Jonathan Morrison, the administrator of the National Highway Traffic Safety Administration, joins the podcast to discuss the importance of prehospital blood programs that allow emergency responders to administer blood at the scene to trauma victims. He’s joined by a former military trauma nurse with deep experience in the field and a policy expert from NCSL.
Prehospital blood programs that allow emergency responders to administer blood at the scene to trauma victims are drawing increased attention from state lawmakers. A technique with origins on the battlefield, these military methods have made their way to civilian EMS programs. Research suggests a significant number of lives can be saved with this approach, especially in car crashes.
On the podcast to discuss these programs are Jonathan Morrison, the administrator of the National Highway Traffic Safety Administration or NHTSA; Randi Schaefer, a former career Army trauma nurse who has helped set up programs around the country; and Aneesa Turbovsky, who tracks EMS-related legislation for NCSL.
Morrison discussed why these programs are a priority for NHTSA and how these programs could reduce the approximately 40,000 traffic crash fatalities in the U.S. each year. Schaefer reviewed some of the challenges in setting up prehospital blood programs and the role state lawmakers can play. And Turbovsky went into detail on the steps legislatures are taking to make it possible for paramedics to administer blood and how lawmakers can bring together the various parties needed to make these programs work.
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ES: (00:12):
Hello and welcome to “Our American States,” a podcast from the National Conference of State Legislatures. I'm your host, Ed Smith.
JM: (00:21):
We have approximately 40,000 highway fatalities every year in the United States, which is just way too high. But when you take a look beneath the surface of that baseline number, if you go from, I think it was 2019 to 2023, we did a deep dive analysis and we found that of those fatalities, 43%, 43% were alive when first responders got to the scene.
ES: (00:48):
That was Jonathan Morrison, the administrator of the National Highway Traffic Safety Administration, or NHTSA, and one of my guests on this podcast to discuss pre-hospital blood programs. He's joined by Randi Schaefer, a former career army trauma nurse who has helped set up programs around the country, and Aneesa Turbovsky, who tracks EMS related legislation for NCSL.
Pre-hospital blood programs that allow emergency responders to administer blood at the scene to trauma victims are drawing increased attention from state lawmakers. An approach with origins on the battlefield, these techniques have made their way to civilian EMS programs. Research suggests a significant number of lives can be saved with this approach, especially in car crashes.
Jonathan Morrison discussed why these programs are a priority for NHTSA and how these programs could reduce the approximately 40,000 traffic crash fatalities in the U.S. each year. Randi Schaefer reviewed some of the challenges in setting up pre-hospital blood programs and the roles state lawmakers can play.
ES: (01:55):
And Aneesa Turbovsky went into detail on the steps legislatures are taking to make it possible for paramedics to administer blood and how lawmakers could bring together the various parties needed to make these programs work.
Here's our discussion, starting with Administrator Morrison.
ES: (02:14):
Administrator Morrison, welcome to the podcast. It's great to have you here.
JM: (02:19):
It's great to be here. Thank you for having me.
ES: (02:22):
Well, again, thanks so much for taking the time to do this and coming onto the show to discuss pre-hospital blood programs. Now, I suspect a lot of our listeners, that would include me, aren't that familiar with pre-hospital blood programs. And I wonder if you could just explain a little bit about what they are and why this is a priority for NHTSA.
JM: (02:43):
Absolutely. I mean, when you think about what might happen if you're in a tragic or a very serious car crash on the side of the road and you may have a severe injury where you may be bleeding, it takes a bit of time for an ambulance or a first responder to get to you. And then they need to stabilize you at the scene and get you back to the hospital for your actual treatment. One of the real issues is if you're bleeding out, how can you be stabilized appropriately? Currently, the standard would be to provide a patient with saline, which can help with hydration and whatnot, but you got to get back to the hospital before you're able to have actual blood product applied to you that allows for oxygen to move and apply to your organs. With a pre-hospital blood transfusion program, the first responder would have training and equipment and blood product to apply to you on the scene itself.
ES: (03:40):
I think that so many of our listeners and probably a lot of people in this country think that emergency medical folks already carry blood products in their ambulances, and it was very interesting to find out how much that is not the case. Let me ask, and NHTSA, of course, is focused on traffic safety. From that perspective, what does that tell you about the life-saving potential of pre-hospital blood, particularly for people who have very serious injuries?
