(972) 432-6700

The Bleeding Edge of Critical Care

How NTREMS became the first EMS service in the region to carry life-saving
low titer O+ whole blood as standard on every ambulance.

Patients that need whole blood can’t afford to wait.

In emergency medicine, there are few things as urgent as the need for a life-saving blood transfusion for a patient that needs it. 

While there are a few services across the country that have elected to give whole blood to select providers in fly cars or chase vehicles, we felt strongly that a patient that needs blood shouldn’t have to wait.

Every medic, every unit.

At NTREMS, every paramedic is trained to identify the life-threatening conditions that require an emergency blood transfusion and to initiate the treatment at the point of care. All NTREMS ambulances carry this life-saving resource at all times.


“When patients are bleeding, they aren’t bleeding out components like fresh frozen plasma or platelets. They are losing whole blood, so we need to replace it with whole blood. It’s why we decided to carry LTOWB on every ambulance at NTREMS.”

Russell Foster, NRP, FP-C, CCP-C

Blood Program Specialist

Medical Advice Disclaimer

The content on this website is provided for informational purposes only, and is not intended to be a substitute for professional medical advice and is not intended to be relied upon for medication or treatment.

Always seek the advice of your physician or other qualified health provider if you have questions regarding a medical condition. Never disregard medical advice or delay in seeking it because of something you have read on this website.

If you have an emergency, dial 9-1-1.

Frequently Asked Questions

What is Low Titer O Positive Whole Blood (LTOWB)?

NTREMS exclusively uses a product known as low antibody-titer cold-stored O+ whole blood (LTOWB). Use of whole blood is based on research and techniques successfully deployed by U.S. military agencies. Received from specially screen blood donors, LTOWB is both FDA licensed and approved by the AABB (formerly the American Association of Blood Banks) for administration in emergency situations. For emergency medical services like NTREMS, LTOWB is utilized when the patient’s blood type is unknown and/or other blood products are unavailable.

A whole blood donor is considered “low titer” after being tested to determine how many antibodies are in the plasma. This test measures IgM anti-A and anti-B antibodies. While military research has demonstrated successful outcomes using titers < 256, NTREMS uses LTOWB with titer levels of < 150.

Each unit of LTOWB has been through the same extensive blood bank testing process, and contains the natural, unseparated blood collected from a screened and healthy donor. LTOWB contains every component that you’d find in healthy blood, like red cells, plasma, clotting factors and platelets.

Is NTREMS taking a precious resource from hospitals that need it more?

Our program actually prevents waste by using blood from O-positive donors, the most common type in the United States. This helps reduce ongoing strains on O-negative inventory across the US.

Unlike many hospitals and services in the Unites States, NTREMS is the first in the country to leverage a third-party online platform that provides us with direct access to a nationwide network of industry-leading blood centers. This allows us to source LTOWB from FDA-approved and AABB-accredited blood banks from anywhere in the country. 

Thanks to this platform, NTREMS is able to source LTOWB from areas of the country with a donor surplus. While some areas of the country are indeed facing a donor shortage, other blood centers may occasionally experience a donor-demand mismatch, with excess units of LTOWB going unused.

Instead of letting such a precious resource go to waste, these blood centers distribute excess units of blood to services like NTREMS where they are more likely to be used. However, because it is impossible for each local blood center to anticipate or predict demand, NTREMS encourages blood donations often! Click here to find a site near you and donate to save a life today.

Don't patients need to be typed and crossed to receive a compatible blood type?

This process to type and cross match patients is too cumbersome and time-consuming to be useful in the emergency setting. NTREMS only administers LTOWB to patients in emergency situations, and any risks of administration are far outweighed by the benefits of transfusion at the point-of-care. Transfusion reactions due to the presence of the Rh factor are typically mild to moderate and occur several weeks after administration. More severe hemolytic reactions can occur with IgM anti-A and anti-B antibodies; however, those reaction risks are mitigated by using low-titer O+ whole blood which has been screened to have very low levels of such antibodies.

What kind of adverse reactions are possible for patients receiving LTOWB?

For a patient that needs blood, the risk of not transfusing LTOWB is hemorrhagic shock and death. For a patient that receives LTOWB in the emergency setting, reactions that may occur are typically mild, develop over weeks, and are typically well-tolerated and treatable.

From JEMS: A mismatch in the Rhesus (Rh) D antigen will not cause an immediate hemolytic reaction after one exposure and is nearly irrelevant in the emergency prehospital setting. According to the American Red Cross, 10-20% of the U.S. population does not have the Rh D antigen on the surface of their red blood cells, also known as Rh “negative.” If such an Rh “negative” patient receives Rh “positive” blood, around 20-26% will develop a sensitivity. This reaction is typically mild to moderate and takes up to 4 weeks to manifest. Even then, < 4% will experience a strong immune response to future administration. While women of childbearing age usually receive Rh-negative blood, if it isn’t available, Rh-positive whole blood should be transfused as it’s still preferred over crystalloid therapy and is most certainly preferable to the risks of withholding a transfusion altogether. Read more…

Why do you carry LTOWB instead of other products, like plasma or platelets?

