Page 60 - JSOM Fall 2025

Accuracy of 6.5" Beaded Cable Tie, 10" Paracord, and
Operator Gestalt in Prehospital Whole Blood Collection Techniques
in Filling Donor Blood Bags to Target Volume

Duncan Carlton, MD ; Cole Jordan, BS ; Matthew Christensen, MD ;
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Kevin Matthews, BS ; Blaine Dassero ; Gregory J. Zarow, PhD ; Samuel Walther, DO ;
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Alec Emerling, MD ; Russell Wier, DO ; Jonathan Auten, DO 10
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ABSTRACT
Background: Whole blood reduces mortality more effectively Whole blood is superior to blood component therapy in re-
than blood component therapy in treating trauma. When ducing mortality in military trauma patients with exsangui-
cold-stored low-titer Type O whole blood (CS-LTOWB) is nation. 3,4,7 For these reasons, whole blood is recommended as
not available in austere environments, a walking blood bank the resuscitative fluid of choice by the Committee on Tacti-
(WBB) strategy is employed, with blood drawn from a local, cal Combat Casualty Care (CoTCCC) and the Joint Trauma
pre-screened donor. Proper blood bag volume is essential for Service (JTS), codified by the military’s Damage Control Re-
avoiding citrate-related complications; however, the optimal suscitation (DCR) Clinical Practice Guidelines (CPG), 1,3–11 typ-
method for determining the correct blood bag volume is un- ically in the form of cold-stored low-titer Type-O whole blood
clear. Methods: Novices (n=65) and experts (n=10) at the 1st ( CS-LTOWB). However, CS-LTOWB is not always available
Marine Division each filled blood bags with the goal of hit- in austere or far-forward deployment settings due to logistical
ting the target volume (450mL ±10%) using the 6.5" beaded issues, such as cold storage space and storage time limitations.
cable tie (BC), 10" paracord (PC), and operator gestalt (OG) When CS-LTOWB is not available, a walking blood bank
techniques. Filled bags were weighed on a digital scale. Cor- (WBB) strategy may be employed.
rect fills, underfills, and overfills were assessed using nonpara-
metric statistics at P=.05. Subjective assessments were also In WBB scenarios, fresh whole blood (FWB) is acquired di-
collected. Results: For novices, OG achieved the highest rate rectly from on-site, pre-screened personnel and immediately
of correct fills (69%), significantly outperforming BC (37%, transfused into the recipient. While the WBB strategy provides
P=.001) and PC (52%, P=.05). In experts, PC had the highest an opportunity to save lives, it is important to fill the donor
rate of correct fills (80%), though not significantly different blood bag to the target volume of 450mL (585g ±10%). The
from OG (70%, P=.59) or BC (50%, P=.08). OG was rated target volume of 450mL is recognized by JTS CPG 21 and the
highest and was preferred by both groups. BC performed Association for the Advancement of Blood & Biotherapies to
worst in objective and subjective measures for both groups. mitigate deleterious effects from concentration or dilution of
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Conclusion: BC performed poorly on all assessments and the citrate anticoagulant contained in the donor bag. Under-
should be avoided. OG was generally superior to BC and PC, filled bags can lead to citrate-induced hypocalcemia, impair-
but was still suboptimal, with ~30% incorrect fills study-wide. ing coagulation, and potentially cause cardiac dysrhythmias.
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Present findings demonstrate the need for better methods for Conversely, hypercalcemia from overfilled bags can cause line
determining donor blood bag fill volume to preserve the life of blockage or induce thrombotic complications. 13,14
the wounded warfighter in WBB scenarios.
The Valkyrie Emergency Whole Blood Transfusion Train-
Keywords: prehospital blood; low-titer whole blood; ing course (“Valkyrie”) prepares Marine Corps members to
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blood transfusion; combat medicine; hemorrhage; damage conduct WBB in the field. Valkyrie is a 4-day program that
control resuscitation; walking blood bank; blood bag filling teaches students how to handle whole blood in the field. Days
techniques; citrate toxicity; military trauma three and four require each student to complete repetitions of
drawing a unit of blood from a volunteer, then immediately
transfusing that unit back into the volunteer.
Introduction
Valkyrie teaches three methods (techniques) for filling donor
Exsanguination remains the leading cause of preventable bat- blood bags: the 6.5" beaded cable tie (BC), the 10" para-
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tlefield death, with early blood resuscitation saving lives. 1,3–9 cord (PC), and the operator gestalt (OG) method. The BC is
*Correspondence to duncanmarkcarltonmd@gmail.com
1 LCDR Duncan Carlton is affiliated with the Combat Trauma Research Group (CTRG)-West, San Diego, CA, and the Emergency Medicine
Residency program, Naval Medical Readiness and Training Command (NMRTC), San Diego, CA. HM2 Cole Jordan, HM1 Kevin Matthews,
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and HM3 Blaine Dassero are affiliated with the CTRG-West, San Diego, CA, and the Navy Education and Training Office (NETO), 1st Marine
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Division (1st MarDiv), Camp Pendleton, San Diego, CA. LT Matthew Christensen, LCDR Alec Emerling, and CAPT Jonathan Auten are affil-
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iated with the CTRG-West, San Diego, CA, and the Emergency Medicine Residency program, NMRTC, San Diego, CA. Dr. Gregory J. Zarow is
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affiliated with the CTRG-West, San Diego, CA, and The Emergency Statistician, Idyllwild, CA. LT Samuel Walther is affiliated with the CTRG-
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West, San Diego, CA, and the NETO, 1st MarDiv, Camp Pendleton, San Diego, CA. LCDR Russell Wier is affiliated with the CTRG-West, San
Diego, CA, and the 3rd Medical Battalion, 3rd Marine Division, Okinawa, Japan.
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