JM: (04:08):
I think when you take a look at the current ongoing traffic safety crisis that we have on our roads, we have approximately 40,000 highway fatalities every year in the United States, which is just way too high. But when you take a look beneath the surface of that baseline number, if you go from, I think it was 2019 to 2023, we did a deep dive analysis. And we found that of those fatalities, 43%, 43% were alive when first responders got to the scene. That's a pretty major aspect where we think there's room for improvement. By looking at other research, there's that critical time window that we're looking to resolve. It's between the first responder arriving at the scene and the patient getting to the hospital. And we know from other research that about 37% of severely bleeding trauma patients can be saved by having pre-hospital blood applied.
JM: (05:06):
So what we're looking to do is really getting at the root of this issue. We think there are so many people whose lives can be saved in that critical period of time from first responders arriving at the scene and the patient arriving at the hospital through application of pre-hospital blood. And to your point, Ed, there just is not a lot of this that's out in the field. Of the approximately 15,000 EMS agencies across the country, only two to 3% have these programs. So we're looking to really push that number up.
ES: (05:37):
That is a pretty persuasive argument, I think, for the importance of this. Let me ask you about some of the ... I don't know if bureaucratic is the right word, but there's certainly hurdles here. And EMS systems are made up of an awful lot of complex interrelationships with people, whether it's health officials, traffic safety people, emergency response. And I wonder if you could talk about what the opportunities are for the state, federal, local, stakeholders, including legislators to work together on this.
JM: (06:08):
Well, again, with only two to 3% of EMS agencies having these programs, there's a lot of greenfield. There's a lot of opportunity for folks who want to help. And we're looking to play a coordinating role. But again, we're just one agency in the federal government. So legislators and their staff at the state and local level, they can start collaborating by reaching out to their state EMS offices. Depending upon the state, those offices can be housed in different departments. Sometimes they're in the Department of Health, sometimes they're in the Department of Public Safety, but I think if you're listening or an interested legislator or staffer here, you might want to reach out to the National Association of State EMS officials. They should have a list of every state's office available. And you can find that at their website, which is nasmso.org.
ES: (07:02):
So, Administrator Morrison, I spoke elsewhere on this podcast with Randi Schaefer in Texas about her work setting up these programs locally, local programs. But from a national perspective, I wonder what kind of challenges you think people face, that your agency faces in trying to get this conversation going, getting more people involved, that sort of thing. What are the hurdles you need to overcome?
JM: (07:28):
We've certainly got a lot of hurdles to overcome in that we're just one agency and we have limited resources. One thing we do have is a pretty good size soapbox and we've got a pretty good set of relationships with state highway safety offices and with state and local EMS agencies and departments. We're really pushing to get these numbers up, as I mentioned before. But one of the biggest challenges is determining how do you pay for this all? Most EMS agencies currently are finding money for equipment training and blood projects in their own budgets, or they're asking for it to be added to budgets. They're looking to do fundraising to pay for this, but really for programs to be sustainable, you got to figure out long-term solutions here. And that is something we've heard that as we're using our soapbox to get the word out about this, that some state legislatures are looking to step in and help.
JM: (08:24):
Texas, for instance, been pretty active in this place. But again, I think we've overcome a lot of challenges to get here. We've overcome some of these early challenges and starting to get funding out there. For instance, just this last year, NHTSA worked with the Department of War to establish a $30 million fund to provide support for some demonstration projects. And then just towards the end of this last year, December of 2025, we were able to get approval through the Safe Street For All grant program through the General Department of Transportation for about $50 million to fund a number of projects to start these up within that local EMS agency. So we're looking to continue those efforts.
ES: (09:14):
Well, certainly the Bully Pulpit is a very important part of this, but as you point out, the money is also a very important part of it. So it sounds like there's some progress there. As we wrap up here, talking with legislators, legislative staff, other people interested in state policy, I wonder what you tell them as you look down the road, what you think states should be paying attention to as they consider supporting, starting or expanding these programs in their states?
