Blood in Action

Applying Lessons Learned on the Front Lines to the Home Front

Appreared in AABB News May 2007. Reprinted with permission.*

As the war in Iraq enters its fourth year, one positive story has emerged from the grim statistics that accompany any armed conflict: 96 percent of injured troops that arrive at U.S. combat medical facilities in Iraq and Afghanistan survive, according to the U.S. Army Institute of Surgical Research. Innovated blood products and blood usage techniques are playing a large part in the successful treatment of these patients – which could make the experience instructive in the event of a mass trauma from a large-scale domestic disaster.

Blood shipments are anxiously anticipated by those treating the injured in theater, as the injuries sustained in a war zone are significantly different than those encountered in U.S. emergency rooms and often require multiple transfusions of blood products to facilitate recovery. Maj. Clayton Simon, a surgical pathologist at a combat hospital in Iraq, notes, “Most of the trauma we see in the states stems from low-velocity trauma such as car accidents in which a person may have an extremity torn off. Here, we have trauma where limbs can actually be blown off.”

Most of the injuries Simon refers to are caused by improvised explosive devices (IEDs) used in roadside bombings and often result in damage to soft tissue including cartilage, muscle and blood vessels, forcing medics to aim for damage control instead of definitive repair. “We try to stabilize the patient and get them back to the U. S. military hospital in Landstuhl, Germany, as fast as possible,” states Simon.

Lt. Col. Joseph Pelletier, officer in charge of apheresis platelet collection for five months while in Iraq, echoes Simon’s assessment of the medical cases seen in Iraq. In U.S. emergency rooms, doctors seek to treat trauma patients within the “golden hour,” a crucial time to reduce post-traumatic disability and death. In Iraq, “it was more like the golden 15 minutes,” said Pelletier. “The shock is that you are right there seeing the patient and sometimes in the operating from with the traumatized patient. Stateside, I’m in the lab directing the needs of the patient,” recalls Pelletier.

Medical teams in Iraq have changed not only how they respond, but also have re-evaluated the type of treatment provided. Maj. Paul Mann, officer in charge of the clinical lab and blood bank at a combat hospital in Iraq, is part of an elite medical team caring for the wounded. Mann stated that sometimes the severity of an injury requires rapid transfusion of a lot of blood components and notes that the laboratory keeps sets of four group O red cell units pre-packaged with emergency release forms readily available for transfusion in severe trauma cases.

Without proper treatment, patients often follow a cycle of hemorrhage, resuscitation, hemodilution and hypothermia, and coagulapathy. Military medical personnel have found that they can break this cycle by giving one unit of plasma for every unit of red blood cells transfused. “Transfusion services also issues a pack of apheresis platelets after the sixth unit of red blood cells in severe trauma cases,” Mann said. “This has resulted in a significant reduction in the number of red blood cells used during mass transfusion cases and has reduced our need to collect and transfuse whole blood. On rare occasions, we resort to transfusion fresh whole blood,” said Mann. “This usually occurs when the number or severity of trauma cases overwhelms our blood supply.”

In addition to progress made in treatment delivery in the field, military researchers at home are making constant blood product advances. The Combat Casualty Care Research Program (CCCRP) is focused on developing safe and effective blood products and blood substitutes that can be used for management of blood loss in combat casualties. Current CCCRP research involves evaluating freeze-dried plasma and platelet-derived hemostatic agents as suitable replacements for current blood products in combat. Improved methods of removing blood-borne pathogens, improving the quality of cellular components for transfusion and freeze-drying additional blood components also are underway.

Lt. Col. Michael Lopatka, deputy director of the Armed Services Blood Program Office (ASBPO), which provided the life-saving blood used in combat, explains that all these advances in medical technique and technology have led to the improved survival rate as compared to prior military engagements. “In previous wars, the type and amount of blood products needed were not readily available close to the action. Now, surgery is going on closer to the front line, and we have developed methods to ensure medics, doctors and other medical personnel have the exact blood product they need when they need it,” he said.

Prior to the Vietnam War, only type O blood was used in combat. Advances were made that allowed the use of all blood types in Vietnam and progress has continued. “Today, military hospitals over-seas have the capability to type blood, and they have access to all types of red blood cells, fresh frozen plasma, cryoprecipitate and platelets,” said Lopatka, who added that these advances far exceed those made during previous wars.

Also contributing to the high survival rate are improvements in air transport that move injured troops quickly and provide “flying intensive care units” that transport stabilized patients to military hospitals in Germany and the U.S.  – within 24 hours of injury in many cases.

Even with these impressive advances, some age-old methods are still saving lives. “Previously, a tourniquet was used as a last resort, but now every soldier carries one because it works,” said Lopatka. “Experience shows that soldiers are able to stop the bleeding, survive and, in some cases, not lose a limb thanks to this simple device.”

Military medical teams have found the balance between sticking with tried and true techniques and cutting-edge innovations, and that has made the difference in the lives of soldiers, sailors, airmen and marines worldwide.

*Reprinted with permission of AABB, Bethesda, Md., Copyright 2007AABB. All rights reserved. To receive your own copy of AABB Newseach month and read articles similar to this one, visit www.aabb.organd click on “Join AABB.”

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