DifronzoCapstonePA2017.pdf

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Marc

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Difronzo

A_​​Capstone_​​Paper_​​submitted_​​to_​​the_​​faculty_​​of the_​​University_​​of_​​North_​​Carolina_​​at_​​Chapel_​​Hill

in_​​partial_​​fulfillment_​​of_​​the_​​requirements ​​for_​​the_​​degree_​​of_​​Master_​​of_​​​​Health_​​Sciences

in_​​the_​​Physician_​​Assistant_​​Program

Chapel_​​Hill December_​​2017

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________________________________

Todd_​​Williams_​​PA-C

11/15/2017

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________________________________

Kim_​​Faurot_​​​​PA,_​​MPH,_​​PhD_​​(epidemiology)

11/15/2017

Background

Loss_​​of_​​blood_​​from_​​traumas_​​suffered_​​on_​​the_​​battlefield_​​is_​​the_​​most_​​common_​​cause_​​of_​​death among_​​potentially_​​treatable_​​injuries_​​in_​​frontline_​military_{​ ​​}operations_​​​(Keenan_​and_{​ ​​}Riesberg_​​2017)_​. Cessation_​​of_​​blood_​​loss_​​and_​​fluid_​​repletion_​have_{​ ​​}been_​​major_​​driving_​​factors_​​that_​​can_​​reduce battlefield_​​casualties._​​Once_​​the_​​hemorrhage_​​has_​​been_​stopped,_{​ ​​}the_​​next_​​step_​​is_​​to_​​replace_​​lost volume_​​to_​​decrease_​​cardiac_​​failure_​​or_​​shock_​(Eastridge_{​​ ​​}et_​​al._​​2012;_​​Butler_​​2017)_​._​​Uncontrolled hemorrhage_​​can_​​lead_​​to_​​the_​​"trauma_​​triad_​of_{​ ​​}death",_​​which_​​consists_​​of_​​hypothermia,_​​acidosis,_​​and impaired_​​coagulation_​​​(Howard_​​et_​​al._​​2017)_​._​​Hemostatic_​​resuscitation_​​involves_​​the_​​blood

components_​​resembling_​​whole_​​blood._​​The_​​goals_​​are_​​to_​​avoid_​​metabolic_​​acidosis,_​​hypothermia, treating_​​coagulopathy_​​and_​stabilizing_{​ ​​}the_​​patient_​​as_​​soon_​​as_​​possible_​​​(Nickson_​​n.d.)_​._​​The resuscitation_​​fluids_​​of_​​choice_​​for_​​casualties_​​in_​​hemorrhagic_​​shock,_​​listed_​from_{​ ​​}most_​​to_​​least preferred_​​are:_​​whole_​​blood;_​​plasma,_​​RBCs_​​and_​​platelets_​​in_​​1:1:1_​​ratio;_​​plasma_​​and_​​RBCs_​​in_​​1:1 ratio;_​​plasma_​​or_​​RBCs_​​alone,_​and_{​ ​​}crystalloid_​​fluids_​​​(Nickson_​​n.d.)_​.

Between_​​October_​​2001_​​and_​​June_​2011,_{​ ​​}4,596_​​battlefield_​​fatalities_​​were_​​analyzed. Non-compressible_​​hemorrhage_​​is_​​the_​​cause_​​of_​over_{​ ​​}2/3_​​of_​battlefield_{​ ​​}deaths,_​​which_​​makes hemorrhages_​​the_​​leading_​​cause_​​of_​​potentially_​survivable_{​ ​​}deaths_​​in_​combat_{​ ​​​}(Keenan_​​and_​​Riesberg 2017)_​._​​The_​​major_​​body_​​region_​​bleeding_​​focus_​​accounting_​​for_​mortality_{​ ​​}were_​​torso_​​48%,