JM: (09:43):
I think the conversations are already taking place at the ground level. And again, we're looking to use our efforts to get the word out more, but I'm hoping that folks can really engage here. If your listeners are hearing this conversation and you think this is something of interest, and I hope it is. Again, reach out to your state EMS agencies, get involved in the local level. I mean, EMS and public safety in general is inherently local and how agencies operate, what they can and can't do, that all happens at the state and local level as well. For instance, even if you had an EMS agency in the state that was really excited about pushing this forward, you sometimes are going to have restrictions on whether or not an EMS responder is even legally able to apply blood. So there's a lot of different small problems that need to be worked through for a successful implementation of these programs.
JM: (10:39):
We at NHTSA are looking to serve as a resource. Again, we have a great connection. We're happy to have conversations with your listeners to see what we can do to help coordinate. Again, just those that are listening to this and you think this is something you want to take on, I hope you'll be proactive and reach out as a federal government. We're looking to help facilitate things to the extent we can, but again, a lot of this is going to take place in the local and state level.
ES: (11:04):
Well, it's certainly a very exciting prospect of being able to save lives with this program. And I really appreciate you taking the time to come on and fill legislators and staff in about how these work and how the federal government can help them. Thank you so much, sir. Have a good day.
JM: (11:19):
You too, Ed. Thank you so much for having me.
ES: (11:23):
I'll be right back after the short break with Randi Schaefer.
Speaker 3 (11:33):
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ES: (12:30):
Randi, welcome to the podcast. Great to have you here.
RS: (12:34):
Thank you for having me.
ES: (12:36):
So, Randi, we're discussing pre-hospital blood programs on this podcast, and we really wanted you on the show because you've got a lot of experience in this area. And I wonder if you could tell us a little bit about your background and what it looks like to start one of these programs.
RS: (12:52):
I am a retired US Army trauma nurse. I did 20 years in the military, and during that time, I had the opportunity to deploy three times, twice to Operation Iraqi freedom and once to operation Inherent Resolve. And each of these deployments, I found myself dealing with blood in a new capacity. On my first deployment in 2005 to 2006 in Baghdad, we were seeing a lot of patients, and we would run out of product on the shelves and there's nowhere to get blood resupplied. So we would turn to each other, take it out of our arms and put it directly into our patients. And that's what's known as a walking blood bank. On my third deployment was also a time where I learned a lot. I had clinical oversight of Iraq, Syria, parts of Turkey and Jordan, and I had to help implement pre-hospital blood programs on the medevac platforms, so the helicopters.
RS: (13:52):
I really had to think about this from a systems level of what worked in Iraq, may not work in Syria. It really gave me a strategic perspective on how to implement these pre-hospital blood programs to make them work for the operating environment where these units were. I retired in 2017 to South Texas where I went to work for the Southwest Texas Regional Advisory Council, where one of my projects was to help Don Jenkins, a great leader in prehospital blood, to set up the first multi-agency regional approach to pre-hospital blood programs where we brought … O positive whole blood into the civilian setting. This was a product that we used downrange, but had not been largely adopted here in the US. I was responsible for setting up a systematic process, so taking what we learned on the battlefield and how do I make this work in a civilian setting.
RS: (14:49):
So we were able to get blood products rolled out to numerous helicopters and ambulances in South Texas. I left STRAC in 2021 and have found myself now able to help agencies on a national level. Approximately 80 agencies I've been able to help walk through this in a systematic process. This is a new capability for ground EMS, so they need someone just to help guide them through the process. And I also have the fantastic honor of being a member of the Prehospital Blood Transfusion Coalition, which is a grassroots effort to bring awareness to prehospital blood transfusions and also to serve as an advocate for prehospital agencies as we are all learning how to navigate this new territory.
ES: (15:43):
So tell me, did these programs exist in the civilian world before say the last decade or so, or is this something that came from the military experience and is now going into civilian utilization?
RS: (15:59):
So prior to 2016, blood was largely found on helicopters only. And in 2016 is where the first ground agencies started embracing this after we started seeing some positive results from the military and wanted to bring those lessons over and equipment has progressed the technology to allow ambulances to carry it. We've have the policies and programs now that can support that. In 2016, there was approximately four 911 ground EMS agencies carrying blood products, and now we're up to 350 plus, which sounds like a great number, but it still represents a very, very small percentage of these 911 agencies.
ES: (16:48):
Well, that still is some remarkable growth in that area. That's such an interesting backstory to this. Tell me this. When you put together one of these programs, and you've got a lot of experience at it now, who has to be at the table? Who do you need to bring together in the community, the emergency medical services world to make this kind of thing work?
