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Introduction Hemorrhage is the second leading cause of death among urban trauma patients, and the provision of prehospital blood‐based resuscitation can be lifesaving. We developed an efficient system to support blood‐based resuscitation by an urban advanced life support ambulance system. Methods We worked with our state health department for permission for fire department paramedics to initiate blood transfusion and built protocols for field whole blood resuscitation. Our regional trauma center transfusion service provided 2 units of O positive, low‐titer, leukoreduced whole blood in an internally monitored and sealed ice box weighing 10 pounds to the fire department paramedic supervisor. When notified, the supervisor transported the blood to the sites of anticipated need. Total blood use and wastage were recorded. Results Following two public hearings, we obtained state‐wide approval for the initiation …