extremities_​​31%,_​​and_​neck/groin/_{​ ​​}axilla_​​region_​​21%_​​​(Eastridge_​​et_​​al._​​2012)_​._​​Casualties_​​with severe_​​hemorrhagic_​​injury,_​​the_​​odds_​​of_​​KIA_​mortality_{​ ​​}were_​​83%_​​lower_​​for_​​casualties_​​who_​​needed and_​​received_​​pre-hospital_​​blood_​​transfusion_​​​(Shackelford_​et_{​ ​​}al._​​2017)_​._​​​Evaluating_​​the_​​influences on_​​mortality_​​is_​​helpful_​​for_​​planning_​​efforts_​​that_​​optimize_​​placement,_​proximity,_{​ ​​}and_​​provision_​​of timely_​​and_​​effective_​​transport_​​and_​​treatment_​​capabilities_​​to_​​minimize_​​casualty_​risk_{​ ​​​}(Malsby_​​et_​​al.

2013)_​._​​​Combat_​​wounded_​​on_​​today’s_​​battlefield_​​experience_​​the_​​highest_​survival_{​ ​​}rate_​​in_​​history. Advances_​​in_​​battlefield_​​medicine_​​during_​​the_​conflicts_{​ ​​}in_​​Iraq_​and_{​ ​​}Afghanistan_​​have_​​included the_​​effective_​​use_​of_{​ ​​}tourniquets,_​​​​damage​​control​​resuscitation,​​​​trauma​​system​​development,​​​​en route_​​care,_​​​​use​of​ ​​tranexamic​​acid,​​​​and​​advanced​​topical​​hemostatic​dressings​ ​​​(Malsby​​et​​al. 2013)_​._​​In_​​2008,_​​there_​​was_​​a_​​mandate_​​that_​​all_​​the_​​injured_​​personnel_​​evacuation_​​to_​​surgeon_​​must occur_​​in_​​less_​​than_​​60_​​minutes,_​​“The_​Golden_{​ ​​}Hour”,_​​that_​​contributed_​​to_​​the_​​lowest_​​mortality rate_​​of_​​any_​​conflict_​​in_​history_{​ ​​​}(Keenan_​​and_​​Riesberg_​​2017)_​.

Component_​​therapy_​​remains_​​the_​​mainstay_​​in_​​trauma_​​resuscitation._​​In_​​prolonged_​​field_​​care, access_​​to_​​packed_​​red_​​blood_​​cells,_​​platelets,_​​and_​​fresh_​​frozen_​​plasma_​​is_​​often_​​limited_​​​(Keenan_​​and Riesberg_​​2017)_​._​​Transfusion_​​of_​​fresh_​​whole_​​blood_​​has_​​been_​​used_​​when_​​access_​​to_​​CT_​​in_​​these settings_​​are_​​limited_​​or_​​have_​​been_​​fully_​utilized_{​ ​​}._​​The_​​process_​​of_​​separating_​​and_​​reconstituting blood_​​can_​​lessen_​​its_​​effectiveness._​​Current_​​Prolonged_​​Field_​​Care_​​standards_​identified_{​ ​​}that_​​the_​​best practice_​​for_​​transfusions_​​would_​​be_​​to_​​maintain_​​a_​​stock_​​of_​​pRBC_​​and_​​FFP_​​and_​​have_​​type-specific donors_​​identified_​​for_​​immediate_​​FWB_​draw_{​ ​​​}(Keenan_​​and_​​Riesberg_​​2017)_​.

PICOT_​​Question:_​​What_​​are_​​the_​​limitations_​​of_​​Fresh_​​Whole_​​Blood_​​transfusions_​​or

administration_​​of_​​blood_​​products_​​in_​​prolonged_​point_{​ ​​}of_​​injury_​care_{​ ​​}on_​​the_​​battlefield?

Crystalloid_​​Fluids

Isotonic_​​IV_​​fluids_​​became_​​popular_​​in_​​the_​Vietnam_{​ ​​}War_​​due_​​to_​​reduced_​​cost_​​and_​​prolonged shelf_​​life_​​because_​​access_​​to_​​supplies_​​was_​very_{​ ​​}limited_​​during_​​the_​​campaign._​​Isotonic_​​fluids_​​also require_​​less_​​equipment_​​and_​​less_​​training_​​for_​​the_​provider_{​ ​​}as_​​well._​​The_​storage_{​ ​​}life_​​of_​​0.9%_​​Normal Saline_​​which_​​is_​​15_​​months_​​to_​​3_​​years_​​depending_​​on_​​the_​​volume_​​of_​​the_​​bag_​​​(Beckett_​​et_​​al._​​2015)_​.

