Page 65 - JSOM Spring 2024

Only 72 had undergone actual prescreening for infectious FIGURE 4 Comparison of walking blood bank participants as
disease and anti-A and anti-B titer levels. The breakdown of a proportion of total crew among three nontraditional maritime
their blood groups is presented in Table 2. Thirty-nine group O casualty receiving platforms.
blood Servicemembers underwent confirmatory blood group-
ing, type and screen, anti-A and anti-B titering, and blood-
borne pathogen screening. Among them, 33 (84%) were
determined to be LTOWB-eligible donors. The 84% LTOWB
status is similar to rates found in the current medical literature
and the ERSS team’s prior experience with WBB screening on
the DDG. Greater capacity for a WBB exists on a CVN as only
72 of the ship’s 2,500 crew underwent WBB screening. The
CVN is also augmented by a carrier airwing (CVW), which
increases the total personnel on the ship to over 5,000. Of
the over 5,000 crew members onboard with the ERSS during
maritime operations, 1,838 were potential group O blood do-
nors. For this particular mission, only 39 (2%) of the 1,838
group O personnel onboard the ship were screened. Using a DDG = guided missile destroyer; LSD = dock landing ship; CVN =
conservative LTOWB prevalence, there could have been over nuclear-powered aircraft carriers.
1,000 potential donors aboard this maritime platform. When
considering only group O whole blood donors of any titer sta- Preparation for possible maritime conflict with peer adversar-
tus, there would have been over 1,800 group O whole blood ies that may affect SSTs like the ERSS will require a review
donors for mass casualty scenarios. In comparison to the LSD of historical injury patterns from conflicts involving similar
and DDG groups, there was a significantly lower level of par- medical dilemmas. Tadlock et al. examined 25 naval mass ca-
ticipation in the WBB program on the aircraft carrier despite sualty incidents since 1980, primarily centered on the Falk-
the existing CVN WBB doctrine (Table 3, Figure 4). land Islands War between Argentina and the United Kingdom.
The top three patterns were penetrating injuries, burns, and
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TABLE 2 Blood Groups Aboard the Arleigh Burke Class Destroyer asphyxiation/inhalation injuries. A similar injury pattern was
Blood group Total no. of Sailors Prescreened observed in WWII with penetrating injuries, burns, and soft
A+ 113 21 tissue injuries. In contrast, casualties aboard the USS Cole
and USS Stark, which were subject to a terrorist attack and a
A– 19 4 missile strike, respectively, presented with soft tissue injuries,
AB+ 19 5 fractures, and traumatic brain injuries as the most common
AB– 2 1 major injuries. 7,34,35 Given the high percentage of penetrating
B+ 52 1 injuries in maritime conflicts, large quantities of blood will
B– 8 1 be required for resuscitation as highlighted in a recent TCCC
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O+ 155 28* missile strike scenario. During a mass casualty event at sea
O– 35 11* in 2017, 54 units of blood products were transfused and 39
*33 of 39 prescreened O blood group participants were found to have were acquired through WBB. This platform, the USS Bataan,
low-titer group O whole blood (84%). was an LHD with a capability of 400 units of frozen packed
red blood cells (pRBCs) and 50 units of fresh frozen plasma
(FFP). Twenty pRBCs and eight units of FFP were available
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TABLE 3 Blood Drive Results immediately when casualties arrived. Despite a robust frozen
No. (%)* of Sailors blood bank, the authors noted that the ship would have run
DDG; LSD; CVN; out of FFP if providing 1:1 component therapy as recom-
n=332 n=364 n=5,000 mended by the current JTS Clinical Practice Guideline (CPG).
Identified group O 84 (25) 165 (45) 1,838 (37) In addition, the LHD had no capability for storing platelets. It
Volunteers from group O 43 (13) 56 (15) 190 (4) was also noted that FWB was quicker to obtain than thawing
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Group O screened 41 (12) 41 (11) 39 (1) FFP and deglycerolizing frozen RBCs. Of the 11 U.S. Navy
Low titer identified 39 (12) 15 (4) 33 (1) maritime mass casualty incidents during the 21st century, 7
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Available at WBB drill 17 (5) 12 (3) no data incidents occurred on a Role 1 platform. Nontraditional mar-
*Percentages compared to total crew. itime medical receiving platforms commonly provide role 1
DDG = guided missile destroyer; LSD = dock landing ship; CVN = medical expectations and blood bank capabilities are unavail-
nuclear-powered aircraft carrier; WBB = walking blood bank. able. Replenishment-at-sea, which can be infrequent, is influ-
enced by weather, sea states, and adversary activity. These
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Discussion logistical challenges can highlight the difficulties of obtaining
group O and, specifically, LTOWB on these maritime receiv-
Despite advances in trauma care, hemorrhage remains the ing platforms. Historical conflicts including WWI, WWII, and
leading cause of potentially preventable military traumatic the Korean War document the safe use of group O blood not
deaths. The Joint Trauma System (JTS), Defense Committee tested for anti-A and anti-B. 16
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on Trauma, and ASBP have endorsed stored LTOWB as the
resuscitation fluid of choice for the treatment of hemorrhagic It is clear that blood group O (and in particular LTOWB) in
shock. 1,25 Our case series is one of the first to describe an mass casualty settings helped avoid clerical mistakes and the
SST’s capabilities and the logistical challenges of a prescreened resultant incompatible blood group transfusions that lead to
LTOWB WBB in this maritime environment. acute hemolytic transfusion reactions (AHTRs), some of which

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