Warren Dorlac, MD, Trauma surgeon with subspecialty training in surgical critical care at UCHealth Medical Center of the Rockies, talks about using wartime trauma techniques at home on civilians.
So you are kind of bringing back something old new again?
Dr. Dorlac: Yeah, I think that is a lot about medicine is bringing back things that were discovered years ago. And so, I think there’s probably a job that could be created just to look at old things that have kind of fallen by the wayside and then resurrect them.
How did you use whole blood in Germany when you were in Germany? Like, what year were you? What were you doing?
Dr. Dorlac: We didn’t use whole blood at the military hospital I was at in Germany at the time that I was there. Whole blood was being used in the combat theater. So, in Afghanistan and Iraq, but it wasn’t being used at any of our sort of receiving hospitals.
And what is it?
Dr. Dorlac: So, whole blood is basically the blood that we would pull out of your body right now would be considered whole blood. It has all the components of the blood. It’s got red blood cells, it’s got platelets, it’s got fibrinogen, it has all the clotting factors in it. That is what is important for the resuscitation of hemorrhagic shock patients. And so, if you just bleed a little bit, we can give you a crystalloid which is like saline or I.V. fluids, just plain I.V. fluids to resuscitate you or to get you back if we need to a little bit. But if you’ve lost a large amount of blood and you’re bleeding whole blood, then the best thing to give back to the patient is whole blood. The way, up until now, that we’ve done is component therapy. We would give you a certain number of red cells and we might add some plasma into that and then we might throw in some platelets. And over the last, say, 15 years since the military started looking at this at the combat support hospital in Baghdad, we’ve implemented more of a one-to-one-to-one strategy, trying to sort of match our whole blood as close as we can with component therapy. Then the easiest way to do that is just to give what you’re bleeding, and that is whole blood.
So, what’s the difference between whole blood and donor blood? Like, everybody lines up at the Red Cross truck.
Dr. Dorlac: When you go to give a unit of blood as a donation, you’re giving a unit of whole blood. Then what they will do at the blood centers is divide it up into the individual components and then, when we have a trauma patient or a hematology oncology patient or an operating room patient that needs certain of those components, you transfuse back just those components that you need. But the difference for the vast majority of blood products that are given in the United States versus those that are given for hemorrhagic shock patients is that the trauma patient who’s in hemorrhagic shock is bleeding whole blood, so what they need back is all those components. Logistically, the easiest way, sort of the fastest way, and probably the best way is to just give them whole blood.
Now, hemorrhagic shock, is that just almost every trauma patients that comes in that’s losing blood?
Dr. Dorlac: No, the majority of patients that come into a trauma center in the United States, it’s different than if you were a trauma patient coming into a combat facility, but in the United States, in the majority of our trauma centers the patients that arrive don’t need any sort of massive blood transfusions. And it’s actually a small percentage of patients that even need blood transfusion, but there is a certain percentage. And depending what facility you’re at, some will have higher concentrations of those kind of patients. So if you’re in an inner city – maybe you’re a trauma patient in Denver and you go to Denver Health, they have a much higher percentage of penetrating trauma than a lot of other trauma centers do. They are going to get a different mix of patients that have this acute blood need.
So, the idea of when they do break it all apart, when you go to the Red Cross truck and then you break it all apart is to basically make the blood go further maybe?
Dr. Dorlac: Yes, the advantages of using component therapy are that I can give you exactly the component that you need. If you are a patient that has a low platelet count and you’re chewing up your platelets or you have an autoimmune disorder that is utilizing platelets or you have a low platelet count for whatever reason, I can just give you platelets. If you have a low red cell count, I can just give you red cells. If you have a clotting problem, I can just give you the clotting factors. So, you can tailor it to the specific patient. You can spread that out so you can really affect a lot more patients by spreading it out that way. But it may not necessarily be the best thing for the trauma patient. So, it may be great for those other patients, but it may not be the best thing for the trauma patient.
In an ideal world, if we weren’t always seeming like we’re always in a blood shortage situation, you would just give everybody whole blood?
Dr. Dorlac: If I have someone that has hemorrhagic shock and has had a large amount of blood loss, then really I want to give him back whole blood, correct.
Can you tell me a little bit about Jimmy?
Dr. Dorlac: Jimmy was a trauma patient that came in and had arrived with what we would call a mangled extremity. So, his right lower extremity was severely damaged in a motor vehicle collision and had lost a large amount of blood before arriving to the hospital. That’s not unusual to have, even an isolated extremity injury which can cause hemorrhagic shock and which can actually cause mortality or death. He actually had an injury that was pretty much isolated to his one leg, but it was a devastating injury and will probably still be on crutches when we see him today as he’s still trying to recover from that. But suffice it to say what happened to him. Acutely, the big problem was not necessarily salvage of his leg but sort of salvage of his life, with a low blood pressure in the field and having lost a large amount of his blood. And he had probably, by the time he arrived to us, probably lost anywhere between 30 to 40 percent of his blood volume. He had bled out into the street or into the car before making it to the hospital.
And by giving him whole blood, do you believe you probably saved his life?
Dr. Dorlac: You know, in his particular case, I’m not sure how much of a difference it really actually made. The average patient, from what we’re seeing from both our military as well as civilian data, that there is a percentage of patients that will have an improved outcome and that will have a higher survival.
