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to be a lifesaving advance in the context of the highly lethal military adopted more than 25 major innovations in care in
combat care environs of World War I forward care facilities. little more than a decade.” 5
To place the methodology of transfusion during World War As US and NATO troops withdraw from Afghanistan, the
I into context, it is of note that Robertson advocated the sy- continued exposure to care of the critically injured combat
ringe-cannula method as opposed to the two other method- casualty will be significantly diminished. The military medi-
ologies available during this period. One of the first methods cal community must continue to advance knowledge and seek
of blood transfusion was originally pioneered by Dr George opportunities to sustain critical lessons learned during the past
Crile (Cleveland, Ohio). In 1906, Crile adopted Alexis Carrel’s two decades. The past 20 years have consisted of “the highest
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technique of vessel anastomosis for transfusion by construct- rate of casualty survival in the history of warfare.” It is of the
ing a temporary surgical vascular anastomosis between the utmost importance that the medical advances discovered—or
radial artery of the donor and the antecubital or basilic vein in some cases, rediscovered (as presented in this review)—are
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of the recipient. This technique proved to be time consuming refined, formalized, and applied across all aspects of training
and technically challenging. The second technique was still in and preparation. Military medical treatment facilities such
evolution during this period and consisted of using glass con- as the Level I trauma center at Brooke Army Medical Center
tainers (sometimes lined with paraffin) with the addition of must be sustained and expanded to continue an intensive ex-
sodium citrate solution to inhibit coagulation. posure to injured trauma patients. The military civilian part-
nerships must be sustained not only as training platforms but
Compatibility Testing Was Possible, as also centers of excellence for inquiry and investigation. Side
Although Not Uniformly Used During World War I by side, military members must transition to the peace-time
3
Robertson discussed using “preliminary haemolysis tests” if setting of the urban training while constantly honing their mil-
time permitted to determine if there was to be a hemolytic reac- itary lessons learned in a contemporaneous CONUS setting.
tion to the donor’s blood. The description of the classic blood
groups (A, B, O) was first published in 1900 by Landsteiner,
1
but its significance in relation to incompatibility reactions was Lest We Forget
not fully established. Robertson and his medical colleagues US military forces have entered every major conflict during
did not routinely complete typing or cross-matching in their the past century with practice guidelines citing the use of crys-
reported series. In this, and subsequent publications, Robert- talloids as the primary resuscitation fluid for the injured. We
son discusses the potential significance of this issue and even leave this conflict with a recognition of the lifesaving benefits
acknowledges that one patient may have died of a hemolytic of whole blood transfusion beginning at the point of injury
reaction. It is important to review this original publication and and extending through the military continuum of care. The
commentary in the context of the medical conditions of the study by Shackleford et al. is perhaps the most recent of nu-
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time. The patients cared for by Robertson and forward field merous confirmations of Robertson’s century-old observation
hospitals were in dire conditions, often in advanced states of that “whole blood is the most appropriate fluid for the com-
hemorrhagic shock at the time of their presentation. Clearing bat casualty.” Whole blood transfusion appears to be securely
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the battlefield of casualties required hours (at best) and some- in place across the clinical practice guidelines of our military
times days. Movement of casualties from clearing stations to medical system from the field to definitive care. Nonetheless,
surgical facilities occurred over a period of days and some- now is not the time for complacency but rather the time to
times weeks, rather than the “golden hour” construct of re- secure these lessons written in blood. It is encouraging to note
cent conflicts. Patients routinely presented to Robertson’s and that there are now multiple areas across the civilian trauma
other forward surgical facilities with profound hypotension, community where whole blood is becoming an accepted prac-
imperceptible blood pressure, absent peripheral pulses, and tice, to include the prehospital arena. A notable example of
concomitant dehydration. In this setting, the additional delay this is the city of San Antonio, Texas, where whole blood is
of testing blood before transfusion appeared to be outweighed available on both ground and rotary wing prehospital sys-
by the dramatic and lifesaving results of the successful whole tems in the region as well as the Level I trauma centers at the
blood transfusion. To view through a historic lens, these pa- University of Texas Health Science Center and Brooke Army
tients were often moribund at presentation and an interven- Medical Center.
tion such as whole blood transfusion was nothing short of
miraculous. (The authors both note that their first experiences Additional inquiry and research regarding best practices for
with the transfusion of warm, fresh whole blood in theater whole blood and massive transfusions must continue and be
struck a similar impression with respect to its positive impact refined. Storage methodology and solutions have changed lit-
on the severely injured casualty.) tle during the past century since the original description of
sodium citrate solution. Further investigation of whole blood
storage solutions and the changes that occur within whole
Where Do We Go From Here?
blood while stored (“storage lesions”) is warranted. This re-
Since antiquity, it has been recognized that periods of armed search offers the opportunity to develop a better understanding
conflict dramatically advance the care of the injured patient; of the limitations of whole blood storage while further refining
the Global War on Terror has been no exception. This concept our knowledge of the potential adverse effects of prolonged
was captured in the comments of Dean (Dr) Art Kellerman storage (particularly in the solute of the stored whole blood).
in Out of the Crucible: How the US Military Transformed
Combat Casualty Care in Iraq and Afghanistan: “The pace The increased prevalence of whole blood in the prehospital
at which this transformation occurred is as astonishing as its environment also supports further investigation into the role
scope. It has long been said it takes an average of 17 years for of ionized calcium levels in patients presenting in hemorrhagic
a new discovery to be adopted into medical practice. The US shock. The addition of calcium as a fourth arm to the “lethal

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