The blood bank: whole lotta shakin' goin' on blood-bank support in U.S. military operations.

In World War II, a soldier, severely injured in battle, had about a 22% chance of dying. Nearly a generation later, a wounded soldier faces significantly better odds with a less than 9% chance of dying. The fighters who now survive owe their lives to an array of advancements in battlefield medicine. Of particular note are the developments in blood and blood-product usage. Today's military medical personnel go about the business of lifesaving with a veritable arsenal of blood and blood products.

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The main blood product used during World War II was plasma due to the knowledge of treatment at the time. In the years leading up to the war, plasma was shown to be as effective in treatment of shock and hemorrhage as the practice of using whole blood. Additionally, the blood industry was able to collect plasma in the mass quantities required at the time, while transport and storage remained a reasonably simple process.

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Some of the most important improvements in today's blood banking are related to the preparation, handling, and transport of blood products. These developments alone have increased a physician's arsenal from solely plasma to packed red blood cells (RBCs) fresh frozen plasma, plasma frozen within 24 hours, cryoprecipitate, and frozen RBCs. And, yet another important advancement, a critical network of blood collection, processing, storage, shipping, and transfusion facilities maintain this blood-product cache. This network of components collectively makes up the Armed Services Blood Program (ASBP), upon which the Department of Defense (DoD) relies in the fight to help ensure our wounded come back home.

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Established formally in 1952 by Executive Order, the ASBP is a joint operation, comprised of the Army, Navy, and AirForce that are tasked with collection, processing, storage, distribution, and transfusion of blood products worldwide, managing blood requests from five major combatant commands by finding available blood supplies, and delivering those supplies to the battlefield. The program's policies, overseas operations, and research and development activities are managed by the ASBP office (ASBPO) while collection, processing, shipping, and transfusion activities are under the direction of each service's blood program office (SBPO). Together, the ASBPO and SBPO programs monitor and implement appropriate guidance and standards set forth by the Food and Drug Administration and AABB (formerly the American Association of Blood Banks), the industry licensure and accreditation agencies, to ensure the safest and most efficacious products for those in need.

To ensure compliance with regulatory protocols and to capitalize on current advancements, the process itself must be rigorous. It begins with ASBP donors and the collection of blood. Currently. the ASBP operates 19 DoD blood-donor centers within the continental United States and three in overseas locations. These donor centers now provide more than 150,000 units annually and have since 2002. Prior to operations in the Middle East, DoD blood centers were responsible for less than 80,000 blood collections per year.

"The success of the DoD blood collection program would not be possible without the dedication of our blood donors and the outstanding staff at our facilities", states Maj. David Lincoln, deputy director for Policy at the ASBPO.

Following collection, ASBPO blood-processing and-testing centers separate the blood into various products, perform testing for required infectious-disease markers, conduct exacting quality-control checks, and finally, store the blood for further distribution.

The distribution and transfusion processes of blood within the DoD system, while similar to civilian blood distribution and transfusion, are also distinctly different in two ways. As with its civilian counterparts in the United States, blood is distributed to medical-treatment facilities for transfusion--using standard commercial shipping organizations--where it is then transfused as needed. But the DoD blood-distribution system is unique because of its presence throughout the world and also because of its international mission--to deliver blood anywhere in peacetime and wartime.

This distribution mission is accomplished by utilizing the military's United States Transportation Command, which is responsible for providing delivery of personnel, equipment, and supplies worldwide. This unique system is the foundation for the next step taken to place blood and blood products into the hands of military medical staff and other customers worldwide, and therefore determines needs and provides the appropriate capability to deliver blood anywhere the ASBP requires. And anywhere can be 200 miles away or thousands of miles away in locations where airports may not even exist. In those cases where blood must be delivered great distances, the transportation time can be long, and the blood requires special preparation to ensure safe preservation.

This is where special facilities within the DoD called the Armed Services Whole Blood Processing Laboratories (ASWBPL) enter the lifesaving process. The ASWBPLs are large-scale blood receiving and shipping centers located on Air Force bases with heavy volumes of available flights and aircraft to ensure the availability of transport going anywhere required. The ASWBPLs responsibilities include receiving blood products from collection facilities, storing products, arranging distribution, checking blood types and the Rh factor, and preparing shipments.

The latter two steps are unique, yet vital, to DoD blood management. Since blood is distributed, in some cases, to locations without the ability to check the blood type of the units being infused, the ASWBPL is the final quality check to ensure safe labeling and transfusion of blood in the field. For long-distance shipment preparation, the ASWBPL packs blood products using standard shipping containers with specific quantities of wet or dry ice. Additionally, blood is packaged onto cargo pallets and tightly strapped down to avoid movement during flight. Throughout its journey, blood may stop at several refueling airfields or the flight may be scheduled for multiple stops. To avoid compromise of the products, the DoD maintains specially trained handling teams at all airfields to verify blood temperature and re-package products for the next leg of the flight. Finally, the product arrives at its destination.

