Page 96 - JSOM Winter 2021

Use of Walking Blood Bank at

Point of Injury During Combat Operations
A Case Report

Matthew Gaddy, NREMT-P ; Alan Fickling, ATP, NREMT-B ;
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Vanessa C. Hannick, MD ; Stacy Shackelford, MD *
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ABSTRACT
The US Military Tactical Combat Casualty Care guidelines Case Presentation
recommend blood products as the preferred means of fluid re-
suscitation in trauma patients;, however, most combat units do A Special Forces Operational Detachment Alpha (SFODA) ex-
not receive blood products prior to executing combat opera- ecuted a night raid in the southwestern region of Afghanistan
tions. This is largely due to logistical limitations in both blood in 2018. The medics on the ground consisted of a US Army
supply and transfusion equipment. Further, the vast majority Special Operations Medical sergeant (18D), a combat medic
of medics are not trained in transfusion protocol. For many (68W), and a US Air Force pararescueman (PJ).
medics, the logistical constraints for cold-stored blood prod-
ucts favor the use of Walking Blood Bank (WBB), however At 2315L, one of the ground maneuver elements moved to
few cases have been reported of WBB implementation at the breach a compound of interest when a barricaded shooter en-
point of injury during real world combat operations. This case gaged the ground forces. This initial volley of fire resulted in
report reviews one case of successful transfusion using WBB two partner force Afghan commando casualties. The casual-
procedures at point of injury during combat. It highlights not ties were dragged away from the breach location and into a
only the feasibility, but also the necessity, for implementation makeshift casualty collection point (CCP). At the same time,
of this practice on a larger scale. an enemy fighter threw a grenade inside the compound re-
sulting in an additional casualty. The assault force and medics
Keywords: prehospital transfusion; fresh whole blood; walking consolidated the three patients into a hasty CCP near the com-
blood bank pound of interest and began initial assessments. Initial triage
revealed two critically wounded patients, including the patient
of interest (patient A) and one walking wounded.
Introduction
Patient A’s initial assessment revealed two penetrating gunshot
Fresh whole blood (FWB) transfusion has been a practice of wounds (GSWs): one to the superior right thigh with a pre-
Special Operations Forces (SOF) medicine since World War sumed exit wound on the left lower back, and the second to
I, however most accounts of its use are anecdotal or histori- the anterior left chest with a presumed exit on the superior
cal. Whole blood was actually the mainstay of resuscitation aspect of the left posterior thorax at approximately the an-
1–4
of trauma patients up until the Vietnam conflict, when crystal- gle of the scapula. Patient A initially presented with Glasgow
loid and component therapy became more common despite a Coma Scale (GCS) scale of 14 with spontaneous eye opening,
lack of evidence to support this transition. In recent years, spontaneous verbal response, and localized pain. Radial pulses
5–7
the benefits of FWB transfusion over blood component, crys- were strong and equal. External hemorrhage control was ad-
talloid, or colloid fluid therapy have been demonstrated in de- dressed first. The initial hemorrhage control attempt for the
ployed surgical settings for hypovolemic trauma patients. 8–10 thigh wound consisted of a combat application tourniquet
Additionally, blood transfusion has been shown to be associ- (C-A-T); however, the wound was too proximal for effective
ated with improved survival only when initiated within about tourniquet application and hemostasis. The decision was then
30 minutes of injury. 11 made to use a size 12 XStat (RevMed, https://www.revmedx
.com/xstat/) syringe to inject hemostatic impregnated pellets
Published cases of military prehospital FWB transfusion into the wound cavity, and this intervention proved effective
demonstrate the Walking Blood Bank (WBB) capability not for achieving hemostasis. Afterward, the tourniquet was un-
at point of injury, but rather at the initial aid station. 12,13 The furled and left in place. A pressure dressing was then applied
sparse documentation of successful prehospital FWB transfu- to the thigh wound and the 68W arrived and began applying
sion has created concern over the procedure’s risks. occlusive dressings to the thoracic wounds.

Recent US military combat experience as well as anticipated fu- After initial treatment, the ground force moved patient A to
ture scenarios highlight the need for early blood transfusion in a safer CCP 400 meters away. Movement was complicated
austere and hostile settings prior to surgical team handoff. 14–20 by danger close air strikes along with stream crossings while
*Correspondence to stacy.a.shackelford.mil@mail.mil
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1 SSgt Matthew Gaddy is a pararescueman with the 212th RQS, Anchorage, AK. SSG Alan Fickling is an 18D with 10th Special Forces Group-
Airborne, Fort Carson, CO. CPT Vanessa Hannick is a physician specializing in emergency medicine at the Carl R. Darnall Army Medical Cen-
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ter, Fort Hood, TX. Col Stacy Shackelford is chief, Joint Trauma System, Defense Health Agency, Fort Sam Houston, TX.
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