By Arielle Zionts for KFF Health News.
Broadcast version by Mark Moran for Big Sky Connection reporting for the KFF Health News-Public News Service Collaboration

Crystal Hiwalker wonders if her heart and lungs would have kept working if the ambulance crew had been able to give her a transfusion as the blood drained from her body during a stormy, 100-mile ride.

Because of the 2019 snowstorm, it took 2.5 hours to drive from her small town of Lame Deer, Montana, to the advanced trauma center in Billings.

Doctors at the Billings Clinic hospital revived Hiwalker and stopped the bleeding from her ruptured ectopic pregnancy. They were shocked that she not only survived after her heart stopped beating and she lost nearly all her blood, but that she recovered without brain damage.

The Montana State Trauma Care Committee, which works to reduce trauma incidents and to improve care, later realized the ambulance that carried Hiwalker had passed near two hospitals that stocked blood. What if Hiwalker had access to that blood on her way to Billings, committee members asked.

That realization, and question, inspired committee members to create the Montana Interfacility Blood Network, which they say is the first program of its kind in the U.S. The network allows ambulance crews to pick up blood from hospitals and transfuse it to patients on the way to the advanced care they need.

“We kind of came up with the idea of having a blood handoff — like driving through a fast-food restaurant drive-thru — and picking up blood on the way,” said Gordon Riha, a trauma surgeon at the Billings Clinic trauma center, where Hiwalker was treated. Riha said timely blood transfusions can prevent death or permanent brain injury.

The network is aimed at rural patients, who face elevated rates of traumatic injuries and death, said Alyssa Johnson, trauma system manager for the state of Montana.

“We have to get more creative. We don’t have a blood bank on every corner, and we don’t have a Level 1 trauma center on every corner,” Johnson said.

Network leaders say the program has helped at least three patients since it launched in 2022. They hope it will be used more in the future.

Hiwalker is excited about the program.

“I’m so glad that something like this got started, because it would save a lot of lives from where I live,” she said.

Hiwalker said she has heard about people bleeding to death after car crashes, gunshot wounds, and stabbings in her rural community. Johnson said work injuries, cancer, gastrointestinal problems, and childbirth can also cause serious bleeding.

The Montana trauma committee began discussing the blood network a few months after Hiwalker’s brush with death. First, it created a map of 48 facilities with blood banks. Then, it created guidelines for how hospitals, blood banks, ambulances, and labs must communicate about, package, transport, document, and bill for the blood.

The network is used only during emergencies, which means there’s no time to test patients’ blood types. So it uses only type O red blood cells, which can be transfused safely into most patients.

The receiving hospital — not the one that provided the blood — is responsible for billing patients’ insurance for the blood. The cost depends on how much blood patients need but typically ranges from several hundred dollars to more than a thousand, said Sadie Arnold, who manages the blood bank at Billings Clinic.

Arnold said blood must be stored in a lab and managed by professionals with specific degrees, clinical experience, and board certifications.

Some rural hospitals lack space for a lab or money to recruit these specialists, Arnold said. Or they may not need blood often enough to justify storing a product that can expire and — especially during the current national blood shortage — is needed elsewhere. The network uses blood that has a maximum shelf life of 42 days.

Rural hospitals that do store blood may have only small amounts on hand. A rural Montanan with severe bleeding experienced that firsthand when he went to the nearest hospital, which had only one unit of type O blood, according to a report on the blood network. But thanks to the new program, ambulance medics picked up more blood from a hospital halfway through an 80-mile drive to the trauma hospital.

Ideally, rural patients with serious bleeding would be transported by medical helicopters or airplanes outfitted for transfusions. But, as in Hiwalker’s case, flying can be impossible during bad weather. That can mean hours-long ambulance rides. Some towns in northeastern Montana, for example, are more than 250 miles away from the nearest advanced trauma center.

“This was truly designed for kind of that last-ditch effort,” Johnson said. When “we’re out of options, we’ve got to get the patient moving towards a larger center, and we can’t fly.”

The blood handoff may involve the ambulance stopping at the second hospital, Johnson said. But during one incident, a police officer picked up the blood and delivered it to the ambulance at a highway exit, she said.

Ambulances may also pick up a paramedic or nurse to provide the transfusion along the way, since many rural ambulance crews are staffed by emergency medical technicians, who in Montana aren’t authorized to do so.

Medics in other cities and states, including ones with rural areas, have started performing blood transfusions in ambulances and helicopters, said Claudia Cohn, chief medical officer of the national Association for the Advancement of Blood & Biotherapies.

She said researchers are also interested in the potential of using frozen and freeze-dried blood products, which could be helpful in rural areas since they’re easier to store and have longer shelf lives.

Johnson said the Montana Interfacility Blood Network is the only program she knows of specifically aimed at rural patients and involving ambulances picking up blood from hospitals along their routes. She said the network is gaining interest from other states with large rural regions, including Oregon.

Hiwalker said receiving a blood transfusion in the ambulance could have prevented her near-death experience and the trauma her husband faced from seeing her suffer as he rode in the ambulance with her. She’s glad her ordeal led to an innovation that is helping others.


