have attracted national attention after designing a promising model for treating critically injured patients.
They’ve created a unique whole blood donor program and delivery system that ensures a stable supply is strategically rotated among medical providers through a program that ensures almost no waste.
Partners in this groundbreaking effort include South Texas Blood & Tissue Center which collects whole blood from volunteers who donate through the specially formed Brothers in Arms program; the Southwest Texas Regional Advisory Council, which manages the supply and demand for whole blood in the 22- county trauma region it oversees; and more than a dozen air and ground emergency medical transport services that transfuse whole blood in the field.
Brooke Army Medical Center known as BAMC, and University Hospital are the partnerships’ two Level I trauma centers that maintain constant supplies of whole blood for patients who are rushed to their hospitals. Though one is military and the other civilian they work closely together to collect data and research, with the aim of demonstrating when and how whole blood can be used most effectively.
One way in which they differ is in where they get their whole blood. BAMC receives its supply from the military. University Hospital is part of the partnership’s strategically developed rotation process that ensures the whole blood is effectively used within its 35 day shelf life.
The donated blood is first provided to EMS ground and transport crews. What they don’t use in the first 14 days is sent to University Hospital, whose high volume of trauma patients ensures the blood will be utilized before the end of its shelf life.
While other hospitals throughout Texas and the country are using whole blood in some way, University Hospital is currently the only one participating in a partnership that maintains a constant supply in its trauma center and reports virtually no waste - less than 1% of the whole blood collected is discarded.
The genius behind the program can, in part, be attributed to the know-how former military doctors and medical personnel have brought to the partnership, and to the get-it-done commitment of one battlefield surgeon.
Whole Blood Revival
The use of whole blood to treat badly bleeding patients isn’t new. It was used as early as the 1800s and during both World Wars.
In the 1960s, however, it was mostly replaced, which was a big mistake according to Dr. Donald Jenkins, a trauma surgeon at University Hospital and the Distinguished Chair in Burn and Trauma Surgery at UT Health San Antonio.
Dr. Jenkins said the unfortunate shift began with the use of chemotherapy to heal cancer patients. Chemo causes a drop in platelets, one component of blood. Because cancer patients primarily just needed extra platelets, medical professionals devised ways to separate the blood into its three primary parts – platelets, plasma and red blood cells. That ushered in an era of using blood components for various treatments instead of transfusing patients with the complete product.
“They literally threw the baby out with the bathwater. They moved completely away from whole blood transfusions. And we are now two generations of physicians and nurses removed from the experience of using whole blood,” said Dr. Jenkins.
Dr. Jenkins realized the enormous potential of whole blood when he was a U.S. Air Force officer, the first surgeon deployed to a base in Oman in 2001.
Not long after arriving, two soldiers fighting in Afghanistan were injured and flown to his mobile hospital. They were losing a lot of blood, but the hospital didn’t have the blood components needed to save them.
So, for the first time in his career, Dr. Jenkins administered transfusions using the whole blood of compatible personnel at the base.
From September 2001 through February 2002 Dr. Donald Jenkins served as a U.S. Air Force officer and combat surgeon on Masirah Island, Oman. He began using whole blood at the mobile surgical hospital there to treat injured soldiers. (Photo courtesy of Dr. Donald Jenkins)
“The only way I knew how to use whole blood was because I had a book from 1988 in my pocket – the NATO Emergency War Surgery Handbook – that told you how to do it. My teachers didn't teach me, because their teachers didn't teach them, because we didn't have whole blood,” said Dr. Jenkins.
The soldiers lived, and Dr. Jenkins became an evangelist for the life-saving value of whole blood – leading a crusade for its renewed use in the combat zone where soldiers who previously would have died began pulling through.
The mortality rate for critically injured patients who require extensive transfusions in hospital trauma centers is about 75%, according to Dr. Jenkins. But, when whole blood instead of blood components was administered on the battlefield – before soldiers reached a hospital – the mortality rate dropped to as low as 20%.
“It's a game changer,” said Dr. Jenkins. “It really makes sense that when you're bleeding whole blood you would replace with whole blood. When you break the blood down into its component parts and then put it back together, it's a lesser product than the unit as it started out. It’s weaker in clotting. It's got a lower hemoglobin value, so it’s carrying less oxygen.”
A Whole Blood Battle Plan for Civilian Health Care
In 2008, when Dr. Jenkins retired from the military, he introduced whole blood to civilians as the trauma medical director at Mayo Clinic in Rochester, Minn. The air transport medics used it to treat patients while enroute to the hospital.
Then in 2016, he brought his experience and passion to South Texas where he helped launch a new battle plan.
As a surgeon at University Hospital’s Trauma Center, and a clinical professor at UT Health, he began talking with the South Texas Blood & Tissue Center about the value of providing a steady supply of life-saving whole blood for trauma patients throughout the region.
They organized the program, Brothers in Arms, and recruited military veterans and other male donors who could contribute O positive blood, the most common type. Male donors are used because they have fewer antibodies that can create adverse reactions in transfused patients.
Air transport medics flying patients from rural locations to hospitals in the San Antonio area now carry whole blood 24/7. They store it in special coolers at temperatures between 32 and 50 degrees Fahrenheit, then use infusers to quickly warm the blood before it’s transfused.
San Antonio Fire Department EMS units can rush it to crash or shooting sites in under 10 minutes, and at least 13 other South Texas ground and air EMS departments carry it on their ambulances, too.
Frio Regional Hospital in Pearsall, 50 miles southwest of San Antonio, and Peterson Memorial Hospital in Kerrville, are building whole blood programs, and the regional partnership, known as the San Antonio Whole Blood Consortium, is exploring options for making it available to additional South Texas hospitals and EMS agencies.
Initially, the coalition partners restricted the use of whole blood to trauma patients ages 10 and older at University Hospital, and 5 or older before they arrived at the hospital.
With a growing understanding of its life-saving potential, however, Dr. Jenkins and others have set their sights on also providing whole blood to non-trauma patients with severe bleeding.
University Hospital has started using whole blood to successfully stabilize women who hemorrhage before and after childbirth. It may also be used for patients bleeding because of ulcers, aneurisms or after surgery.
Growing a Movement
Stories of patients like Tiffany Kieschnick-Rivas who are alive because of whole blood have gained national attention, and convinced hospitals and emergency medical providers from around the country to explore its use in their communities.
“Training people how to do this is our mission now,” said Dr. Jenkins. “We have been contacted by places as diverse as the state of Washington, Maryland, rural Georgia and New York City. It’s been an amazing transformation.”
In January, the San Antonio partners organized a two-day training session for four cities that want to launch their own programs. The American Red Cross says it is providing whole blood to over 30 hospitals nationwide and will soon be adding more.
Once again, Dr. Jenkins is applying battlefield science as he and the partnership execute a plan to save lives. He’s collecting data, looking at results and organizing health care partners to take the next hill.
Dr. Jenkins thanks volunteers donating blood through the Brothers in Arms program and explains how their contributions are saving lives.
Dr. Donald Jenkins promotes the use of whole blood at University Hospital’s Level I Trauma Center after seeing how it helped saved soldiers injured in combat. Jenkins is a trauma surgeon at the hospital and the Distinguished Chair in Burn and Trauma Surgery at UT Health San Antonio.
Dr. Jenkins embraces Tiffany Kieschnick-Rivas at the Brothers in Arms program. She thanks him for his pioneering work to promote the use of whole blood which saved her life following a car crash.