Page 87 - JSOM Winter 2019

Shared Blood

Expeditionary Resuscitative Surgical Team (ERST-5) Use of Local Whole Blood to
Improve Resuscitation of Host Nation Partner Forces

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Melanie Bowman, RN ; Joshua Ashbaucher, SOCM ; Brian Cohee, MD ;
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Michael S. Fisher, CRNA ; John B. Jennette, MD ; John D. Huse, DSc, MPAS ;
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Chans Copeland ; Kathryn B. Muir, MD *
ABSTRACT
US Special Operations Forces work by, with, and through Any products in excess of 20U PRBCs and 20U FFP could be
partner forces (PFs) to accomplish mutual objectives. Surgical used for PF casualties. To avoid overusing our products in the
teams support these forces directly and may assist in treating heat of a busy resuscitation, we kept a running total of prod-
injuries sustained by PF, based on established medical rules uct availability and discussed our status daily.
of engagement. These surgical operations are often conducted
in austere conditions, with limited access to blood products. Case Example
Limited blood product availability decreases US medical ca-
pacity to resuscitate injured PFs and augment the local trauma In September 2018, a PF patrol (colocated with a US military
system. We present an innovative solution used by an expe- team) encountered an improvised explosive device and sus-
ditionary resuscitative surgical team (ERST) and Special Op- tained severe casualties. Twelve PF soldiers were killed in action
erations civil affairs team to partner with host nation (HN) and two were transported to a PF medical station. The ERST
medical personnel to improve PF access to damage control was contacted to assist with triage and treatment. Upon ESRT
resuscitation and surgery. Whole blood obtained through a arrival, one of the soldiers was pronounced dead, whereas the
local HN hospital was provided to the ERST to allow for in- other was found to have severe facial trauma and multiple ex-
creased capacity to resuscitate PF casualties and augment the tremity injuries. The patient was maintaining his airway and
local trauma system. The ERST subsequently used this blood oxygenating adequately (91% Spo on portable pulse oxime-
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to resuscitate two PF surgical casualties. try). The decision was made to rapidly transport the patient to
the adjacent ERST treatment facility for definitive care. Before
Keywords: walking blood bank; stored whole blood; austere the patient’s arrival in the medical tent, the ERST team identi-
surgical team; US military fied that we had blood products in excess of our predetermined
minimums.

On arrival to the ERST medical tent, the team performed a full
Background
trauma assessment. Immediate procedures included a cricothy-
US Special Operations personnel are often colocated with PFs, roidotomy for airway control and a left needle decompression
working together for a common goal. Colocated US surgical followed by chest tube for a tension pneumothorax. The re-
teams frequently provide care for these PFs in accordance with mainder of the trauma assessment was notable for a nega-
established medical rules of engagement. This cooperation tive abdominal FAST examination, multiple facial fractures,
increases the capability of the PFs and improves their rela- an open skull fracture, an open right forearm fracture with a
tionship with the United States. However, for austere surgical tourniquet in place, a closed right ankle fracture, and an initial
teams, deciding when to use blood products for resuscitations Glasgow Coma Scale score of 11. The patient was also hemo-
on PF casualties can be difficult and nuanced. dynamically unstable, as evidenced by tachycardia and weak
pulses. Although he initially had a palpable femoral pulse with
The ERST team’s austere location resulted in a long supply no obvious active bleeding, as the primary survey progressed,
chain and infrequent, inconsistent flights to supply blood femoral pulses diminished and then became nonpalpable. One
products. To be continuously ready to accomplish our primary unit of PRBCs was initiated (Figure 1). Cardiac ultrasonogra-
mission, treating a US casualty, the team had determined that phy at that time demonstrated a severely collapsed left ventri-
20U of packed red blood cells (PRBCs) and 20U of fresh frozen cle with very poor wall motion consistent with hypovolemic
plasma (FFP) would be maintained at all times, which would shock, poor cardiac perfusion, and imminent death. A femo-
theoretically allow for two patients to undergo a significant ral central line was placed, and the blood component therapy
resuscitation while allowing time for activation of the walking was transitioned to the central line. After the first unit of PR-
blood bank (WBB) and collection of fresh whole blood (FWB). BCs and FFP, the patient had return of femoral pulses. Repeat
*Correspondence to Kathryn B. Muir, William Beaumont Army Medical Center, 5005 N Piedras St, Department of Surgery, El Paso, TX 79920;
or kathryn.b.muir.mil@mail.mil
1 MAJ Bowman is affiliated with William Beaumont Army Medical Center. 2SFC Ashbaucher is affiliated with 91st Civil Affairs BN. MAJ Cohee
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is affiliated with Landstuhl Regional Medical Center. LTC (Ret) Fisher is affiliated with Carl R. Darnall Army Medical Center. MAJ Jennette is
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affiliated with Winn Army Community Hospital. MAJ Huse is affiliated with Womack Army Medical Center. SSG Copeland is affiliated with
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Walter Reed National Military Medical Center. MAJ Muir is affiliated with William Beaumont Army Medical Center.
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