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the age of administered blood products. However, given the for the US military as operations expand in the AFRICOM the-
initial experience within CENTCOM and current challenges ater of operations. However, further refinement of the storage
within AFRICOM, it is possible these blood products were methods is needed before the blood products can withstand
aged with short shelf lives. The resulting narrow time window the stress of drone transportation. Militaries are not the only
for blood product transfusion coupled with continuous stor- institutions challenged by the size and austerity of Africa. Civil-
ing disruptions may partially explain the infrequent rate of ian hospitals and providers also have trouble obtaining blood
blood product administration observed. Given the limitations products. An innovative method of delivering blood that has
in documentation within the entries, we are unable to charac- even piqued the interest of the US military is the use of drone
terize cases in which blood products were likely beneficial but technology. Since 2014, Zipline (San Francisco, CA; www.fly
not administered unless explicitly documented. zipline.com) has over 35,000 deliveries across the world. 37
Given the challenges within AFRICOM, part of the medical Our analysis is limited by several issues, namely the lack of
support strategy for operational forces is to preposition small, case volume to analyze in a quantitative method combined
surgical elements capable of delivering remote DCR and dam- with incomplete data entry into TRAC2ES. Personnel enter-
age control surgery (DCS). These teams must be supplied with ing data into TRAC2ES may be nonmedical personnel, which
blood products to leverage their full capabilities, but under- introduces a possible source of error in data entry, specifically
stand local procurement of whole blood may be necessary in to the data that medical personnel may find useful in a retro-
accordance with published military medical management guide- spective review. We have no reference standard available for
lines. 21,30 Within our dataset, only one human subject received the data documented so we are unable to assess for missing
whole blood, and the type [warm fresh whole blood (WFWB), variables or free text errors or omissions. Patient movement
stored whole blood (SWB), cold stored low-titer type O whole records are often produced during the early phases of care,
blood (CS-LTOWB)] was not specified. This may indicate leading to incomplete documentation of performed diagnostics
low utilization stemming from operational forces not engaged and treatments. There is no consistent standard as to which
in kinetic armed conflict, which is consistent with a previous data are included in the free form section detailing the patient
analysis of AFRICOM casualty statistics utilizing a different history and course of care. This limits the ability to both doc-
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database. However, none of our subjects were host nation ument interventions consistently and to extract the data accu-
forces or local national civilians for whom there are case reports rately during analysis. Of note, the TRAC2ES is designed for
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and anecdotal evidence of blood product transfusion. Conse- management of the patient movement throughout theater – it is
quently, this finding may be due to database limitations. This is not designed for research or performance improvement, which
likely due to the nature of the database which only tracks move- is a limiting factor. Expansion of the Joint Trauma System data
ments of US military personnel or non-US military that move collection mandate from CENTCOM into other theaters in-
through US military transport mediums. As such, we are unable cluding AFRICOM would be highly beneficial for performance
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to capture casualties that may have been moved from the point- improvement. Such a larger data collection mandate would
of-injury to a local hospital system. We must also note that a allow for more advanced methods of analysis, allowing for uni-
high proportion of the military personnel in Africa are engaged form data capture and comparisons across groups. We must
in non-combat roles and thus likely do not have resuscitation also note that TRAC2ES only tracks movements of living ca-
teams positioned nearby (e.g., embassy personnel). sualties, and thus if someone died before transport they would
not be captured within this system. Perhaps, the authors likely
The Armed Services Blood Program (ASBP) is responsible for missed many opportunities for blood resuscitation that we are
“blood products and services for all worldwide customers in not able to characterize. Last, previous studies found that bat-
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peace and war.” The majority of blood products shipped by tlefield documentation has largely been poor and inconsistent –
the ASBP meet US Food and Drug Administration (FDA) and this is likely amplified within AFRICOM given that the Joint
American Association of Blood Banks (AABB) requirements. Trauma System (JTS) does not have a data collection mandate
Because of these requirements, there are significant hurdles for within this theater of operations. 14,15
storage, shipping, and inventory management. As technology
has improved, management of blood products have become
more flexible; however, there are still several obstacles before Conclusions
blood makes it to the ground forces. Our dataset highlights the Within the TRAC2ES database, blood product administration
need for further advancements with regards to storage, main- within AFRICOM was infrequent, with some cases highlight-
tenance, and logistical movements. ing lack of access to adequate blood products. Furthermore,
the limitations within this database highlight the need for
European countries have a long history of expeditionary forces systems designed to capture medical care performance im-
on the continent of Africa. Because of this, they have demon- provement, as this database is not designed to support such
strated the ability to successfully care for and evacuate casual- analyses. A mandate for performance improvement within
ties. The French often use freeze-dried plasma as the optimal AFRICOM similar to that of the US Central Command would
resuscitation blood product. It is immediately available and be beneficial if major improvements are to occur.
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can be stored at room temperature for 2 years. The French use
Role II military treatment facilities (MTFs) scattered strategically Acknowledgments
across the continent based on military operations. They also We would like to thank Mark R. Barnes from TRANSCOM
have a robust medical evacuation program that uses fixed and for providing us with this dataset.
rotary-wing platforms. 34,35 Across the spectrum of care, blood
transfusions are available. The use of air-drop for blood prod- Ethics
ucts is an option. Delivering blood to austere locations either The US Air Force 59th Medical Wing regulatory office re-
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by manned or unmanned flying platforms may offer a solution viewed protocol FWH20180147E and determined it was
Blood Product Administration in the African Theater | 69