RS: (17:10):
So there's a lot of parties that need to be at the table and interesting parties that don't necessarily work together in the first place. So we need the pre-hospital agencies, absolutely, but we also need to bring in blood suppliers who have not traditionally worked with EMS. And we need to bring in hospitals in a new role, not just delivering the patients and leaving, but there's important information clinically and administratively that needs to be shared with that receiving facility. So we've got our clinical partners with the blood supplier, the hospitals, and the EMS agency, but we also need community engagement. These agencies can't give blood if there's no blood supply. So reaching out to their community members to support blood drives, to help get awareness raised. And yeah, we want also our political partners involved as this is a capability that has tremendous impact for their constituents.
ES: (18:13):
Instituting anything new anywhere always runs into some challenges. And I wonder what are the big barriers to instituting these kind of programs?
RS: (18:24):
It can largely be divided into three buckets. So one would be scope of practice. EMS, their license are not federally regulated. It's often left to the state level. And in many states, paramedics are allowed to maintain a blood transfusion. So if I take a patient from hospital A to hospital B, I'm allowed to maintain a transfusion. They cannot initiate a transfusion independently. And it's that one word that's tripping up some of the states, allowing these paramedics to do this. We had 11 states approximately three or four years ago that did not allow paramedics to initiate a blood transfusion, but we've made progress in removing that barrier. And now we're down to four states where we still have some work to do and allowing these paramedics to independently initiate a transfusion without a nurse or physician present.
ES: (19:26):
So of course, speaking of those politicians, those policymakers, we're talking here to state legislators, state legislative staff, other people interested in state policy. And what do they need to do if they want to move ahead to allow these kind of programs to go on in their state? You just mentioned allowing paramedics to initiate a blood transfusion. Is there special training and that sort of thing that needs to accompany starting these programs so that the people handling this in the field are up to speed on it?
RS: (19:57):
There is a training requirement. It's not burdensome, but it's something that they are currently not learning in their paramedic programs. So it is incumbent upon the agencies to help develop training programs that meet the federal regulation and any state regulatory requirements and just best practices of what's being done across the US.
ES: (20:21):
When I talk to legislators, often the question they want to ask is, "Does it work? Can you show me that it works?" And I wonder what you would tell them in terms of how successful this has been in places where you've helped set it up. And if you have any particular anecdote to sort of demonstrate how this can really make a difference, life and death difference.
RS: (20:46):
Yes, it does work. And I will tell you what we do know is that what we have been doing for decades is not working. Trauma still remains the leading cause of death for people aged one to 44. We haven't moved the needle on that in decades, so we need to try something different. And through some of the great studies in the military, we have shown that time matters. Every minute matters in getting that initial blood transfusion going. So anytime we can push that capability closer to the patient, we know that we increase their chances of survival. There are great civilian studies that have looked at different blood products showing that, yes, it does improve patient outcomes. EMS is bringing patients that are better resuscitated to the hospital where they have a chance at survival. And the National Highway Traffic Safety Administration also looked at their fatality database.
RS: (21:45):
So these are motor vehicle crashes where a patient either died on scene or died shortly after arriving at the hospital, and that's roughly 50% of these fatalities. That's a huge gap where we have an opportunity to really go after this death due to prehospital bleeding, is get that blood product out there where it's needed, when it's needed to the right patients. And it's not just trauma patients. We have a lot of evidence showing that prehospital blood is being used for women that are having maternal hemorrhage, whether it's a miscarriage or a postpartum hemorrhage. The US has some abysmal maternal mortality numbers, and a lot of that is postpartum hemorrhage that we can go after, particularly in these areas where access to prenatal care or postpartum care is dwindling. When these rural hospitals look to downsize, one of the first areas they want to downsize is their labor and delivery and their prenatal care.
RS: (22:52):
So EMS is going to serve as that bridge, that lifeline to getting these women to the hospital. Another interesting patient population that is emerging is gastrointestinal bleeding. We have a lot of folks across the country who are 65 years and older that are suffering from the effects of GI bleeding. And on top of that, they're on all kinds of great advanced anticoagulants or antiplatelet therapies, which is great, but when you start bleeding, that poses some problems. So it's trauma, it's non-trauma, it's medical patients, pediatric patients. One of my favorite stories is a young girl who was six years old and she had a tonsillectomy. And your listeners may not know that you can bleed to death from a tonsillectomy days after you're discharged from a hospital. If that clot gets dislodged and you can't press that bleeding, there's no way to ... So it is a bleeding that's very scary.