Do you know those percentages off the top of your head?
Dr. Dorlac: So, it’s kind of difficult because it’s hard to talk about civilian trauma and use the military data. And really, right now, the best civilian paper looking at the use of whole blood is coming. There’s actually a few, but the best large series came out of the University of Texas at Houston and they did show a nice survival advantage in those patients that received whole blood versus. component therapy.
Shelf life the same for whole blood compared to component blood?
Dr. Dorlac: Shelf life for a whole blood that we’re using right now is keeping for 21 days. The shelf life for red blood cells in the United States is 42 days depending on the storage component solution that it’s in. Europe uses 35 days for red blood cells, but I think that stored whole blood can be actually kept longer. It’s just dependent on what you mix it in with. But we’re using it as 21 days because beyond a certain time period the platelets become less functional and their maximum benefit is going to be in the first seven to 10 days, and so ideally we want to try and use it within the seven to ten day period.
Now do you get the whole blood the same way you would get a donation of regular blood in the hospital or whoever just decides if it’s going to stay whole or be broken down?
Dr. Dorlac: No, actually, I think most of the programs that have this, they’re doing whole blood internally, which is what we do. So, we get our whole blood from the Garth England Blood Center here, which is one of UC Health’s facilities. And they manufacture it for us as we need it and when we need it. So we get it if we go short, if we’re using it up, then we’ll get that faster. The blood program in San Antonio, which was one of the first big cities in the United States to implement pre-hospital use of whole blood, they have a similar program and we’ve tried to use them as a model for our program where they have a certain set of donors that are already designated to donate for whole blood because we’re looking for a specific type of blood. And they use a list of patients that just donate for that purpose. So, they, again, use them as they have a need, then they bring those people in.
And is it the same criteria too, like A can only donate for A and B…
Dr. Dorlac: Yes, that’s one of the advantages of whole blood and actually there’s probably a little nuance that’s worth discussing. In the military it’s one of the things that we’ve used, and we’ve transfused over 10,000 thousand units of what we call fresh whole blood. When we’re using fresh whole blood in the military, what we’ve been using for the last 16 years is type-specific blood. If the casualty is a type A, then we would get a type A donor to donate for that specific casualty. However, the Department of Defense sort of resurrected an old program that has been around since World War 2, and that is using what we call low titer O whole blood. So, the donor for that blood is a O types. About 46% of Americans are Type O, and they can be either O-negative or O-positive, and so it’s actually a common blood type. But they are the universal donor, and so the advantage of using that blood is that we only have one type stored and we can administer that one type to anybody, and so we’re using O for all recipients.
Now, is this a program that’s pretty much going nationwide?
Dr. Dorlac: I think I would say that it’s not mainstream totally yet, but there are about 70 difference trauma centers across the United States that are either working on developing a whole blood program or have implemented a whole blood program.
Now, did you bring it here?
Dr. Dorlac: So, we rolled it out as a system. And so, the memorial in Colorado Springs, our Memorial Hospital, and then University Hospital in Denver, as well as Medical Center of the Rockies, all three of us sort of rolled it out at the same time as a system-wide performance improvement program.
How would Jimmy have fared if he didn’t have whole blood here when he came in?
Dr. Dorlac: So statistically speaking based on the data that we have right now, those patients that do meet the criteria and are a recipient of full blood will probably have an improved survival. And so, there’s lots of things that can happen to a trauma patient. It’s not just surviving the first hour or so. It’s getting them, you know, to survive the hospital, getting them to survive the first 30 days and getting them to go on to recover. And, you know, we know statistically speaking it may not necessarily be for this particular patient, but statistically speaking we will improve their survival using whole blood and those patients that meet those real stringent criteria that we’re using. So right now, the great things about it are that because there are a number of programs across the United States that are implementing whole blood, one of the things that we encountered was we’d actually set up an arrangement with our local blood, one of our blood suppliers, to provide us whole blood. Just about 30 days or two weeks actually, I think it was about two weeks out from the day that we were going to implement our program here in the north, that donor came back and said hey, we’re not going to be able to supply you. And we went through all the different issues with contracting and things to see how we could make that happen. And they just said, you know, we just don’t have the ability to supply another hospital at this time. And our local blood center, the Garth England blood center, stood up and implemented a whole blood program for us within 30 days. It’s something that can be done but we really had tremendous support from our laboratory and our blood services to make that happen. So, I think that was probably a sort of a neat thing that they were able to pull that off on such short notice because anytime you try and start up any new program in medicine can take months because of education, training, logistics. There’s lots of things that go into it.
Now were you in Baghdad?
Dr. Dorlac: Yeah I’ve been to all those kind of fun places.
Yeah? And were you using whole blood there?
Dr. Dorlac: So yeah we’ve used a whole blood at almost all of our military combat sites and have implemented whole blood at one point or another. So, I’ve used it in Iraq as well as in Afghanistan.
And what was your title when you were in the military? Rank.
Dr. Dorlac: Well I retired as a colonel in the Air Force and my last real big deployment was the joint trauma system director in the combat theater. I worked for Central Command. Maybe not necessarily the senior, but I was the trauma medical director for both Iraq and Afghanistan during the six-month period. So, I had an apartment in Baghdad and one in Afghanistan, you know?
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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