Page 17 - Journal of Special Operations Medicine - Spring 2014

Fresh Whole Blood Transfusion for a
Combat Casualty in Austere Combat Environment

Christopher B. Cordova, MPAS, PA-C;
Andrew P. Cap, MD, PhD, FACP; Philip C. Spinella, MD, FCCM

ABSTRACT
There are many challenges to treating life-threatening improved survival. When FWB is collected at these fa-
1,2
injuries for a healthcare provider deployed to a remote cilities, the process is supported by ancillary staff and
location in a combat setting. Once conventional treat- follows well-developed protocols. No such protocol is
3
ment protocols for exsanguinating hemorrhage have in common use by conventional military forces, though
been exhausted and no medical evacuation platform is a protocol for emergency whole blood collection has re-
available, a nonconventional method of treatment to cently been developed, which could serve as the basis for
consider is a fresh whole blood (FWB) transfusion. A training deploying personnel to cope with the difficult
FWB transfusion can be a life-saving or life-prolonging clinical scenario. 4
intervention in the appropriate setting. The authors
present the case of a combat casualty in hypovolemic
shock and coagulopathy with delayed medical evacua- Operational Context of Patient Care
tion to a surgical team. While the ultimate outcome was The casualty whose case we present was cared for in
death in this case report, the patient arrived to a surgi- the context of a large (300–350) enemy force attack-
cal team 15 hours after his injury, alert and oriented. In ing a small, remote American outpost. The enemy forces
this scenario, FWB transfusion gave this patient the best executed a highly coordinated attack, suppressing the
chance of survival. outpost with fire superiority. In addition to the over-
whelming enemy firepower, multiple buildings caught
fire from exploding ammunition. The fire destroyed the
majority of the buildings on the outpost and threatened
Introduction
to spread to the aid station as this casualty was receiving
A healthcare provider deployed to a remote location treatment.
in a combat setting is at a distinct disadvantage when
facing the challenge of treating life-threatening injuries. During the 12-hour intense battle, the medical team
The environment is often too austere to allow practice treated a total of 43 casualties, including penetrating ab-
to the typical “standards” of modern, hospital-based dominal wounds, severe facial trauma, gunshot wounds
military medicine. The comfort of a rapid air medical with vascular compromise, and minor shrapnel wounds.
evacuation platform is arguably the greatest asset of The medical team evacuated 16 casualties for further
the military medical system in a deployed environment. treatment from the Forward Surgical Team.
When a remote region loses this vital asset because of
terrain, weather, or security, the healthcare provider,
operating in an austere environment, is forced to con- Case Presentation
sider nonconventional methods for keeping combat ca- A 21-year-old active duty Soldier sustained multiple
sualties alive. shrapnel and gunshot wounds as he defended his combat
outpost from enemy fighters. His wounds included pene-
Once standard treatment protocols for exsanguinating trating shrapnel wounds to the left lower quadrant of the
hemorrhage have been exhausted, and no medical evac- abdomen and left upper thigh, a gunshot wound to the
uation platform is available, FWB transfusion should be right upper arm, and open fractures of the left tibia and
considered. The use of FWB in Level 2 and Level 3 com- fibula. The Soldier received “buddy aid” from a fellow
bat support hospital facilities has been documented in Soldier that included tourniquet application to the left
the Iraqi and Afghanistan conflicts to be associated with upper thigh, an improvised splint for the leg fracture, and

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