RS: (24:01):
Six days after her surgery, she started having horrible, horrible bleeding. And her father is a fire chief whose agency happens to carry whole blood. And we have his 911 call where he's asking for blood to be brought to his house and he's blessed to be in an area where they have this capability. So his daughter went unresponsive pictures from the scene, she was minutes away from death, gave her that whole blood and she started perking up. She started waking up and didn't require more blood products when she got to the hospital, didn't require surgery. So these are stories where we can show that prehospital blood, while it was born on the battlefield, that it's got great implications for all kinds of patients here in the US.
ES: (24:58):
Well, that's a story I'm sure that will resonate with a lot of listeners. What do you see as the future of this? Is this something you really see growing and becoming adopted in more communities?
RS: (25:12):
Absolutely, but we need legislators help to do it. EMS funding across the board is terrible. They don't get reimbursed for the care that they deliver. It's still based upon antiquated reimbursement models. So a twofold approach. One, the states, if they can provide that initial money to help get these programs up and running, purchasing the equipment, helping with some of the training, helping with some of the data collection will help growth. We have rural EMS agencies, even where I live, who are holding barbecue plate sales just to keep their programs up and running. And this is a lifesaving intervention that does require a small amount of money to get things started. We're also simultaneously advocating through CMS and private payers that if we can get this recognized and reimbursed for care, that we will be able to sustain more programs across the country. EMS agencies are right now taking it out of their operating budget and they run on shoestring budgets.
RS: (26:22):
I mean, it's incredibly tight. They're seeking out philanthropic opportunities, asking people to help donate equipment. And I think that the legislators can really help close that gap by providing some funding to make sure that we get this life-saving intervention everywhere, rural settings, urban settings, frontier settings. It impacts all patient populations. I hope that one day this will be widely implemented. Maybe I'll put myself out of a job and I'd be very happy with that.
ES: (26:59):
Well, Randi, thank you so much for running this down for us. I think this is not an area that a lot of people have a great deal of familiarity with. So I think this is really, really helpful. Thanks so much. Take care.
AT: (27:11):
Thank you.
ES: (27:13):
I'll be right back after this with Aneesa Turbovsky from NCSL.
Speaker 3 (27:23):
When it comes to podcasts, only one organization NCSL keeps a focus on the people, policy, and politics of state legislatures. Each episode of our podcast offers behind the scenes insights into the legislative process. First, the program Our American States provides in- depth discussions twice a month on key state policy issues shaping our nation or explore bipartisan dialogue with our special series Across the Aisle, where diverse political perspectives converge to create constructive conversations in state legislative chambers. And for history buffs, we've also produced a six-part series called Building Democracy: The Story of State Legislatures. Listen to learn more about the creation and development of the first branch of government in the United States. Stay connected, stay informed. Subscribe to these programs now on your favorite podcast platform. Learn more at ncsl.org.
ES: (28:39):
Aneesa, welcome to the podcast.
AT: (28:42):
Hi, thanks for having me. So good to be here.
ES: (28:46):
So, I've been talking on this podcast with Jonathan Morrison, the administrator of NHTSA, and Randi Schaefer, who set up a number of these pre-hospital blood programs around the country. And I wonder if you could walk us through the state legislative role in pre-hospital blood programs. What kind of policy options do lawmakers have? What's their role here?
AT: (29:05):
From NCSL's research and legislative tracking, we see three main areas where state legislatures tend to have the biggest impact on pre-hospital blood programs, scope of practice, blood supply, and funding. First, the scope of practice, basically what EMS clinicians are allowed to do under state law and regulation. In some states, statutes clearly authorize paramedics to administer blood. In others, that authority is set by licensure boards or delegated to a medical director through protocols. According to the Prehospital Blood Transfusion Coalition, paramedics can initiate blood transfusions in the field in at least 42 states, while another eight states have scope of practice rules that may limit or prevent it. That's why it's so important for policymakers to understand the scope of practice environment in their own state. Legislatures can help by clarifying authority and statute, authorizing pilot programs, or directing state EMS offices to update protocols so trained clinicians can administer blood in the field.