From St Emlyn’s: the other option is for resuscitation is the mainstream 1:1:1:1 protocol, with patients receiving packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate. Bringing these blood products back together provides a hematocrit of 29%, coagulation factors that are about 65% of normal, 80,000 platelets, and 1g of fibrinogen – all with a significant load of citrate and amounting to a volume of almost 700mL. 500mL (1 unit) of fresh whole blood, on the other hand, has a hematocrit of 38-50%, coagulation factors at 100%, platelets at a normal range, 1g fibrinogen, and much lower amounts of citrate. To get the equivalent amount from component therapy would require twice the volume (and twice the citrate) of components. The citrate, while useful as a preservative, binds calcium, something that is critical for both hemostasis and cardiac function in these already critical patients. Read more…

I had a LTOWB transfusion, what should I expect?

Please consult with your physician. If you or your medical team would like to speak with one of our blood program specialists directly, please call (855) 219-2929.

How do you ensure the safe storage and handling of the whole blood on your ambulances?

On arrival, each unit of cold-stored whole blood is checked and verified to be within FDA required temperature ranges. The whole blood is then immediately transferred to our on-site Thermo Scientific™ Jewett™ High-Performance Blood Bank Refrigerator for storage. The refrigerator has continuous temperature monitoring, with audible alarms and instant digital notifications in the event of any temperature aberrancy. Once moved to each ambulance’s BloodBoxx™, temperatures continue to be monitored with continuous professional recording devices. These temperature monitors have wireless capabilities and will also immediately alert on-duty supervisors to any temperature variations. On-duty paramedics verify temperatures independently during daily check-offs. This configuration requires no power and allows us to transport and keep whole blood at refrigerated temperatures without regard for ambient temperature.

Who else is doing this in the prehospital setting?

While the benefits of emergency whole blood transfusions have been well-documented in US military literature dating back to World War I, a recent program was instituted by the South Texas Regional Advisory Council and their local EMS and HEMS partners. The program demostrated the feasibility of LTOWB transfusions in the prehospital environment and has paved the way for additional services like NTREMS to also offer similar services to their communities. You can read more about their groundbreaking approach by visiting the STRAC website here.

What research do you have that demonstrates the safety of this program?

The concept of LTOWB for emergency transfusions is not new. Links to articles, research and other helpfuls sites are below (links will open in a new window): 

Disclaimer: these links are being provided for informational purposes only; they do not constitute an endorsement or an approval by North Texas Regional EMS of any of the products, services or opinions of the corporation or organization or individual. NTREMS bears no responsibility for the accuracy, legality or content of the external site or for that of subsequent links.

ARTICLE: Get ready: whole blood is back and it’s good for patients. (PDF) (Transfusion)

ARTICLE: The Use of Low Titer Group O Whole Blood in Emergency Medicine (EMResident)

ARTICLE: Whole Blood in EMS May Save Lives. (JEMS)

ARTICLE: Whole Blood in Trauma: Ready for Primetime? (emDocs)

ARTICLE: Whole Blood – More than the Sum of Its Components? (Taming the SRU)

NEWS: ASBP’s Low Titer Type O Whole Blood Helps Save Lives On The Battlefield (New Jersey Association of Blood Bank Professionals)

NEWS: Blood on ambulances helps EMS agencies save more lives (Gulf Coast Regional Blood Center)

NEWS: Brothers in Arms: Transforming Trauma Care (South Texas Blood & Tissue Center)

NEWS: Emergency Release Low Titer Group O Whole Blood Is Now Permitted By The AABB Standards (Trauma Hemostasis and Oxygenation Research Network)

RESEARCH: Clinical outcomes among low‐titer group O whole blood recipients compared to recipients of conventional components in civilian trauma resuscitation (Transfusion)

RESEARCH: Low titer group O whole blood in emergency situations. (Shock)

RESEARCH: Prehospital low-titer cold-stored whole blood: Philosophy for ubiquitous utilization of O-positive product for emergency use in hemorrhage due to injury. (PDF) (Trauma Acute Care Surj.)

RESEARCH: Safety profile of uncrossmatched, cold-stored, low-titer, group O+ whole blood in civilian trauma patients. (Transfusion)

RESEARCH: The state of the science of whole blood: lessons learned at Mayo Clinic (PDF) (Transfusion)

RESEARCH: The use of low-titer group O whole blood for the resuscitation of civilian trauma patients in 2018. (Transfusion)

RESEARCH: Whole blood for the acutely haemorrhaging civilian trauma patient: a novel idea or rediscovery? (Transfusion Medicine)

Questions? Let's get in touch.

7 + 15 =