Modern blood transfusion systems are a success story built upon years of experience and learned lessons. They provide lifesaving support for the management of trauma-related injuries, obstetric hemorrhages, anemias, and malignancies. They also make possible sophisticated surgeries and interventions such as extracorporeal membrane oxygenation (ECMO), plasmapheresis, and red cell exchange, cementing their role as an indispensable pillar of modern health care.¹ Click or tap here to enter text.Yet these intricate systems are logistically complex and financially demanding. As a result, despite their central importance, they remain unevenly accessible.

Access to blood differs markedly between low- and high-income countries. Forty percent of the 118.5 million blood donations collected globally are in high-income countries, home to 16 percent of the world’s population. And we know that the whole blood donation rate is an indicator for the general availability of blood in a country^.2 Therefore it is not surprising that many patients who require transfusion do not have timely access to safe blood. It is estimated that there is an annual shortage of 102 million units in low- and middle-income countries, depriving patients of optimal care. To address this issue the Blood DESERT (Blood Delivery via Emerging Strategies for Emergency Remote Transfusion) Coalition published a consensus statement to define blood deserts and to guide research and innovation to overcome this impactful inequity.³

A blood desert is defined as a geographical region where essential clinical demand for blood components cannot be met at the point of care in a timely and affordable manner, which affects at least 75 percent of cases requiring transfusion.³ The lack of access in these regions can be due to supply not meeting demand, affordability of the blood, or access delays (patients reaching care and blood reaching patients). This definition is enlightening and clarifies that blood deserts are not limited to low-income countries. Many rural settings served in North America can meet this definition as they do not have access to timely transfusion.⁴Click or tap here to enter text. Furthermore, while a center may be equipped to deal with limited routine transfusions, it can quickly turn into a blood desert when faced with a sudden surge in demand by a mass casualty incident. Without timely access to transfusion, standards of care cannot be maintained.

Innovative and reimagined strategies have been proposed to overcome the challenge of meeting transfusion needs in blood deserts. Some strategies relevant to emergency and prehospital care include establishing civilian walking blood banks (WBB), drone-based delivery of blood, and the development of innovative and logistically less-demanding blood products.

The WBB is rooted in military transfusion practices. Also known as an Emergency Donor Panel, the WBB is an emergency transfusion protocol in which blood donors are mobilized on demand from a predefined pool. The process involves the identification of potential universal whole blood donors, frequent testing of these donors for transfusion-transmitted infections (TTI), just-in-time blood collection at times of need, testing donations with rapid TTI kits, and transfusion of fresh whole blood to patients with emergent need.

Guided by its success in military settings, civilian iterations of WBBs have been implemented to meet a surge in demand during mass casualties and to mitigate chronic shortages in geographically constrained regions. Moreover, recent efforts have described enhancing donor mobilization through digital platforms, enabling faster identification and activation of eligible participants.⁵ But it is important to realize that a WBB cannot replace a robust blood banking system providing laboratory-screened blood. It should only be seen as a contingency strategy when conventional blood is unavailable.

Drone delivery is another well-described innovation that focuses on systems-level mobilization of products instead of donors. Countries like Rwanda and Ghana have pioneered drone delivery with success and have delivered thousands of units to rural facilities, markedly reducing delivery times and wastage. Among high-income countries, Switzerland and parts of the United States have integrated drone delivery of blood products into their blood banking systems.

The appeal of drone technology lies in its ability to bypass traditional logistical barriers. By traversing difficult terrain, traffic constraints, and long transport distances, drones can extend the reach of centralized blood banks into areas where fixed infrastructure is absent or impractical. However, drone delivery infrastructure is not a stand-alone intervention, and its success relies heavily on the health system in which it operates. For it to be successful, drone implementation will need to be accompanied by concerted efforts to augment the existing blood supply.³

Perhaps the most transformative lever for improving the availability of blood and blood products in geographically remote or resource-limited settings lies in reducing the logistical burden of blood banking itself. Traditional systems depend on tightly controlled storage conditions, short shelf lives, and complex distribution networks—constraints that are difficult to sustain outside well-resourced centers. In response, both novel and reemerging blood products are being actively explored to extend shelf life and simplify storage requirements.

Cold-stored and frozen platelets offer extended shelf lives and simplified storage by standard refrigeration without the need for continuous agitation. Similarly, the resurgence of dried and lyophilized plasma, now with the added benefit of pathogen reduction, offers products that can be stored at room temperature for months, only to be reconstituted at the time of need. This is in contrast to the notorious logistical demands of thawed plasma.

Freeze-dried platelets, on the other hand, are an emerging product currently under clinical investigation that also offer significantly longer shelf life requiring reconstitution before administration. Introduction of these products alongside other shelf-stable hemostatic adjuncts, such as tranexamic acid, fibrinogen concentrates, and prothrombin complex concentrates can provide greater capacity to manage acute hemorrhage in environments where conventional blood components are not immediately available. They can bridge patient care through the most vulnerable phases of bleeding until blood products can be accessed.⁶Click or tap here to enter text.

Emergency physicians are often expected to maintain care standards under conditions that are not ideal. It is important to know the limitations of one’s health care system and to be prepared. Blood deserts represent a system-level failure, one that demands coordinated, system-wide solutions. Yet within this landscape, emergency physicians can play a pivotal role in advocating for and coordinating innovations to facilitate the flow of blood into these deserts.

Dr. Tabatabaey is an emergency medicine specialist at Oakville Trafalgar Memorial Hospital and a Transfusion Medicine Fellow at Canadian Blood Services and the University of Toronto. He has also completed a master’s degree in health informatics at the University of Toronto Institute of Health Policy, Management, and Evaluation.  His interests include management of bleeding in the emergency department, management of bleeding during mass casualty incidents, goal-directed bleeding management, and health informatic solutions in transfusion medicine.

References

1. Morgan Reed. Transfusion Medicine: An Integral Component of Modern Healthcare. Hematology and Blood Disorders. 2024;6(4):164.
2. World Health Organization. WHO Fact Sheets [Internet]. 2025 [cited 2026 Apr 14]. Blood safety and availability. Available from: https://www.who.int/news-room/fact-sheets/detail/blood-safety-and-availability
3. Raykar NP, Raguveer V, Abdella YE, Ali-Awadh A, Arora H, Asamoah-Akuoko L, et al. Innovative blood transfusion strategies to address global blood deserts: a consensus statement from the Blood Delivery via Emerging Strategies for Emergency Remote Transfusion (Blood DESERT) Coalition. Lancet Glob Health. 2024 Mar;12(3):e522–9. doi:10.1016/S2214-109X(23)00564-8 PubMed PMID: 38365422.
4. Laor B, Kundu S. Blood deserts in a universal health system: Addressing structural inequities in northern Canada. Transfusion (Paris). 2025 Sep;65(9):1746–50. doi:10.1111/trf.18347 PubMed PMID: 40689537.
5. Kundu S, Gerk A, Glatter R, Poenaru D. Innovative transfusion strategies for blood deserts in disaster settings. BMJ Glob Health. 2024 Oct 21;9(10). doi:10.1136/bmjgh-2024-016854 PubMed PMID: 39433403.
6. Linda S. Barnes, Mike Fitzpatrick, Ali Tabatabaey. Emergency transfusion protocols for blood deserts: Innovation, creativity, and transdisciplinary collaboration [Webinar] [Internet]. USA: Wellsky; 2025 [cited 2026 Apr 14]. Available from: https://info.wellsky.com/103125-Revolutionizing-emergency-transfusion-in-blood-deserts.html