AT: (30:13):
For example, West Virginia developed protocols for whole blood administration on ambulances in 2023, paired with statewide EMS training. New York allows ambulances to store blood products and authorizes qualified EMS clinicians to administer them. The second piece is the blood supply itself. So pre-hospital blood programs depend on a strong coordination among blood banks, hospitals, and trauma centers. This is where the legislature's role as a convener really matters, supporting trauma system coordination, investing in blood collection and strong infrastructure, and helping stabilize the blood supply, especially in rural or high need areas. To address blood supply shortages, Illinois, for example, allows paid time off for donating blood, and Washington allocated 500,000 to staff donation centers and support mobile blood drives. And then there's that age old question of funding and sustainability. Blood products, training, storage, quality assurance, all cost money. States are using appropriations, grants, and trauma system funding to help programs start or expand without mandating a one size fits all model.
AT: (31:33):
So, for example, Texas appropriated $10 million in funding to expand a regional whole blood pilot into a statewide program, using the Trauma System and Regional Advisory Council to guide implementation. Massachusetts, on the other hand, allocated funding to initiate a regional mobile blood transfusion program, effectively fostering innovation without mandating its implementation across the entire state. So at the end of the day, the legislative role is really about removing barriers, providing clarity, and making sure the system is set up so EMS clinicians can deliver lifesaving care as early as possible. Well,
ES: (32:13):
That's great. That really lays out that state legislative role, I think, in a way that we really haven't talked about yet on the podcast. Now, you track legislation that affects emergency medical services around the country. And I wonder how state action on these blood programs reflect some of the broader trends you've seen in EMS legislation.
AT: (32:32):
Pre-hospital blood transfusion programs are a great example of how EMS fits into the broader trauma system, especially for time critical and lifesaving care. So as you said, NCSL tracks enacted EMS legislation across all 50 states, Washington, DC, and the territories. In 2025, we saw five major themes emerge: transportation revenues to support EMS sustainability, grants and structured funding models to address immediate needs, data integration, collection and reporting, investments in trauma systems, and workforce recruitment and retention. Data in particular helps policymakers better understand the unique needs of their state. For example, California funded an IT project to modernize its crash database and improve real-time reporting across EMS, crash, and trauma systems. As I mentioned earlier, funding remains a major challenge for many, many EMS agencies. We've seen states experiment with more sustainable approaches. Maine directs its Department of Public Safety to conduct a funding needs analysis to support regional collaboration and system improvements.
AT: (33:48):
Alabama authorized Pinkins County to levy additional fees to support ambulances services.
ES: (33:55):
Let me ask you about, as we close up here, if you've got one takeaway for legislators listening to this podcast on these pre-hospital blood transfusions or these EMS trends you're seeing around the country as a whole. It does sound like money is a big one. Funding, of course, is always a big issue, but what would you highlight?
AT: (34:16):
My takeaway would be there's no single model or silver bullet policy solution, unfortunately, that works for every state or every community. Each EMS ecosystem looks different. State EMS offices may sit in a department of health or public safety. Agencies may be public or private, staffed by full-time clinicians or volunteers. Funding comes from health expenditures, grants, fees, or direct appropriations. So ultimately, as Randi mentioned, the key for legislatures and staff is understanding who the stakeholders are and in their state's EMS system and how policies can help facilitate lifesaving care, including pre-hospital blood transfusions.
ES: (34:58):
Well, I think the old adage that if you know one state legislature, you know one state legislature sounds like it applies to these EMS programs as well. And that's why you really need to look at these state by state. We hope legislators get some benefit from this discussion. And if they want to take a look at some of those programs and get some more information, we have lots of information in the show notes and they can always call NCSL. Anissa, thanks so much. Take care.
AT: (35:26):
Thank you.
ES: (35:29):
I've been talking with administrator Jonathan Morrison of NHTSA, Randi Schaefer, and Aneesa Turbovsky about pre-hospital blood programs and the role of state legislatures. Thanks for listening. Search your NCSL podcasts wherever you get your podcasts. This podcast, Our American States, dives into some of the most challenging public policy issues facing legislators. Our occasional series across the aisle features stories of bipartisanship. Also, check out our special series, Building Democracy on the History of Legislatures.