Page 63 - JSOM Spring 2024

blood group similar to the ROLO program has the potential medical casualties. This nine-person ERSS team consisted of
to augment RDCR medical capabilities on board vessels that a general surgeon, an anesthesiologist or nurse anesthetist, an
lack standard blood banking capability but may host an ERSS emergency medicine physician, an emergency room nurse, a
and receive casualties requiring resuscitation and surgical care. physician assistant, a critical care nurse, a respiratory techni-
In this case series, we sought to describe the experience of an cian, a surgical technician, and a general Corpsman. A total of
ERSS with three LTOWB WBBs on three separate vessels, over three WBB drives were performed during the predeployment
6 months, highlighting both challenges and potential future period for each of the different naval platforms (Figure 1).
medical capability development opportunities for Distributed The prescreening blood drive process was similar to a WBB
Maritime Operations (DMO) and Expeditionary Advanced activation event. Prior to prescreening, the respective command
Base Operations (EABO). leadership sent a message to all blood bank department heads.
Although individuals in all blood groups that came to the pre-
Historical Importance screening were accepted, donor selection was targeted for pre-
Whole blood transfusion (WBT) for the treatment of hemor- identified group O blood donors. The prescreen blood drive
rhagic shock in armed conflict dates as far back as the Ameri- was set up in two stations. At the first station, a donor ID was
can Civil War, when its use was described in two soldiers with assigned, the top portion of the Armed Services Blood Program
varying levels of success. 15,16 After the discovery of the ABO (ASBP) Form 572 was completed, vital signs were obtained,
typing system, WBT was broadly implemented in World War I and health history was taken. At the second station, phlebot-
(WWI). In the early stages of WWII, dried plasma was consid- omy was performed using four lavender top tubes (EDTA) and
ered the preferred resuscitative agent for logistical reasons. 17–19 one red top tube (no anticoagulant). ASBP 572 was checked
However, battlefield experience rapidly reconfirmed the pri- for errors (Appendix 1). Once collections were completed,
macy of whole blood as the mainstay of resuscitation, with the ASBP 572 forms and blood tubes were collected and sent
dried plasma assuming a supportive role as a bridge therapy to NMRTC San Diego for a final clerical check and shipping
until whole blood could be made available. 20,21 Over the de- to Joint Base San Antonio Lackland Blood Donor Center for
cades that followed, the development of blood fractionation transfusion transmissible infection screening and anti-A, anti-B
for medical therapies, combined with concerns for infection, titration testing. Results were received in 2 days, and NMRTC
drove blood component therapy (BCT) to replace WBT. The San Diego Blood Donor Center sent results, with roster and
Vietnam War (1955–1975) unfolded in parallel with this ASBP 572 forms, back to each naval vessel’s medical team. Ab-
change and saw the use of large-volume isotonic crystalloid stracted data included age, sex, gender, blood group, titer status,
with plasma, BCT, and some WBT in the resuscitation of hem- and infectious disease screening. Results were obtained from
orrhaging warfighters. 22–24 While aggressive fluid resuscitation the ASBP 572 forms and results from Joint Base San Antonio.
with BCT and large-volume crystalloid led to improved im-
mediate survival in patients with hemorrhagic shock, acute re- FIGURE 1 Platforms augmented by the expeditionary resuscitative
spiratory distress syndrome (ARDS) due to pulmonary edema surgical system, consisting of three maritime platforms not
25
emerged as an early cause of death after severe hemorrhage. traditionally designed for receiving maritime casualties:
(A) Guided missile destroyer, DDG; (B) Dock landing ship, LSD;
During the more recent conflicts in Afghanistan and Iraq, (C) Aircraft carrier, CVN.
shortages of blood components on the battlefield and clini- (A) (B) (C)
cal assessment that component therapy—frequently lacking
platelets—could be ineffective in massive hemorrhage led to
4
the use of emergency whole blood collection and transfusion.
Results from WBT appeared promising, so component therapy
was expanded to include apheresis platelets wherever possible,
and WBB use was expanded. Observational studies demon-
strated that WBT outcomes were superior to or at a minimum
comparable to full component therapy. 2,26 In addition, several Case Series
large observational studies leading to a large randomized trial
suggested that attempting to mimic WBT with early, balanced LTOWB Walking Blood Bank (Arleigh Burke Class DDG)
resuscitation, in a 1:1:1 ratio of red blood cells, plasma, and The INDOPACOM ERSS team deployed onboard an Arleigh
platelets, resulted in improved hemostasis and potentially a Burke Class Destroyer (DDG) during Northern Pacific Ocean
decrease in mortality when compared with components in a operations from February to March 2022. In the 2-week
2:1:1 ratio of red blood cells, plasma, and platelets. 27–29 Whole pre-mission period, the ERSS team coordinated with the ship’s
blood offers a more desirable physiologic balance of blood medical staff and the NMRTC San Diego Blood Bank to con-
components and avoids the logistical complexity required to duct an O blood group drive. Of the total crew (332 mem-
deliver BCT. Studies have since shown that the use of WBT bers), 84 members were determined to be potential group O
over BCT improves outcomes in both military and civilian blood donors on initial screening of medical records. Of the
trauma settings with an acceptable safety profile. 2–4,30–32 84 group O blood Servicemembers, 43 volunteered to undergo
further blood grouping, anti-A and anti-B titer testing, and in-
fectious disease screening. Of the volunteers, 2 were found to
Methods
be ineligible for donation because their Defense Enrollment
A process improvement project was initiated in July 2021 as a Eligibility Report System (DEERS) documentation was incom-
collaboration between the Naval Medical Readiness and Train- plete. The samples of 41 blood donor volunteers were sub-
ing Command (NMRTC) San Diego and the United States mitted to the ASBP for blood group confirmation, antibody
Indo-Pacific Command (INDOPACOM). This is a qualitative screening, titer status testing, and screening for blood-borne
assessment of a single ERSS team’s operational experience on pathogens. The results of blood donor screening were returned
three different warships not traditionally designed to receive to the ERSS team prior to the operational mission. Of the 41

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