Page 14 - JSOM Summer 2025

Lessons learned over the next several decades, including (similar to ROLO), it also places emphasis on using existing
through U.S. involvement in the Global War on Terror, demon- DoD systems to support the drawing, testing, labeling, and
strated a shift in focus back to blood products for resuscitation storing of blood rather than relying solely on walking blood
13
of hemorrhagic shock, with WB emerging as the fluid of choice banks. The SOLO protocol recognizes that walking blood
4–7
when it is available. Typed and matched WB is primary in the bank–procured FWB is not an FDA-licensed product and,
non-emergent, hospital setting, though low-titer O type blood therefore, should not be thought of as a primary method for
is now recognized as the standard of care across the Advanced meeting CONUS blood needs. It reiterates that walking blood
Trauma Life Support (ATLS) and Joint Trauma System (JTS) bank FWB has an increased risk to forces when compared to
protocols for prehospital or emergency trauma care. Product FDA-approved cold whole blood (CWB) due to the latter’s
Component therapy at a 1:1:1:1 ratio (packed red blood cells risk of transfusion-transmitted infections and increased risk of
[pRBC], platelets, plasma, CRP) remains an acceptable option clerical errors leading to transfusion mismatch. 14
8,9
when WB is unavailable. Intuitively, as the body loses WB,
WB should replace it. This is borne out in current literature as As medics and providers with significant SOF experience, 2/1
well. However, there are many logistical challenges associated SFG(A) Med recognizes that there is rarely a single solution
with WB on the battlefield, given the need for either immediate to a complex issue such as point of injury blood transfusion.
use, or tightly temperature-controlled storage. Unit structure, operational setting, and geographic location
will affect medical practice and Commanders’ responses to
The Ranger O Low-Titer (ROLO) program, one well publi- risk. Guidelines from CoTCCC, JTS, SOCOM, and other or-
cized SOF-led initiative, sought to mitigate barriers to WB far ganizations provide a litany of deployed protocols ranging
forward on the battlefield. ROLO depends on drawing of units from obtaining blood/blood products from the ASPB supply,
of WB from Rangers who have been pre-screened as having to pre-screened low-titer O type blood drawn as needed, to
low-titer O type blood. For the purposes of this and other De- the establishment of walking blood banks organic to the force.
partment of Defense (DoD) programs, low titer is defined as The same is not true for the CONUS environment. Despite
10
blood group O, with IgM, anti-A, and anti-B titers <1:256. current data suggesting that 32% of non-overseas deaths of
Under a ROLO protocol, once a massive transfusion scenario active-duty Servicemembers occurred due to accidents, there
15
takes place, pre-identified Ranger donors serve as a walking is currently no guidance on storage and transfusion of blood
blood bank of fresh whole blood (FWB) for purpose of resusci- products for SOF elements in the CONUS setting. As a result
tating critically wounded unit members. This protocol has be- of this paucity of guidance, very few SOF units routinely carry
come highly praised and was recognized by the Army Materiel blood or blood products on training missions within the U.S.,
Command as the individual military winner of the annual Ar- regardless of risk level or proximity to definitive care. It is our
my’s Greatest Innovation Award in 2014. It has been effective belief that this has led to training scares and violates the mili-
in saving the lives of combat casualties in at least one docu- tary mantra of “train as you fight.” FWB donated from emer-
mented case, in Wardak Province in 2020. Despite the over- gency unit walking blood banks is part of training in Special
11
whelming success of the ROLO protocol, there are significant Operations Combat Medic (SOCM)-producing courses and
barriers to its broad application to all units, even within SOF. re-trained and assessed at the refresher and team level; autol-
ogous FWB transfusion for the purpose of training is com-
While JTS clinical practice guidelines (CPGs) state that FWB monplace throughout SOF and beyond. Conversely, proper
donors have not shown significant decrements in military- maintenance, transport, and transfusion of CWB is rarely dis-
10
relevant task performance following donation, other studies cussed and exercised, despite its improved safety profile and
argue that although negative physiological effects on the in- often improved practicality.
dividual donor are minimal, they claim consensus on the fact
12
that performance is temporarily reduced. In the heat of battle, Study purpose
it is instinctively unfavorable to return Servicemembers who Understanding that walking blood bank procured FWB does
have recently donated blood to a situation where they have a not answer the organizational concerns of Special Forces ODA
higher likelihood of becoming casualties themselves. If injured, and USSOCOM guidance favoring prioritization of ASBP-sup-
they would begin with the disadvantage of having less blood plied, FDA-approved CWB. Also considering additional qual-
volume than they would otherwise have had. Moreover, JTS ity restraints when practicing in the U.S., the medical section
CPGs suggest that, due to the potentially chaotic conditions in at 2/1 SFG(A) developed a feasibility study to determine if the
which FWB such as ROLO is used, there is an increased risk organic capability existed to store and transport CWB to po-
of transfusion-transmitted infections (e.g., HIV, hepatitis B or tential points of injury within CONUS. While conducting typi-
C, syphilis), and an increased risk of clerical errors leading to cal unit training, SOF Operators brought CWB to the training
major mismatches. For SOF units structured or immediately sites where the medics tracked the product’s refrigerated lifes-
supported by platoon or company-sized elements, these costs pan. We hypothesized this capability would be feasible and
and considerations might be offset by the size of the available that demonstrating success would lead to additional studies
donor pool and accompanying manpower. Though some SOF and pilot programs, facilitate novel methods of blood pro-
units are routinely organized into elements of 4–12 Operators, curement to mitigate training risk in the CONUS pre-hospital
even temporarily removing a portion of the fighting force rep- setting, and improve our medics’ competence in working with
resents the potential for critical degradation in capability to CWB in any setting.
perform continuing operations.
Methods
Special Operations Command (SOCOM) at large has estab-
lished a Special Operations Low-Titer O Blood (SOLO) pro- Three male volunteers aged 25–41 years were selected from
gram. While this protocol ultimately supports the use of a 2Bn 1SFG(A) Support Company. Their selection was based
walking blood bank program with low-titer O whole blood on gender, volunteerism, and the criteria that they had not

12 | JSOM Volume 25, Edition 2 / Summer 2025