Beyond FDP is whole blood. FWB has been used by the military since World War I. Blood is composed of white blood cells, platelets, red blood cells (RBC) and plasma. The difficulty and safety of FWB transfusion is the blood of the patient and donor must be compatible. The compatibility of blood is found on the RBC and in plasma, there are two types of antigens A and B. A person’s blood may have A, B, AB, or none of the antigens-type O.
To further complicate matters, a person’s blood will make antibodies for the other blood types. Therefore, type A will have anti B in their plasma. There is one more antigen, that is the Rhesus Factor (Rh), which is either positive (+) or negative (-), therefore when someone says they are A-, it means they have the A antigen and no Rh antigen. The preferred method of FWB transfusion is giving the exact type, but there are studies that show giving type O regardless of the patient’s blood type is not only safe, but has been done multiple times since WW II.
There is a correlation between amount of antibodies in the donor’s plasma and the severity of the reaction. There are very few deaths associated with type O transfusions. Since, roughly 40% of all Americans have type A blood, all type A patients will receive type A, and all other patients will receive type O blood.
The 75th Ranger Regiment has not only stepped back in time, but it has also done so with the intent of getting the skill of FWB transfusion down the lowest level, that of the Advanced-RFR. The idea of teaching the Advanced-RFR the FWB transfusion is met with some skepticism. Some medical professionals feel, nonmedical people performing such a critical task could dangerous. But, the senior medical person on the ground makes risk mitigation through supervision and guidance. This will allow for FWB transfusions to be completed safely and timely. The algorithm established is comprehensive with multiple backstops.
Every Ranger upon in-processing the unit has a checklist of necessary items to be completed. One is to ensure that the Ranger has an adequate bleeder kit; two, get all immunizations up to date; and three, complete blood typing through the local hospital lab. This is done with every new Ranger that arrives at one of the four battalions, even if it was completed during basic training or MEPs. Two confirmed lab results (initial entry and unit) of the same blood type gives the medical staff very high confidence of their blood type, close to 100%.
Each platoon medic maintains a roster of all personnel in his platoon. The roster includes each member’s blood type, and when enablers such as EOD are attached to organic Ranger units in combat zones, blood typing is done in theater at the local military treatment facility. Rangers with type O blood will require additional testing. Titers for IgM anti-A and anti-B are drawn. Rangers with low titer levels will be identified and will be the “universal donor.” A third backstop is a different type of blood typing, using an Eldoncardâ. This small card has four small circles with a different type of antigen. To check a blood type, the Ranger takes a very small amount of water and blood and swirl them together in each circle. As mentioned before, each blood type has proteins that identify it as A, B, O, AB, and + or -. This is similar to the process in the lab. The accuracy of this test being interpreted correctly is close to 100%. The purpose of this step is to further help the Advanced-RFR and/or medic gain confidence that the donor and patient is a match.
The protocol is written as such that once someone is injured, the medic will give the patient 1 G of Tranexamic Acid via intravenous line over 10 minutes. While mixing the FDP, he will call for a FWB match. Once the donor has been identified, the Advanced-RFR will confirm, with the medic of correct name and blood type. The Ranger Regiment uses a prepackaged whole blood transfusion kit. At this point, the medic would either be addressing the needs of the patient or triaging/treating other patients. If there is no response, or still showing signs and/or symptoms of shock, the patient can receive another unit of FWB.
If the second unit must be taken from the same donor, that donor must be evacuated with the patient. It is theorized that a third unit could be taken in extremis, but the donor must not have any injuries or chronic illnesses that could cause a catastrophic event. If the patient requires more than two units, or there are no similar blood types available, the predetermined type O with low titers will be used as a donor. All documentation will be made in writing on the blood bag and all bags will stay with the patient.
Since World War I, the whole blood transfusion has been saving lives on the battlefield. As the conflict in Afghanistan dwindles down, the ability to get injured Soldiers and Rangers to definitive care will be increasingly difficult. Whole blood transfusion seems to be a lesson relearned in each conflict. Hopefully, this time it will stay fresh in the minds of the medical professionals. This simple procedure, completed by an infantryman, will change the battlefield and will hopefully bring more injured Rangers home.
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