Page 17 - JSOM Winter 2022

Improvised Management of Polycythemia Vera
Using Whole Blood Transfusion Kits

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Brandon M. Carius, DSc, PA-C *; Peter M. Dodge, BS, NRP ;
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Joshua A. Bates, 68W ; Philip Castaneda, DSc, PA-C 4

ABSTRACT
Polycythemia vera (PV) is a frequent myeloproliferative dis- complaint of a persistent pruritic neck rash. He reported these
ease resulting in excessive red blood cells, white blood cells, symptoms to his primary care provider approximately 2
and platelets rarely identified in military populations. Increased months after arrival overseas without planned management for
blood viscosity and platelets can lead to fatal myocardial in- his PV. He had previously been referred to a physical evaluation
farction and stroke. Historically, regimented phlebotomy man- board (PEB) for PV and retained by the Army. He reported tak-
aged this condition, but modern medicinal advances now are ing aspirin 81mg daily and lisinopril 20mg daily as part of his
utilized. These immunosuppressive medications are generally treatment for PV and hypertension, respectively. Additionally,
incompatible with active-duty service and can lead to medical prior to transfer overseas, he received near-weekly phlebotomy
discharge. Phlebotomy therefore is critical for readiness and treatments at a civilian institution for PV management, which
health; however, this can be challenging in resource-limited en- was last performed approximately 3 months prior to his pre-
vironments, necessitating effective improvisation. We describe sentation. Upon arrival to the ED, his blood pressure (BP) was
an active-duty Soldier with PV symptoms consisting of subster- 135/83mmHg with a heart rate (HR) of 72 beats per minute;
nal chest pressure, bilateral lower extremity paresthesias, and his remaining vital signs were also within normal limits. Phys-
persistent pruritic neck rash. He had an elevated hematocrit ical exam revealed a mildly erythematous maculopapular rash
(Hct) of 47%, necessitating phlebotomy and posing a challenge along the neck. An electrocardiogram showed no acute findings
to his primary care team. The local emergency medicine team of cardiac strain or ischemia, and troponin levels were not el-
employed blood collection bags from whole blood (WB) trans- evated. A complete blood count (CBC) found significantly ele-
fusion kits, including proven volume estimation methods, to vated levels of white blood cells (WBC), red blood cells (RBC),
routinely draw one unit of blood and effectively manage this hemoglobin (Hgb), and Hct (Table 1).
condition. This is the first reported case in military literature of
PV managed with improvised field resources and techniques. Consultation with internal medicine determined a need for im-
mediate phlebotomy given the patient’s elevated Hct of 47%.
Keywords: phlebotomy; hematology; blood disorder; case report AN Hct level above 45% can lead to complications such as
stroke and myocardial infarction. However, the laboratory
personnel determined that they could not facilitate such a large
volume in a measured way without numerous venipunctures.
Introduction
Through coordination with local military medical personnel,
PV is a well-established medical disease of excessive production ED staff secured a WB transfusion kit and collected one unit of
of blood cells with fatal outcomes if not managed correctly. blood from the patient using proven field-expedient measuring
Medication therapy is effective but generally not compatible techniques of paracord at 6.5 inches around the waistline of
with active-duty military service. Routine phlebotomy is there- the collection bag (Figures 2 and 3). ED staff proceeded to
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fore the best management option; however, this can be seem repeat this procedure over the next 9 months after telecon-
difficult with limited access to dedicated laboratory resources. sultation with hematology and in coordination with internal
The availability of WB transfusion kits in operational settings medicine during the patient’s tour of duty to maintain a largely
may enable frontline providers to supplement specialty care stable CBC profile, which relieved much of the patient’s symp-
and decrease the risk of PV complications. We report a case of toms. The patient maintained his daily medications during this
an active-duty Soldier with PV whose condition was success- time and had no significant adverse events from the procedure
fully managed by phlebotomy utilizing WB transfusion kits, or his polycythemia vera condition. Despite the authors pre-
with a subsequent relevant review of the literature. viously utilizing this process in a deployed setting, this is the
first reported case of such management in military literature.
Case Presentation
A 44-year-old active-duty man diagnosed with PV was trans- Discussion
ferred to the local emergency department (ED) for acute man-
agement after complaining of ongoing substernal chest pressure PV is a myeloproliferative neoplastic disorder characterized
and bilateral lower extremity paresthesias, with a secondary by excessive stem cell production resulting in abnormally high

*Correspondence to brandon.m.carius.mil@mail.mil
1 Brandon M. Carius is affiliated with the Department of Emergency Medicine, Madigan Army Community Hospital, Joint Base Lewis-McChord,
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WA. Peter M. Dodge is affiliated with the University of New Hampshire, Durham, NH. Joshua A. Bates is affiliated with the 5th Medical Re-
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cruiting Battalion, Dallas, TX. Philip Castañeda is affiliated with the Department of Emergency Medicine, Madigan Army Community Hospital,
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Joint Base Lewis-McChord, WA
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