There_​​is_​​no_​​evidence_​​that_​​supports_​​isotonic_​fluid_{​ ​​}being_​​a_​​life-saving_​​measure_​​to_​​traumatic_​​injuries (Beckett_​​et_​​al._​​2015)_​(Beckett_{​​ ​​}et_​​al._​​2015)_​._​​In_​​fact,_​​it_​​leads_​​to_​​following_​​complications:_​​(1)

exacerbation_​​of_​​bleeding_​​due_​​to_​​possible_​clot_{​ ​​}disruption,_​​(2)_​exacerbation_{​ ​​}of_​​anemia,_​​(3) thrombocytopenia,_​​and_​​(4)_​coagulopathy_{​ ​​}due_​​to_​​hemodilution_​​​(Nickson_​​n.d.)_​._​Ley_{​ ​​}et_​​al._​​found that_​​receiving_​​intravenous_​​crystalloid_​​>1.5_​​liters_​in_{​ ​​}the_​​emergency_​department_{​ ​​}(ED)_​​is_​​an independent_​​risk_​​factor_​​for_​​mortality.

Other_​​Adjunct_​​Methods

Many_​​other_​​methods_​​have_​​been_​​utilized_​in_{​ ​​}conjunction_​​with_​blood_{​ ​​}transfusions_​​in_​​remote environments_​​to_​​decrease_​​mortality_​​such_​​as_​utilizing_{​ ​​}Factor_​​VII_​and_{​ ​​}TXA_​​(tranexamic_​​acid) (Anon_​​n.d.)_​._​​These_​​are_​​used_​​for_​​short_​​term_​resuscitation_{​ ​​}and_​​can_​​“buy_​​time”._​​​​TXA_​​is_​​an_​​FDA approved_​​anti-fibrinolytic_​​that_​​prevents_​​clot_​​breakdown_​​but_​​can_​​lead_​​to_​​thromboembolic_​​events such_​​as_​​deep_​​venous_​​thrombosis_​​or_​​pulmonary_​​embolism_​​​(Anon_​​n.d.)_​._​​Factor_​​VII_​​is_​​a_​​crucial initial_​​component_​​of_​​the_​​coagulation_​​cascade._​​A_​​double-blind_​​randomized_​​control_​​trial_​​conducted by_​​Anantharaju_​​et_​​al._​​demonstrated_​​a_​​statistically_​​significant_​​reduction_​​in_​​blood_​​transfusion requirements_​​in_​​patients_​​with_​​blunt,_​but_{​ ​​}not_​​penetrating,_​​trauma.Tourniquets_​​are_​​user-friendly, cheap,_​​and_​​transportable_​​and_​​their_​​role_​​is_​​to_​​stop_​​the_​​hemorrhage._​​The_​​physiological_​​effect_​​of_​​an appropriately_​​placed_​​tourniquet_​​will_​​stop_​​arterial_​​flow_​​to_​​the_​​extremity,_​​but_​​at_​​a_​​lower_​​pressure,_​​it will_​​stop_​​the_​​venous_​​flow_​​to_​​the_​​extremity_​​and_​​trap_​​the_​​blood_​​in_​the_{​ ​​}extremity._​​As_​​a_​​result,

clotting_​​occurs,_​​and_​​the_​​blood_​​lactate_​​concentration_​​will_​​rise_​​in_​​the_​​retained_​​blood_​​and_​​will_​​be released_​​into_​​the_​​systemic_​​circulation_​​when_​​the_​​tourniquet_​is_{​ ​​}released_​​​(Tang_​​et_​al._{​ ​​}2013)_​._​​This_​​can lead_​​to_​​hypercoagulability_​​and_​​lactate_​​acidosis._​​The_​tourniquet_{​ ​​}has_​​a_​​role_​​when_​​it_​​comes_​​to