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Having been tightly controlled and properly maintained to its final destination, blood has now reached a remote locale. What happens next demonstrates the importance of blood-product availability and is another crucial advancement. The DoD maintains special blood units manned by laboratory technicians to establish mobile blood-handling and-storage facilities worldwide under any conditions. These special units are in all three services and may be established in tents, hardened mobile shelters, or afloat on ships. All blood specialists, regardless of service affiliation, have the refrigeration and shipment capability to support any medical facility established in their area of operations. Stringent requirements combined with innovative research and development allows the ASBP to identify and obtain special refrigeration devices and utilize state-of-the-art technology.

Therefore, because of selfless volunteers, medical advancements in blood banking, strict quality control and testing, rigorous transportation protocols, and outstanding personnel, the Armed Services Blood Program, almost 70 years after World War II, is proud to provide the safest and farthest reaching blood supply in the world--and, even more importantly, that this mission serves those who risk their lives for our nation every day.

An additional unique feature of the ASBP is that it is not only responsible for blood collection and distribution, but it manages the transfusion services within all DOD medical-treatment facilities within the United States and abroad. Perhaps the largest organization in the United States responsible for the entire blood-management lifecycle, the ASBP ensures laboratory technicians are trained in all aspects of blood banking to ensure the safe administration of blood products to patients and casualties in peace and war. The combination of blood-collection centers and transfusion services includes more than 100 full-time blood-banking facilities worldwide.

RELATED ARTICLE: CONTINUING EDUCATION 

To earn CEUs, see current test at www.mlo-online.com under the CE Tests tab.

LEARNING OBJECTIVES

Upon completion of this article, the reader will be able to:

1. describe the Department of Defense's (DoD's) distribution mission and system.

2. describe the preparation, handling, and transport of blood products by the U.S. military blood-bank support operations.

3. identify DoD organizations charged with worldwide blood banking processes.

4. describe actions involved with preparation of peacetime and wartime shipments.

5. identify technologies for soldiers requiring massive transfusions.

6. list six phases of implementation of a physicians office laboratory transfusion service.

RELATED ARTICLE: Army's greatest inventions of 2007 recognized

Gen Benjamin S. Griffin, commanding general, U.S. Army Materiel Command, praised the Army's Top 10 Greatest Inventions for 2007, which were recognized during a June 12 luncheon ceremony at the Hyatt Crystal City in Arlington, VA; all 10 inventions have been deployed in theater.

Now in its sixth year, the Army-wide awards program is dedicated to highlighting the best technology solutions for the soldier. From nominations submitted from across the Army laboratory community, nine of the 10 recipients are elements of the U.S. Army Research Development and Engineering Command. The Army--from active duty divisions to the Training and Doctrine Command to the Army's vice chief of staff--chose the 10 winning programs based upon their impact on the Army capabilities (e.g., breadth of use and magnitude of improvement over existing systems), inventiveness, and potential benefit outside the Army.

One of the winning technologies came from the Army Institute of Surgical Research: Damage Control Resuscitation of Severely Injured Soldiers. This is a new set of treatment steps for the soldiers who require massive transfusions. Limiting the amount of intravenous saline solution (normally three times blood volume), and transferring an even mix of plasma and blood rather than the usual 4/ plasma:1/blood unit ratio, stabilizes the patient's blood pressure, lowers the likelihood of fatal shock, and minimizes renewed bleeding. Early use of a clotting factor called rFVIIa has also been beneficial, and other blood products (e.g., platelets and cryoprecipitate) are used as needed. The treatment works especially well for non-compressible injuries which comprise 70% of lethal combat injuries. The Army says that the technique has reduced the mortality rate for severely injured soldiers in the field from 65% to 17%.

Civilian medical centers have taken notice and are expected to begin using these techniques themselves. For more in-depth information, go to www.defenselink.mil/news/newsarticle.aspx?id=50204 and/or www.defenseindustrydaily.com/US-Army-Awards-Top-10-Inventions-of-2007-04997/.

General reference

(1.) Kendrick DB, Brig. Gen., Blood Program in World War II. Washington, DC: Office of the Surgeon General, Department of the Army; 1964.

Lt. Col. Michael J. Lopatka is deputy director of the Armed Services Blood Program Office at Falls Church in Northern Virginia.