Farming accident an unlikely catalyst for medevac transfusion bill

ALBANY — On March 13, Travis Flanagan – a nurse anesthetist from the Binghamton area – was plowing corn on his family farm when he hopped off the tractor to push some stalks back. The powerful machine caught the edge of his coveralls and dragged his legs under with them. 

Flanagan was stuck for nearly an hour, his phone lost in the devoured coveralls, before his father found him. Still hanging on to consciousness, Flanagan called 911 himself, using his medical knowledge to explain the scene and warn dispatchers how much blood he’d lost. 

“They ended up asking for a helicopter. LifeNet, which is based in New York, was already dispatched on a call. So I ended up getting (Pennsylvania-based) Guthrie Air by a stroke of luck,” Flanagan said, explaining that LifeNet and other local providers are prohibited under New York laws from carrying and transfusing blood at trauma scenes. But Pennsylvania medevac operations follow different rules. 

“It took them two hours and 45 minutes to actually get me out of the machine. While they were doing that, Guthrie Air gave me blood,” he said, adding that the transfusion was key to his survival. 

Flanagan’s survival story drew attention from lawmakers and a couple months after his accident the state Legislature unanimously supported a bill that would give air ambulances in New York the ability to carry and transfuse blood products, including while responding to trauma cases. The legislation still needs Gov. Andrew M. Cuomo’s signature to become law.

The measure was among an unusually large swarm of bills that passed the Legislature this year before it adjourned in June. A spokesman for Cuomo, in a typical response for that office when asked whether the governor would sign the legislation, would only say, “the bill is under review.”

But for many observers in the medical and emergency response communities, the law change is overdue, especially for New York's nine ambulance companies that provide air medical services.

“This would bring us in compliance with a scope of care that's provided in 49 other states,” said Dr. Michael Dailey, the chief of pre-hospital care at Albany Medical Center who also volunteers as the regional Emergency Medical Services medical director. He said EMS physicians across New York have long been pushing to change the regulations.

“I've been involved in a lot of these discussions,” Dailey said. “We've watched successful programs be initiated in other states across the country. It all comes from experiences with the military, where we know that acute transfusions for sick trauma patients are life-altering, lifesaving,” he added, referring to the origin of medevac flights that began in World War II.

A peer-reviewed study published this year examined the effectiveness of air-medical transfusions. Its authors found that early transfusion of blood products was significantly more effective at reducing mortality than water-soluble electrolyte solutions, or crystalloids, including saline, which are often used in New York. “Patients with hemorrhagic shock should receive pre-hospital blood products when available,” the researchers concluded.  

Earlier research, including other academic studies published between 2017 and 2020, foreshadowed the results. 

Assemblywoman Carrie Woerner, D-Round Lake, was a sponsor of this year’s bill and had put forward similar legislation a year earlier, after she was approached by former state Sen. Jen Metzger with the idea. But Woerner said the energy behind the bill this year was different. 

“Travis’ accident in the Southern Tier got a lot of press,” Woerner said. “That made the conversation more relevant for lawmakers; they had something recent they could point to and say, ‘oh, yeah, this is why.’” 

Flanagan learned about the variation in EMS regulations after he had been in the hospital for a couple of days recovering. His younger brother Trevor, a respiratory therapist, told Flanagan he'd heard a New York helicopter wouldn't have been allowed to give him the same on-site transfusion that Guthrie Air could.

“At first I didn’t believe it,” Flanagan said. “And from there, there was talk of, ‘Oh, we need to do something about this.’”

Flanagan's brother started a Change.org petition and community members and legislators started reaching out in support, including Broome County Assemblywoman Donna Lupardo and state Sen. Fred Akshar, R-Endicott.

“When I spoke to Travis, he said to me, 'please use my tragedy to save other people's lives,'” Akshar said. “And honestly, had I not known about Travis's accident, quite frankly, I probably would have never known about the inability to carry and transfuse blood in this particular way.”

Mike Vella, a physician and associate medical director at the Kessler Trauma Center in Rochester, also reached out to Flanagan to show his support. Vella performs surgeries on patients who arrive via helicopter from the Finger Lakes region and had previously practiced medicine in Tennessee and Pennsylvania, where medevac flights are equipped with blood transfusion capabilities. 

“When I came to New York about two years ago, one of the things I was shocked about is that there wasn't blood available on helicopters,” Vella said. “The earlier you get blood product resuscitation, the earlier you get surgical control of major bleeding, the better their (chances of) survival.”

In Pennsylvania, air ambulance services have had the broad ability to store, transport and transfuse blood products for 25 years, according to Air Methods, the parent company of both Guthrie Air and LifeNet. That state’s Department of Health reported that from the beginning of 2018 through June 2021, 2,900 patients received blood products from a Pennsylvania licensed air medical service, and there were an additional 722 instances where EMS monitored patients receiving blood transfusions during inter-facility transfers. 