stopping_​​the_​​hemorrhage_​​and_​​is_​​best_​used_{​ ​​}in_​​conjunction_​with_{​ ​​}FWB._​​Autotransfusion_​​tourniquets

are_​​being_​​utilized_​​in_​​the_​​civilian_​​setting_​​as_​well._{​ ​​}Dr._​​Noam_​​Gavriely,_​a_{​ ​​}professor_​​of_​​medicine_​​and formerly_​​an_​​emergency_​​physician_​​and_​​member_​​of_​​the_​​Israeli_​​Defense_​Force,_{​ ​​}invented_​​the_​​FDA approved_​​device_​​which_​​is_​​currently_​​used_​​in_​​the_​Operating_{​ ​​}Room_​​setting_​​​(Tang_​et_{​ ​​}al._​​2013)_​._​​The device_​​could_​​be_​​used_​​on_​​a_​​hemorrhaging_​​extremity_​​or_​even_{​ ​​}on_​​an_​​open_​​fracture_​​if_​​it_​​can_​​be_​​rolled over_​​the_​​injury._​​The_​​removal_​​of_​​the_​​device_​had_{​ ​​}to_​​be_​​done_​gradually_{​ ​​}after_​​correction_​​of_​​bleeding, and_​​restoration_​​of_​​the_​​blood_​​volume_​​​(Tang_​​et_​​al._​2013)_{​ ​}._​​If_​​it_​​was_​​removed_​​too_​​rapidly,_​​would_​​be the_​​same_​​as_​​the_​​immediate_​​loss_​​of_​​one_​​liter_​​of_​​whole_​​blood._​​Another_​​advantage_​​over_​​the

traditional_​​tourniquet_​​is_​​the_​​shorter_​​time_​​it_​takes_{​ ​​}to_​​apply_​​the_​​device._​​A_​​pre-hospital_​​study application_​​in_​​a_​​California_​​Emergency_​​Medical_​​System_​​is_​​in_​​the_​process_{​ ​​}of_​​a_​​randomized prospective_​​study_​​​(Tang_​et_{​ ​​}al._​​2013)_​.

Component_​​Therapy

Component_​​therapy_​​(CT)_​​is_​​part_​​of_​​the_​​current_​​standard_​​of_​care_{​ ​​}as_​​well._​​Component therapy_​​does_​​convey_​​benefits_​​in_​​financial,_​​logistical_​​and_​​inventory_​​management_​​in_​​controlled environments_​​​(Ramakrishnan_​​and_​Cattamanchi_{​ ​​}2014)_​._​​CT_​​needs_​​to_​​be_​​thawed_​​and_​​warmed before_​​use_​​to_​​avoid_​​causing_​​hypothermia._​​Blood_​products_{​ ​​}that_​​have_​​been_​​used_​​longer_​​than_​​24 hours_​​result_​​in_​​increased_​​mortality._​​FWB_​​has_​more_{​ ​​}clotting_​​factors_​​and_​​none_​​of_​​the_​​storage problems_​​that_​​CT_​has_{​ ​​​}(Ramakrishnan_​​and_​​Cattamanchi_​​2014)_​._​​When_​compared_{​ ​​}with_​​fresh_​​whole blood_​​cells,_​​the_​​transfusion_​​of_​​large_​​amounts_​​of_​​pRBC_​​contributes_​to_{​ ​​}a_​​dilutional_​​coagulopathy which_​​is_​​primarily_​the_{​ ​​}result_​​of_​​thrombocytopenia_​​and_​​poor_​​platelet_​​function._​​​​Stored_​​platelets demonstrate_​​decreased_​​thrombotic_​​function._​​This_​​is_​primarily_{​ ​​}because_​​of_​a_{​ ​​}decrease_​​in_​​expression of_​​high-affinity_​​thrombin_​receptors_{​ ​​}during_​​platelet_​​storage_​​​(Kauvar_​​et_​​al._​​2006)_​._​​Clinically,_​​FWB has_​​demonstrated_​​to_​​reverse_​​dilutional_​​coagulopathy,_​​with_​evidence_{​ ​​}that_​​a_​​single_​​unit_​​of_​​FWB_​​has

