Combat blood operations in Iraq: providing blood for injured Soldiers during combat operations is a complex task. A blood supply unit from Germany overcame the challenges it encountered in Iraq to meet the needs of Soldiers there.

In January 2004, l0 Soldiers from the Blood Platoon, 226th Medical Logistics Battalion (Forward), 30th Medical Brigade, in Miesau, Germany, deployed to Balad, Iraq. Their mission was to serve as the blood supply unit (BSU), supplying class VIIIB (blood and blood products) for Operation Iraqi Freedom (OIF) II. The dynamics of rapid-paced combat operations required those in the blood supply chain to adapt quickly and make on-the-spot decisions.

Operational Challenges

The austere environment in Iraq presented unique challenges to blood distribution operations. Many of these challenges resulted from a sporadic communications capability and the exceptionally short shelf life of many of the blood products. Additionally, insurgent activities increased during the months of April and November 2004, producing increased casualty rates for coalition forces and Iraqi civilians. These increases in hostilities and subsequent injuries increased the need for blood products exponentially.

During the first 6 months of the deployment, blood shipments to the BSU were unpredictable and the average shelf life of packed red blood cells (PRBC) received was about 12 days. The rapid expiration of PRBC supplies tested the blood distribution chain by increasing the need to procure blood products, monitor blood products on hand, and distribute them to meet needs. The limited PRBC storage capabilities of forward support teams created additional problems. Many of the challenges that the BSU faced were reduced when, later in the operation, it started receiving PRBC with a shelf life of at least 14 days.

The 226th BSU supported nearly twice the medical treatment facilities (MTFs) recommended for one BSU. The supported facilities included Army combat support hospitals and forward support teams, Air Force expeditionary medical support and expeditionary wings, Navy MTFs, and a Polish MTF. The BSU also provided emergency support to the Allied hospital in the Spanish sector in April 2004, when operational conditions exceeded the hospital's blood supply capabilities. Because of this additional demand and the increased use of blood for wounded coalition members, insurgents, and civilians, the BSU functioned at a capacity well above normal during April.

Blood Shipments

The 226th BSU received routine blood product shipments once a week from the blood transshipment center in Qatar in quantities that were based on the requirements of ongoing missions. The average weekly shipment contained 450 units of PRBC, 100 units of Cryoprecipitate, and 60 units of fresh frozen plasma.

The BSU initially used medical evacuation (MEDEVAC) assets to transport blood from the BSU to the MTFs throughout Iraq. However, this presented a problem for the MEDEVAC units because too much of their time was being used exclusively for transporting blood products rather than their primary mission--evacuating casualties. To augment its means of transporting blood products and reduce its use of the MEDEVAC system, the BSU established routine air shipments using Army fixed- and rotary-wing aircraft.

The BSU monitored the blood products on hand at the different MTFs and their projected rates of consumption to determine the quantity that should be shipped routinely by air. Air movement requests were submitted 48 hours before the stocks on hand in the MTFs were expected to be critically low. By working air requests through the 1st Corps Support Command movement control cell, the BSU was able to use opportune airlift, including C-23 Sherpa airplanes and CH-47 Chinook and UH-60 Black Hawk helicopters. ("Opportune airlift" refers to aircraft that were scheduled for other missions and had space available to transport the blood products.) In fact, nearly 90 percent of MTF blood shipments were sent as routine shipments using opportune airlift rather than using MEDEVAC flights. However, MEDEVACs were used extensively to transport emergency blood shipments.

Blood Management

The Joint Blood Program Office (JBPO) and the BSU used disposition and transfusion reports to track the inventory of blood products. Each

MTF sent the 226th BSU a daily report indicating the quantities of blood products that were on hand, used, and expired. These reports were sent by Internet to the BSU, where they were compiled and sent to the JBPO using a secure Internet system.

The BSU relied on the Internet and telephone to communicate with its customers and the blood transshipment center. Communications were adequate during most operations. However, sometimes an installation or forward operating base shut down Internet communications for security reasons. When this happened, telephones became the primary means of communicating. At other times, the Internet service went down because of technical problems with the service provider. Fortunately, the BSU had access to multiple telephone systems, such as Army and Air Force phone networks and an Iridium satellite phone, so that it could place orders when the Internet was down. Disposition and transfusion reports were sent as soon as the Internet came back on line.

Blood Product Disposition

It was extremely important to track every unit of blood product that moved through the blood supply system. The daily blood report contained disposition information as well as information on blood products on hand. Disposition information had complete data on expired and transfused units, including information on the patients receiving the transfused units. (Expired blood products were incinerated on location.) JBPO maintained archives of all blood reports for future research.

The BSU used the Theater Defense Blood Standard System (TDBSS) to track which MTF received each blood product. Although it was helpful in managing the overall flow of products, the TDBSS was not helpful in tracking final disposition information because supported MTFs did not use it.

The 226th BSU distributed over 20,000 blood products (2,500 gallons of blood) throughout the Iraq area of operations during OIF II. In the end, the driving enablers of success were the Soldiers, Sailors, and Airmen who made the system work despite the austere environmental conditions, limited access to transportation, short shelf life of blood products, and sporadic communications capability.

Blood Products.

Packed red blood cells (PRBC) are collected from individual donors and packed into a small package for transfusion to a patient. Packed red Blood cells do not provide viable platelets or clinically significant amounts of clotting factors.

Cryoprecipitate is the product (rich in factor VIII clotting factor) formed when normal blood plasma is cooled.

Fresh frozen plasma is taken from whole blood and frozen within 8 hours of collection. It contains normal concentrations of clotting factors.

FIRST LIEUTENANT MARIA F. JOHNSON IS THE OFFICER IN CHARGE OF THE CENTRAL PROCESSING SECTION AT LANDSTUHL REGIONAL MEDICAL CENTER IN GERMANY. SHE HAS A BACHELOR'S DEGREE IN MEDICAL TECHNOLOGY FROM KEAN UNIVERSITY IN NEW JERSEY AND IS A GRADUATE OF THE ARMY MEDICAL DEPARTMENT OFFICER BASIC COURSE.