Jeffrey Hammond, a spokesman for New York’s Department of Health, said their agency will not comment on pending legislation, but confirmed that storing blood or blood products requires a blood bank permit, which multiple sources familiar with emergency medical services operations said is not realistic for ambulance or medevac companies to obtain. Hammond also said that under current regulations, both ground ambulances and medevac operations are eligible to “obtain approval as an Ambulance Transfusion Service,” although even when certified, EMS crews are limited in how and when they can transfuse blood.

Nineteen of New York’s 1,107 ambulance services fall into the recently established category. Stony Brook University Hospital’s in-house fleet was the first, in 2016; since Stony Brook is the highest-level trauma center in Suffolk County, their EMS crews needed to pick patients up from smaller facilities nearby while keeping blood transfusions going – adding a bag when necessary – while en route to their surgery or definitive care. 

Even with Ambulance Transfusion Service status, “you can't just have blood in the cooler in the ambulance and use whatever's there,” said Stephen Slovensky, Stony Brook’s Emergency Medical Services director. He explained that when Stony Brook EMS crews arrive at a medical facility sending a patient, the facility has to follow a specific process for designating and logging the blood products they supply for the road. But he said that for his teams, the long certification process was worth it. 

“About a month ago, there was a case of a police officer who was injured badly on duty,” Slovensky said. “We were able to move him from the community hospital to Stony Brook to get the care that he needed (in a ground ambulance) … and those blood products made a big difference in his survival.”

These interfacility transfers differ significantly from 911 calls like Flanagan’s. If first responders are picking a patient up from a medical facility, there is a blood bank on-site authorized to distribute patient-specific blood for transfusions. And even then, Ambulance Transfusion Services have to obtain a three-way contract between them and each of the other facilities involved, for every possible route.

Dr. David Stuhlmiller, a medical director for LifeNet’s parent company Air Methods, said that their early attempt at this web of contracts had proven fruitless. Unlike Stony Brook’s EMS crews, the company transports patients “from any hospital in New York to any other hospital in New York,” so they would need to maintain “literally hundreds” of legally binding three-way agreements to comply. Meanwhile, storing blood products to transfuse at the scene of a trauma like Flanagan’s, where there is no sending facility, would be impossible even with certification.

Mercy Flight, which operates both air and ground ambulances in western New York, decided it was worth it to work towards an Ambulance Transfusion Service certification. 

“It’s been a very labor-intensive process,” said Michael Gugliuzza, the company’s director of medical operations, noting that staff have been working on the paperwork for about two years. They were recently approved and he expects the certification to be helpful, particularly for ground ambulance paramedics who would be trained and approved to continue a patient’s ongoing blood transfusion during inter-hospital transfers. 

But he and Mercy Flight’s medical director, Dr. Kaori Tanaka, said they expect the unsigned bill propelled by Flanagan's story to be a better fit for their medevac operation. “It takes this a step further for our air medical crews,” said Tanaka, who pointed out that – like Air Methods – Mercy Flight already has a nurse on every flight who is trained on initiating blood transfusions. She said the company is “pushing in support of the bill 100 percent.”

For Sen. Michelle Hinchey, D-Saugerties, who authored this year’s version of the bill after Akshar shared his constituent’s story with her, its core issue is healthcare equity across the state, especially in rural areas. 

“I have counties that don't even have a hospital,” Hinchey said. “So if you are in a farm accident, like Travis was, or if you're driving and in a car accident, a blood transfusion just really is life or death; especially if you’re over an hour away from a hospital, you need that emergency care.” 

Judi Whittaker, who has a dairy farm near where Flanagan’s accident occured, said she “didn't realize that there was even a problem” with New York life flights carrying blood products until the incident. “Travis's accident brought a lot of awareness,” she said. 

She’s now among the community members calling for the governor to sign the legislation, saying she is “disheartened” that the bill was passed unanimously by all of the democratic and republican lawmakers in Albany, “and it sits unsigned.”

“We are the only state in the NATION not to allow this,” Whittaker wrote in a letter to Cuomo in June, which she said was hand-delivered to his desk. The governor’s office did not respond to a request for comment on whether or how the governor responded to Whittaker. In her letter, Whittaker conveyed her urgency to the governor with bits of the now-famous narrative of Flanagan’s survival, saying it “could be one of (her) family” next. 

After his blood transfusion and airlift, Flanagan spent two weeks in a hospital and underwent three surgeries – including two below-the-knee amputations. He’s already been fitted for prosthetics. He hopes to begin taking his first steps with the artificial limbs this month. 

“My goal has been, the whole entire time, that I will be standing for the birth of my baby,” Flanagan said. His wife had been pregnant with his third child when he had his accident. “I’m not positive that will happen. But at least I’ll be there,” he said.