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are fatal. The use of an LTOWB WBB program like the 75th member as an O blood group, when on predeployment screen-
Ranger Regiment ROLO program is a modern use of this con- ing they were determined to be group A blood type (wrong
cept that offers a tactical advantage by enrolling prescreened blood type in records).
donors who are confirmed to have low anti-A and anti-B titers,
and enabling rapid collection and transfusion of warm fresh A traditional type-specific WBB in a nonprescreened popula-
LTOWB to massively bleeding casualties close to the point of tion requires coordination with the Area Joint Blood Program
injury. This prescreened LTOWB WBB is the preferred strat- Officer (AJBPO) for type-specific whole blood–specific WBT.
egy for U.S. Army and Marine Corps operational units when This type-specific blood drive should also be conducted in
stored products are limited or not available during ground consultation with the medical treatment facility (MTF) med-
combat operations or EABO. French medical forces have used ical authority (e.g., Deputy Commander for Clinical Services
lyophilized plasma during military operations as an alternative [DCCS], Trauma Director, and Trauma Surgeon) and Labora-
39
to crystalloids or colloids as a point-of-care resuscitation fluid tory/Blood Bank Officer in Charge (OIC). In addition to a
during ground or maritime operations before WBT. However, knowledgeable provider at the point of collection, the AJBPO,
36
the published literature is limited to the description of only MTF medical authority, and laboratory/blood bank OIC are
type-specific WBB to augment stored blood products in a mari- involved in starting a traditional WBB, which can take up
8,9
time setting on robust traditional medical receiving platform. to 45–60 minutes or longer to obtain a unit of type-specific
Nontraditional maritime medical receiving platforms like the blood. In contrast, prescreened O blood group–specific WBB
ones SSTs will be employed on, do not have organic labora- is an immediately accessible resource for RDCR. The current
tory testing capability and rarely undergo predeployment WBB success of a WBB on nontraditional medical receiving vessels
screening. This presents an additional challenge for SSTs, like will depend on the number of prescreened individuals. As seen
the ERSS, to perform RDCR and is particularly important in on the LSD deployment, only 56 sailors, out of 165 reported to
the U.S. INDOPACOM Area of Responsibility (AOR), which have group O blood, were screened. In the event of a mass ca-
covers more than 50% of the earth’s surface and where mari- sualty event, this would be a severe limitation in hemorrhagic
time assets are spread over great distances. 37 volume resuscitation. Although not all the unscreened sailors
participated in the follow-up survey, several factors were iden-
Among those eligible and willing to participate as donors in tified suggesting that proper education and communication
the group O WBB drives during our ERSS deployments, the could improve participation. Sailors reported being unaware
prevalence of low anti-A and anti-B titers was highly variable. of the blood drive, being too busy, or not being on the ship on
While a large proportion of donors (87%–95%) aboard the the day of the drive. With the support of leadership, providing
DDG and CVN were low-titer, only 37% of screened donors incentives, further dissemination of information, and holding
on the LSD met LTOWB criteria. The low-titer prevalence on multiple screening drives could increase the potential pool of
the LSD occurred in a crew that had undergone three separate donors. Some also reported thinking that glucose-6-phosphate
COVID-19 outbreaks over the previous 9 months. It is unclear dehydrogenase (G6PD) or sickle cell trait would be a dis-
whether this history is of any causal significance, as a previ- qualifying factor—neither condition disqualifies from blood
ous study of 21 patients did not find statistically significant donation. On the DDG, about half of the available group O
changes in anti-A IgM titers in group O platelet donors after personnel were screened and were found to have LTOWB lev-
COVID-19 infection. A large U.S. Army review of LTOWB els similar to those in the previous experience and published
38
titer levels found initial LTOWB rates at 69.5% but achieved literature. Although less than 4% of the available members
100% of eligible donors meeting low-titer criteria after five were prescreened on the CVN, the percentage of LTOWB was
screen tests over the 18-month time frame. Historically, O similar to that of the previous experience and published liter-
14
blood group transfusion of both high- and low-titer O blood ature, and the available LTOWB donors were similar to those
has been used safely in mass casualty settings and avoided of the DDG. Only 34% of the available O blood group mem-
clerical errors and fatal AHTRs. 3,23 The JTS CPG for prehos- bers were screened on the LSD with only 37% being eligible
pital blood transfusion requires that WBB donors ideally be LTOWB donors, which is a significant discrepancy with the
retitered every 90 days but allows up to 12 months between other two ships as well as previous published literature and
titers, given lack of access in deployed settings. Among those provided limited capacity for the ERSS to perform RDCR. The
eligible and willing to participate as donors in the WBB pro- new Department of Defense Instruction 6480.04 (Jan 2022)
gram, the prevalence of low anti-A and anti-B titers was highly requires all deploying personnel to be screened as blood do-
41
variable (37%–95% LTOWB). The U.S. Army Rangers and nors (Appendix 2). Medical departments onboard all naval
U.S. Marine Corps have implemented the ROLO and Valkyrie vessels will need to overcome the fear of needles, miseduca-
programs to deliver prescreened fresh LTOWB at the point of tion on disqualifying conditions for blood donation, and poor
injury. Titers for LTOWB donors in these programs are ob- communication of the predeployment requirement.
tained during predeployment and should not be more than 12
months prior to donation. 39,40 As described above in our case Group O whole blood not tested for anti-A and anti-B was
series, a prescreened O blood group-specific WBB can rapidly safely utilized in historical conflicts in WWI, WWII, and the
produce similar capabilities for an SST on a nontraditional Korean War. A DMO strategy of combining prescreened
16
maritime platform. In a distributed maritime environment, group O whole blood and lyophilized blood products (e.g.,
unique challenges like a lack of a laboratory technician, small freeze dried plasma) appears to be the best path forward to
(7–8-person) medical teams, and competing operational in- perform DCR reliably despite contested resupply. 36,42 With the
terests during a general quarters setting, make a type-specific advancement in titer testing, LTOWB is clearly recognized as
WBB high risk and not feasible. Prescreened O blood group a preferred resuscitation product for combat trauma. 25,40 Fu-
donors do not carry the same risk for a blood type mismatch ture research efforts to align and optimize maritime LTOWB
error in a mass casualty scenario, as a blood group–specific WBB should study the impact of having formal training for all
program. In this case series, one member’s record had the Navy ships including blood group, titer, and infectious disease

64 | JSOM Volume 23, Edition 1 / Spring 2024