“This great stride forward in the technique of blood transfusion coincided so nearly with the beginning of the war that it seemed almost as if foreknowledge of the necessity for it in treating war wounds had stimulated research.”
– Geoffrey Keynes, 1922

100 years on from Geoffrey Keynes’ statement, the ADF has the opportunity of being on the right side of history and reaping the rewards of recent military-led research into pre-hospital whole blood, but only if action is taken now. History is littered with examples of failure to prepare for what were, in retrospect, obvious problems. Most recently, despite 20 years of war games, planning, and warnings from experts; the COVID-19 pandemic caught the world unprepared.

In October 2019, Event 201 was a fictitious scenario played out in a New York City conference centre. The name was chosen due to the fact that the world was experiencing 200 epidemic events a year and experts knew that it was only a matter of time until one would eventually cause a pandemic. It was prescient that the virus chosen was a coronavirus, given that only two months later China was reporting the outbreak of a severe form of pneumonia in the city of Wuhan – the beginning of a pandemic that rocked the world.

Despite the urgent warnings of experts and the outcomes of this theoretical exercise to demonstrate the problem, “the failure to adequately fund and execute these plans has exacted a heavy human and economic price”. This lesson of recent history is salient for the Australian Defence Force (ADF) health services as we risk sleepwalking into the next conflict unprepared to meet the challenges of providing pre-hospital blood for our wounded.

“For the first time in war the transfusion of blood has been carried out successfully and no treatment has been more spectacular or effective as a life-saving measure in cases of haemorrhage.”
– Alexander Primrose, Canadian Surgeon 06 June 1918

The History of Blood

Whole blood transfusion has been in use as early as World War I, with Type O blood shown to be safe as a universal donor product as early as 1917. The use of blood products continued to evolve during World War II when it was noted that patients infused with Type O blood containing antibody titres greater than a certain level were experiencing transfusion reactions. The response was to develop a low-titre program, which was used extensively up until the end of the Korean War. Whole blood then began to fall out of favour due to its short shelf life and the risk of transfusion transmitted diseases.

Civilian health systems transitioned to products derived from the fractionalisation of blood, a process of dividing blood into individual components which can be stored separately. Whilst this is advantageous in a civilian setting, for military personnel operating during conflict the requirement to maintain tight temperature control of frozen components, the ability to thaw these products correctly, and the ability to rapidly deliver the individual components to replicate the effect of whole blood presents a logistic challenge to pre-hospital providers. The current ADF process of sourcing and providing blood reflects the shift to civilian priorities, processes, and supply. Ambivalence around the lack of suitability of these products and processes further reflects the legacy of 20 years of warfare against a technologically overmatched enemy in Iraq and Afghanistan where ADF forces also enjoyed significant coalition support.

Strategic Environment

In August this year, emeritus professor of strategic studies at the Australian National University, former director of the Defence Intelligence Organisation, and former deputy secretary for strategy and intelligence in the Department of Defence – Professor Paul Dibb – highlighted that “we now face the probability of high intensity conflict in our own immediate strategic environment.”[1]

In light of the increasing likelihood of significant conflict in our near future, the need for a comprehensive ADF pre-hospital blood policy to ensure that this life-saving intervention is available has become more apparent. Given the training burden the ADF faces to upskill our clinicians in forward resuscitation with blood, there is a growing sense of unease and urgency amongst Army doctors regarding the ADF’s current lack of a robust and responsive means of supplying whole blood to pre-hospital providers. This is something that should concern all combat commanders within the ADF.

In 2021, the US Joint Trauma System, the Defense Committee on Trauma, and the Armed Services Blood Program issued a consensus statement on whole blood, endorsing the following:

• Whole blood should be used to treat combat casualties in haemorrhagic shock.
• Low titre ‘O’ whole blood is the resuscitation product of choice for the treatment of haemorrhagic shock for all casualties at all roles of care.
• Whole blood should be available within 30 minutes of casualty wounding, on all medical evacuation platforms, and at all resuscitation and surgical team locations.
• When whole blood is not available, component therapies in the order of preference specified in the TCCC guidelines should be available within 30 minutes of casualty wounding.
• All Role 1 (pre-hospital) medical providers should be trained and logistically supported to screen donors, collect fresh whole blood from designated donors, transfuse blood products, recognise and treat transfusion reactions, and complete the minimum documentation requirements.
• All deploying military personnel should undergo walking blood bank pre-screen laboratory testing for transfusion transmitted disease immediately prior to deployment. Those who are blood group O should undergo anti-A/anti-B antibody titre testing.
• A tracking system for pre-screening results must be accessible worldwide to verify donor status and be readily available for each role of care.
• All deploying military units, particularly ground combat units, should maintain a pre-screened walking blood bank roster and the capability to draw fresh whole blood at or near the point of injury.
• Personnel must be trained and supplies maintained at every role of care to support a walking blood bank for mass casualty events.
• Pre-positioned frozen red blood cell stockpiles can be considered a means to gradually restock blood components in denied environments but cannot support a rapid need for blood during resuscitation or mass casualty events.
• Commander support of walking blood banks, both in garrison and in deployed environments, is required for adoption and implementation of this life-saving capability.
• These recommendations should be incorporated into medical planning, pre-deployment training, and theatre entry requirements.

Despite the unambiguous messaging of the US, the ADF’s blood program remains stuck in the Afghan-era paradigm: dependent upon a submission to the Australian Red Cross to release blood products for a specific operation. Current blood options, if approved and released, are products optimised for prolonged shelf life, and designed for use in the domestic hospital system (with no agreed guarantee on supply). Newer products with less onerous storage requirements exist, but approval processes and access to training supplies remains problematic.

A Holistic Program

Due to the enduring nature of war and the added complexity offered in the current strategic environment, the ADF must have the capacity to generate a supply of whole blood in theatre. The concept of an emergency donor register is not new, with a high profile example being the donation of blood by Australian soldiers to save the life of President Jose Ramos Horta in Dili on 11 February 2008. Experience tells us that militaries are poor at anticipating the future operating environment and as such, the ADF blood program needs to be flexible enough to provide a range of options for provision of pre-hospital blood products, including not only whole blood but also component blood products. Blood saves lives, and combat commanders regardless of service should therefore not only be aware of current deficiencies in the ADF’s ability to rapidly collect and provide blood to casualties in the field in the absence of air superiority and large coalition hospitals within their area of operation, but should be agitating for ADF health services to exercise and prove this capability.