Arielle Zionts wrote this story for KFF Health News.


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Community developers are tasked with balancing infrastructure needs - like roads, with amenities for the public to enjoy.

Organizers behind an upcoming North Dakota event feel their efforts might inspire creativity with centralized spaces.

Bismarck-Burleigh Public Health is teaming up with AARP to host a pop-up block party at the end of the month.

The department's Nutrition Services Coordinator Katie Johnke said it's not just setting up tables and chairs in the middle of the street and serving food.

There will be live music, community art, and recreational activities such as pickleball and yoga.

"We can promote to the community what it looks like to be able to do movement in the streets," said Johnke, "and create a sense of livability that is, kind of, separated from roads and streets and cars."

Johnke said not only do they hope city planners from Bismarck and other communities take notice, but neighborhood organizers as well.

With the right safety planning, she said they can carry out similar events on a smaller scale. The Bismarck block-party happens on July 30 from 6 p.m. to 8 p.m.

AARP also is working on a broader level with the nonprofit 8 80 Cities, in shifting away from the status quo in mapping out municipal needs.

While things like economic development are important, Johnke agreed that healthier and more equitable cities need to be higher up on the priority list.

"When we think about urban sprawl, that can have detriment to the health of communities," said Johnke. "And so really supporting that walkability, bikeability - that's where some of the overlap with the open-streets ideas and this block party can help reimagine the redesign of a community."

Johnke said the multi-dimensional approach to these events and design concepts can also help older populations overcome isolation issues that were made worse by the recent pandemic.

As the summer sun blazes, especially in the Sunshine State, it is easy to get caught up in the fun and excitement of the season. But according to health experts, staying mindful of hot weather health risks is crucial.

With searing temps causing a spike in emergency room visits for heat-related issues in some states, health experts said there are simple steps to stay cool and spot potential signs of overheating, including headaches, nausea or dizziness.

Dr. Del Carter, family medicine resident at Tallahassee Memorial Healthcare, said as a general rule, people should drink at least 64 ounces of water daily, or about eight glasses, and dress for the weather.

"Long, loosefitting clothing is helpful, sunscreen is definitely helpful to protect your skin as well," Carter outlined. "Then, really just trying to stay out of the environment when it is at its worst is going to be the most helpful things."

For being in and around water, he recommended ensuring protective barriers around pools, actively monitoring kids and wearing flotation devices. It is also smart to take swimming lessons and be CPR certified to ensure safety for all.

Heatstroke requires emergency treatment. Symptoms and signs include an altered mental state or behavior, nausea and vomiting, and a racing heart rate.

Donna O'Shea, chief medical Officer of population health for UnitedHealthcare, said virtual care is also an option for discussing symptoms with a health care professional.

"How long to wait before you go to the emergency room? Same thing, even for sunburns or for bike safety: 'Do I need to go in? Do you think I need stitches?'" O'Shea explained. "We don't think about that with virtual care, but the technology is really good."

O'Shea added among the benefits of virtual care is the ability to connect to someone for help 24/7, and most insurers offer it at no additional cost, including some of her company's plans.


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As summer kicks into full gear, North Carolina dentists stressed the importance of maintaining children's dental health.

Dr. Miranda Kalaskey, a dentist in Raleigh and member of the North Carolina Dental Society, said with more outdoor activities and changing routines, dental care can often be neglected, leading to cavities and dental trauma. Her advice is for parents to keep up with preventive care and encourage healthier eating habits.

"Try to pick a healthy summer snack. That can be fruit. That can be vegetables. Just not something dry, not something processed," Kalaskey outlined. "And the more processed you have, the more dried it is, the more likely it is to stick to their teeth."

She pointed out left-behind food can cause cavities. Tooth decay is the most common chronic disease among children in the U.S., with more than half of eight-year-olds having had at least one cavity in their baby teeth, according to the Centers for Disease Control and Prevention.

Warmer weather also means more outdoor play. Kalaskey highlighted the rise in dental trauma cases during the summer because of increased outdoor play and sports activities.

"Oftentimes, kids are going and playing basketball, and sometimes high schools are really good about, 'Hey, here's a mouth guard,' or 'You need to get a mouth guard for practice,'" Kalaskey noted. "But during the summer, a lot of times kids will play with other kids, which is great, but making sure they're aware that tooth trauma is a thing."

If a tooth gets knocked out, contact your dentist immediately. If it is after hours, she suggested the ToothSOS app for guidance.

She added another major key to dental hygiene for kids over the summer is a consistent schedule.

"Summer oftentimes is going to change that routine but your brushing, flossing routine does not need a change," Kalaskey recommended. "You still want to do brushing twice a day, flossing at least once a day. So kind of making sure we incorporate that, even though the kids might be waking up at 10 o'clock."

Kalaskey emphasized routine is also important for dental visits. She advised children should be seen by a dentist when they get their first tooth and then every six months afterward. In addition to keeping teeth healthy, she stressed it also builds a good relationship with dental visits in the long term.


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