Page 72 - JSOM Spring 2025

Blood Supply Challenges in a Denied Combat Environment

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Brian C. Riley *; Michael J. Lauria, MD ; John R. Hess, MD, MPH ; Daniel J. Roubik, MD 4

Background
During two decades of combat in Southwest Asia, improve- optimal storage parameters. Before deviating from regulations,
ments in the combat trauma system enabled a 44% reduc- providers should understand the basis for those regulations
tion in mortality for the most critically injured casualties. and the scientific justification for deviation. Storage regula-
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Medics transfused blood products at the point of injury and tions exist to deliver safe and effective blood to the average
transported casualties to awaiting surgical teams within the patient. In a denied combat environment, the patient is not
“golden hour.” Stabilized patients were moved by helicopter average and the standard of care may not be possible.
to theater medical facilities on par with level 1 trauma centers,
then spirited off to Landstuhl Regional Medical Center aboard The Joint Trauma System (JTS) publishes a robust collection
aircraft outfitted as flying intensive care units. The military of Clinical Practice Guidelines (CPGs) to address the vast ma-
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medical system delivered the highest combat trauma survival jority of combat medical scenarios. This article is not meant to
rate in history. However, those outcomes were only possible supersede the relevant guidelines. The intent of this article is
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because of America’s air supremacy, which enabled the rapid to address transfusion dilemmas medical teams may face in a
aerial transport of patients, medics, and supplies. All of that contested, degraded, and operationally limited combat envi-
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will change in a major conflict with a near-peer adversary. ronment, which are not addressed in the CPGs.
Medical care during large-scale combat operations (LSCOs) Regulations
will be defined by disrupted supply chains and communication
links, long casualty transport distances, and extended periods Blood product storage requirements are derived from expert
of stop-movement due to air threats. Instead of training to consensus based on in vitro and in vivo studies; they have never
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meet the golden hour, teams are training to manage critical been tied to clinical outcomes. Liquid products have wide vari-
patients at the point of injury for hours or even days. Pro- ability in storage quality based on uncertain donor characteris-
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longed Field Care has entered the military medical lexicon tics. Therefore, regulations aim to deliver high quality products
and is quickly becoming the new normal. Previously mature to the vast majority of patients with a conservative safety mar-
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combat theaters in the Middle East have retrograded to cen- gin to account for storage quality variation. Although the U.S.
tral hubs with few forward-operating bases. Medical teams Food and Drug Administration (FDA) has codified storage re-
in Eastern Europe are managing mass casualty events under quirements, deviation is permitted when clinically indicated.
constant aerial threat. In the Pacific, teams are preparing to
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execute their missions without the logistic support or commu- The Association for the Advancement of Blood and Biothera-
nication connectivity previously enjoyed under the umbrella pies (AABB) acts as an industry organization for transfusion
of air and space supremacy. In the future fight, teams will go medicine in the United States, providing standards, inspection
forward with the equipment needed for their mission, and they services, and other aids to help individual blood banks stay
may not be resupplied for several weeks until air superiority within FDA regulations. According to AABB Standards section
is established. Shelf-stable supplies such as ammunition and 1.3.2, “Any exceptions to policies, processes, and procedures
meals-ready-to-eat (MREs) will be readily available, but blood warranted by clinical situations shall require justification and
products, with expiration dates and refrigeration require- preapproval by the medical director.” The FDA maintains a
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ments, will be in short supply. 6 cumulative list of previous exceptions demonstrating the wide
variety of circumstances under which regulatory deviation was
In a combat environment where medical evacuation and re- necessary. If a pre-approved exception is not feasible, the
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supply are significantly delayed, physicians and medics may be medical director must report the deviation through the Armed
faced with the decision to transfuse blood products outside of Services Blood Program.
*Correspondence to briley1@uw.edu
1 Maj Brian Riley is a member of the USAF Reserve, 304th Rescue Squadron, Portland, OR and a medical student at the University of Washington,
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Seattle, WA. Capt Michael Lauria is a member of the USAF Reserve, 624th Aeromedical Staging Squadron, Joint Base Pearl Harbor-Hickam, HI,
Assistant Professor of Emergency Medicine at the University of Washington, Seattle, and Associate Medical Director/Flight Physician for Airlift
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Northwest. COL (Ret) John Hess is the Transfusion Service Medical Director, Harborview Medical Center, Seattle and former commander of the
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US Army Blood Research Detachment, Walter Reed Army Institute of Research, Silver Spring, MD. MAJ Daniel Roubik is a US Army Trauma/
Critical Care surgeon with dual affiliations at Madigan Army Medical Center, Joint Base Lewis-McChord, WA, and the University of Washington,
Seattle, WA.
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