Page 36 - JSOM Winter 2024

external support. To maintain capacity, it is suggested that the prevent hypothermia. The goal of infusing warmed IV fluids/
BDE S-4 monitors and manages supply requests needed from blood is to reduce negative heat balance rather than to ac-
0–47 hours. The SPO will monitor and manage the supplies tively warm the patient, because every decrease of 1.0°C
required for 48–96 hours out and provides this information (1.8°F) in core temperature below 36°C (96.8°F) results in a
to the BDE S-4 to maintain “push” and “pull” logistical oper- 10% increase in RBC consumption in the first 24 hours of
ation efforts. admission. Furthermore, data emphasizes the need for effec-
tive hypothermia prevention at the POI, and continued patient
To maintain these logistical efforts, BDE assets require the warming during massive transfusion, with warmed 38–42°C
equipment necessary to maintain blood products, such as (100.4–107.6°F) whole blood . These devices need to be light-
temperature control storage, blood fluid warmers, individual weight (~2 pounds), small in dimension, portable, and capable
carry systems, and subcomponents for blood administration of warming 4 units of whole blood with a flow rate of 150mL/
and hemorrhage treatment. min.¹¹ BMSOs need to review their Authorized Stockage List
with the BDE surgeons to ensure the appropriate medications
To understand this requirement, we suggest starting with un- and subcomponents for blood administration are standard-
derstanding the capacity limit from the maneuvering medic ized and listed to facilitate the ordering process. BDE surgeons
and working back to the Brigade Support Battalion (BSB). must take the time to educate BMSOs on the requirements
This will set the baseline of what can actually be supported. and why they are needed. For example, patients given 4 units
Using the Light Infantry Brigade Combat Team structure, we of blood that was stored in citrate blood bags will need 30mL
determined that one maneuvering (combat) medic can carry 2 of calcium gluconate or 10mL of calcium chloride to prevent
units of blood, and each maneuvering company has 15 maneu- hypocalcemia; or, to reduce hemorrhagic shock, medics will
vering medics. The total carrying capacity for all maneuvering use 2g of tranexamic acid. By understanding the “why” behind
medics alone per single Infantry Battalion is 30 units. Addi- products, the BMSO can tailor their limited capacity to meet
tionally, these medics will be limited to the amount of weight priority requirements.
they can carry individually and will require a materiel solution
that supports dismounted operations. The most commonly Global Supply Chain Management
used materiel solution is the “Golden Hour Box,” which al-
lows blood to remain at appropriate storage temperature for Objective determination of the supply chain’s survivability
up to 72 hours all maneuvering medics alone per single Infan- is vital. This must be done through supply chain stress tests,
try Battalion is 30 units. These medics will be limited to the which can help the DoD identify issues in manufacturing
amount of weight they can carry individually and will require nodes, distribution, transportation, and financial solvency.
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a materiel solution that supports dismounted operations. The These tests can be conducted virtually; however, the distribu-
most commonly used materiel solution is the “Golden Hour tion and transportation testing must be conducted in live exer-
Box,” which allows blood to remain at appropriate storage cises. To produce the most reliable data for global supply chain
temperature for up to 72 hours. management, practitioners need to determine the estimated
blood demand and lead time between the manufacturing and
The Battalion’s Role 1 possesses a stronger potential for ma- distribution nodes (industry, BDC, EBTC, BPD, etc.).
neuvering equipment and must be able to resupply their ma-
neuvering medics. For these reasons, it is necessary for the This can be done by first estimating the WIA within each AOR
Role 1 to possess up to 2 temperature control storage units using the Casualty Rate Estimation Tool (CREstT) in the Joint
that can store a (minimum) total of 30 units of blood and can Medical Planner’s Tool Kit (MPTK). Once WIA is determined,
support Role 1 split operations when needed. using the Joint Staff Surgeon’s recommendation of 8 units (2 at
POI and 6 at follow on roles of care), we can then determine
Eventually all six of the BDE’s Role 1s will require resupply the estimated blood requirement. It is vital that medical opera-
from the BSB. Additionally, the BSB will need equipment capa- tions officers include the Joint effort, and not just their parent
bility to maintain their Role 2 operations. The Role 2 patient Service, while collecting WIA estimations. This estimation is
capacity within 24 hours is 50 WIA, with an estimated 10 WIA just a baseline; it will not account for ongoing armed conflict,
needing blood. The minimum blood required at the Role 2 which introduces a random fluctuation element in determining
is estimated to be 60 units. The BMSO will need equipment a demand pattern.
capability to meet the Role 1 (150 units) and Role 2 (60 units)
requirements for resupply, which totals to 240 units. Again, Next, global managers need to consolidate the estimated re-
split operation capability is paramount and the materiel solu- quirements from each AOR and determine if the supply chain
tion for storage needs to support this. can meet or exceed demand. This can be done initially with site
visits to industry and BDC locations to observe current oper-
The BDE’s requirements to match omnidirectional support ations and investigate limiting factors for manufacturing and
must be considered so that they can support partner forces, current, maximum capacity. A recent CNA study determined
special operation forces, forward resuscitative surgical detach- that the bottlenecks within the BDCs are donor availability
ments, etc. BSB commanders need to consider what other op- staff limitations and consumable supply shortages. 13
tions are available to maintain blood products, like the use
of the multi-temperature refrigerated containerized systems This discovery allows global managers to determine solutions
(MTRCS) found with the field feeding team inside both the that increase capacity for materiel sourcing. However, lead
BSB and maneuvering FSCs, to match these demands. time delays are inevitable. Global managers cannot estimate
when and how external factors, like our supply chains being
To support hemorrhage treatment and blood administration, targeted, will affect the DoD, but they can identify whether
medics and providers will require blood fluid warmers to internal factors are further limiting. For example, by running

34 | JSOM Volume 24, Edition 4 / Winter 2024