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describes both teams working together in Operation Free- incorporate the latest evidence and technology, and adapt to
dom’s Sentinel while deployed in support of SOF in central an evolving battlefield.
Afghanistan during the summer fighting season.
2019;19(4):123–125
2019;19(4):88–90 A Case for Improvised Medical Training Michael R. Hetzler,
Prehospital Whole Blood in SOF: Current Use and Future Di- NRP
rections Thomas B. Jones, 18D; Virgil L. Moore, 18D; Akira ABSTRACT: The hyper-resourced, uber-controlled, ultrareac-
A. Shishido, MD
tive, constant environment that we have come to know in the
ABSTRACT: The US Joint Trauma System (JTS) recommends past 20 years should not be mistaken as the norm in conflict.
stored whole blood (SWB) as the preferred product for pre- In truth, unrealistic expectations of both commanders and sys-
hospital resuscitation of battlefield casualties in both their tems in resourcing is presently being reinforced almost daily.
Tactical Combat Casualty Care (TCCC) guidelines and their Only in the past few years of this decade have the majority
clinical practice guidelines (CPGs). Clinical data from nearly of allied forces experienced challenge in resupply and support
2 decades of war during Operation Iraqi Freedom (OIF) in contingency operations. When logistical lines are cut, lim-
and Operation Enduring Freedom (OEF) suggest that whole ited, or untimely, we must know and exercise other means of
blood (WB) is safe, effective, and far superior to crystalloid providing the highest level of medical care possible—if not
and colloid resuscitation fluids. The JTS CPG for whole blood with indigenous ways and means, then by improvisation.
transfusion reflects the most recent clinical evidence but poses History has proved that improvised medicine can be capable,
unique challenges for execution by Special Operations Forces professional, and ethically sound if practiced properly and to
(SOF) operating in austere environments. Given the limited standards, the price being time, education, and investment in
shelf-life of 35 days, WB requires a constant steady pool of the requirement. Most often, these are already time-honored
donors. Additionally, the cold-chain requirement for storage means of care
poses challenges for SOF on long missions without access to
blood refrigerators. SOF operating in less-developed theaters References
face additional logistical challenges. To mitigate the challenges 1. NATO Special Operations Medicine Research Workshop. “The
of WB delivery, US SOF have implemented various protocols Special Operations Prolonged Field Care Challenge April 2013.”
to ensure optimal donor pool, awareness/education among 29 April 2013. Notes by Dr Dan Irizarry.
medics and specialized equipment for tactical methods of 2. Ball J, Keenan S. Prolonged Field Care Working Group position
paper: prolonged field care capabilities. J Spec Oper Med. 2015;15
blood-carry and delivery. In general, steps taken include the (3):76–77.
following: (1) Prior to deployment, Soldiers are screened for 3. Mohr C, Keenan S. Prolonged Field Care Working Group position
blood type and titers in order to establish a large donor pool. paper: operational context of prolonged field care. J Spec Oper
Support Soldiers have been found to be particularly beneficial Med. 2015;15(3):78–80.
donors as they typically are in closer proximity to the blood
support detachment. (2) In units that operate in smaller teams,
such as ODAs, medics are outfitted with “blood kits” to carry
blood on missions for point of injury transfusion. In units with
larger teams, LTOWB donors are identified on missions and IN CONCLUSION . . .
deliver fresh WB in the event of casualties. (3) Medics receive
a WB transfusion refresher tabletop exercise and review after As this Then and Now section reveals, prolonged field care
action reviews from previous rotations. Additionally, prehos- (PFC) is certainly not new to the military or austere prehos-
pital WB delivery is a required component of scenario-based pital care organizations around the world. Special Operations
premission training. The expectation is that medics will ad- has always had PFC in its DNA, and now the move is afoot to
minister WB on missions when tactically feasible. Using the expand the PFC skills and mindset for all conventional forces.
prolonged field care framework (ruck, truck, house) as a tem- Clearly, future conflict including near-peer adversaries will
plate, medics now use different methods to store and transport challenge current “golden hour” principles, and many of our
the SWB depending on phase. Medic “truck” and “house” trauma systems will need to adapt. Some of the challenges that
kits include the Dometic CFXTM powered coolers that run conventional forces will face as they seek to add prolonged
on AC, DC, or solar power and allow for constant tempera- casualty care (PCC) to their medics’ and corpsmen’ skill sets
ture monitoring. When on foot, medics have been outfitted include: lack of hands-on patient clinical rotations during their
with tactical blood coolers including the Pelican Biomedical initial training courses, time constraints for advanced medical
Medic 4TM or Combat Medical Blood BoxTM along with a training, lack of sustainment and refresher courses to address
Belmont Buddy-LiteTM intravenous (IV) infusion warmer and key PCC medical skills, and paucity of longitudinal clinical
IV administration kit with standard micron filter. Presently, care (especially trauma and ICU) experience. What encom-
SOF medics have the donor support, logistical framework, passes the best practices for PFC/PCC training and sustain-
training, and equipment to deliver WB at the point of injury. ment? The Joint Trauma System’s newly established Defense
However, widespread implementation will require expanded Committee on Trauma’s PCC Working Group will endeavor
distribution and standardization of “blood kits.” Additionally, to answer this question and provide realistic training tasks and
SOF medical planners must put greater emphasis on education standards. Many thanks to all of our colleagues who, like the
and the importance of WB over crystalloids or colloids—as authors of the articles cited in this section, have given their
many medics continue to carry only these products out of time and talents to build our capabilities for PFC/PCC!
convenience. As SOF strive to establish tactics, techniques,
and procedures (TTPs) and streamline prehospital WB deliv- —Jamie Riesberg, MD
ery, we must constantly reassess and refine our procedures, LTC, MC, USA

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