In severe emergencies, paramedics often give patients IV fluids to help maintain circulation while transporting them to a hospital. But when patients lose large amounts of blood, those fluids cannot replace the blood cells and clotting factors their bodies need.
Nathan Rogers, a paramedic and blood transfusionist with Taney County Ambulance District, now has another option available to him: administering blood before a patient reaches the hospital.
“We'll clear the line with normal saline but to clear the system,” Rogers said. “Once it gets all the air bubbles out of the line. Once we get it clear, then we put blood through.”
The practice is called pre-hospital blood transfusion. It allows emergency medical personnel to administer blood products at an accident scene or during transport, starting treatment before patients reach the hospital.
“If we arrive on scene, we won't waste time on scene giving them blood there," Rogers said. "We'll load them in the truck, get them going, give them blood while en route. And by the time we get to the hospital, most usually we're finished up with the blood products.”
Taney County Ambulance District began offering the service in June to serve its 10,000 residents and the roughly 200,000 tourists who visit the Branson area throughout the year.
Fewer than 10 ambulance services in Missouri currently offer pre-hospital blood transfusions.
Taking cues from the military
The practice was developed in military medicine to treat hemorrhagic shock, a life-threatening condition caused by severe blood loss. Medical experts have long understood that replacing lost blood can be critical to survival. But transporting and storing blood outside hospitals presents significant logistical challenges.
Blood is a sensitive medical product that must be stored within a specific temperature range to remain safe to use. Hospitals and blood banks have established systems to maintain those conditions, but extending that infrastructure to ambulances requires additional equipment, monitoring and training.
Taney County Ambulance District clinical manager Rick Lawler said traditional IV fluids can help maintain circulation but cannot replace what patients lose through severe bleeding.
“If you go into hypovolemia shock as it's commonly known, you're probably gonna get an IV and you're probably gonna get saline, which is salt water,” Lawler said. “Salt water is not blood. It can increase the pressure so we can circulate the blood that you still have, but it's not gonna help things like clotting, it's not gonna help you carry more oxygen to your end tissues. And that's the big issue is when somebody goes into shock, they're not getting oxygen at the cellular level.”
Bringing blood out of hospitals has a high price tag. Taney County has spent about $50,000 to establish its program, including two specialized coolers, a refrigerator, blood supplies, monitoring equipment and staff training.
At the center of the system is a specialized cooler inside an insulated bag. Taney County uses a cooler measuring about 14 inches by 14 inches by 12 inches, with sensors that continuously monitor the temperature.
“So the blood products go down inside that green case. And it's just insulation on top of insulation that's in there,” Lawler said.
The cooler keeps blood between 33 and 42 degrees Fahrenheit. Staff replace the ice packs every 12 hours, and the monitoring system records the temperature every 15 seconds. If the temperature falls outside the required range, the system alerts staff.
“It's just an ice chest. A very expensive, very technical ice chest," Lawler said. "It records every 15 seconds, it records the temperature and then it sends it via cell signal to us. That goes into our server that continuously logs it."
The cooler carries one unit of plasma and one unit of red blood cells. Rather than carrying whole blood, the district uses component therapy, which separates donated blood into individual parts so patients can receive the components they need.
Lawler said the decision also comes down to storage time.
“For the way we're set up with our blood supplier, they have whole blood, but the turnaround time of whole blood is a lot shorter than with the plasma and the packed red blood cells. So logistically, again, it makes more sense to do it as component therapy for our patients when we’re dealing with critical situations,” Lawler said.
Blood products typically have a shelf life of about three weeks, depending on the component and storage requirements. To avoid waste, Lawler said the district returns unused products to the blood bank by the end of the second week, giving hospitals time to use them before expiration.
Taney County has 13 ambulances and six quick-response vehicles, which provide emergency medical care but do not transport patients to hospitals. Two of those vehicles typically carry the blood coolers.
Dispatchers and emergency medical personnel determine whether a patient may need a transfusion based on the circumstances of the emergency and the patient's condition.
Blood is expensive, Lawler said, so the district does not equip every vehicle with the supplies.
“Blood isn't cheap. It is actually one of the more expensive treatments we have. So it adds up very quickly, you see that it's an expensive thing to do. It's worth it to save lives, not a good idea to carry it on every single truck where we might have problems, might waste money, waste blood,” Lawler said.
Lawler said requests for transfusions involve both medical emergencies and traumatic injuries. Common situations include gastrointestinal bleeding, pregnancy-related emergencies and trauma.
Expanding across Missouri
Pre-hospital blood transfusion programs have been operating in the United States for years. Texas launched a regional civilian pre-hospital whole-blood pilot program in 2018, helping advance the practice outside military settings.
States including California and Colorado also have similar programs.
Julie Stilley, a researcher at MU Health Care and an academic partner with the Missouri Department of Health and Senior Services' Bureau of Emergency Medical Services, said grassroots efforts by individual ambulance services are encouraging others to adopt the practice.
“Agencies that are adopting this practice are often early adopters with high-quality EMS services. They run careful programs and work closely with their partners and blood banks to make sure they’re following strict regulations and handling blood products safely. Ultimately, this is helping our sickest patients,” Stilley said.
The practice could be especially valuable in rural Missouri, where patients often have to travel long distances to reach a hospital.
Missouri Highway Patrol crash data show that only about 30% of patients reach a hospital within roughly an hour, according to Stilley. She said administering blood sooner could help emergency medical personnel begin resuscitation earlier, particularly after crashes in remote areas.
Washington County was the first in Missouri to introduce the service. As more ambulance services adopt pre-hospital transfusions, emergency medical professionals are discussing the formation of a statewide coalition to share resources, training and guidance.
Currently, Missouri programs operate independently. Jeffrey Siegler, an emergency medicine physician who serves as medical director for two advanced life support agencies, is helping lead the effort to establish a coalition.
“We're starting to see an uptick in Missouri based blood transfusion capable EMS agencies. So then we said, okay, well, how do we help them? All the other counties in the state of Missouri, whether they're inner city or they're completely rural, the way to acquire blood from a blood transfusion service or a blood distribution service,” Siegler said.
He said the coalition could help agencies navigate the regulatory requirements and establish relationships with blood suppliers.
“It's not really much different. You still have to follow the same regulations and compliance related as regular requirements so we can help them,” Siegler said.
Missouri recorded about 100 pre-hospital blood transfusions in 2025, up from roughly 60 in 2024 and 40 in 2023, according to state tracking data.
Those involved in the programs expect the numbers to continue rising as more agencies explore the service and look for ways to bring blood transfusions to patients sooner.