a_​​hemostatic_​​effect_​​similar_​​to_​​ten_​​units_​​of_​​platelets_​(Kauvar_{​​ ​​}et_​​al._​​2006)_​._​​A_​​1:1:1_​​ratio_​​of_​​plasma, PRBCs_​​and_​​platelets_​​component_​​therapy_​​does_​not_{​ ​​}contain_​​equivalent_​amounts_{​ ​​}of_​​clotting_​​factors, platelets_​​or_​​fibrinogen_​​as_​​WFWB_​​​(Ramakrishnan_​and_{​ ​​}Cattamanchi_​​2014)_​._​​Necessity_​​is_​​the mother_​​of_​​invention_​​in_​​extending_​time_{​ ​​}to_​​a_​​patient's_​​definitive_​​care.

Fresh_​​Whole_​​Blood

Battlefield_​​blood_​​transfusions_​​have_​​been_​​used_​​since_​​WWII._​​There_​​is_​data_{​ ​​}that_​​supports_​​the use_​​of_​​FWB_​​in_​hypovolemic_{​ ​​}shock_​​​(Spinella_​​2008)_​._​​It_​​contains_​​red_​​blood_​cells_{​ ​​}that_​​carry_​​O2_​​to the_​​tissues;_​​platelets_​​that_​​promote_​​clotting;_​​and_​​other_​​proteins,_​​such_​as_{​ ​​}albumin,_​​that_​​maintain blood_​​pressure._​​Criteria_​​indicating_​​need_​​for_​​blood_​​transfusion_​​was_​​defined_​based_{​ ​​}on_​​the_​​following criteria:_​​(1)_​​systolic_​​blood_​​pressure_​​(SBP)_​​≤_​​90,_​(2)_{​ ​​}heart_​​rate_​​(HR)_​≥_{​ ​​}120,_​​or_​​(3)_​​multiple

traumatic_​​amputations_​​at_​​or_​​above_​​the_​​knee_​or_{​ ​​}elbow_​​​(Spinella_​​2008)_​._​​​FWB_​​resuscitation_​​can reduce_​​the_​​23%_​​mortality_​​among_​​hypotensive_​​trauma_​patients_{​ ​​​}(Smith_​​et_​​al._​​2016)_​._​​Whole_​​blood has_​​a_​​24hr_​​lifespan_​​and_​​needs_​​to_​​be_​​destroyed_​​after_​​this_​​time_​​has_​​passed._​​​​They_​​should_​​not_​​be_​​left out_​​of_​​controlled_​​temperature_​​storage_​​for_​​more_​​than_​​thirty_​​minutes_​and_{​ ​​}transfusion_​​should_​​be complete_​​within_​​four_​​hours_​​from_​​controlled_​temperature_{​ ​​}storage_​​​(Mclennan_​et_{​ ​​}al._​​2017)_​.

Transfusion_​​Reactions

Transfusion_​​reactions_​​can_​​happen_​​between_​the_{​ ​​}donor_​​and_​​potential_​​patient._​​Compatibility is_​​based_​​on_​​antigens_​​A_​​and_​​B_​​found_​​in_​​the_​​red_​​blood_​​cells._​​A_​​person_​​can_​have_{​ ​​}A,_​​B,_​​AB,_​​or_​​O (none_​​of_​​the_​​antigens)._​​A_​​person's_​​blood_​​will_​​make_​​antibodies_​​for_​​the_​​other_​​blood_​​types._​​For example,_​​type_​​B_​​will_​​have_​​anti-A_​​in_​​their_​plasma_{​ ​​​}(Spinella_​​et_​​al._​2009)_{​ ​}._​​If_​​an_​​incompatible transfusion_​​occurs_​​such_​​as_​​an_​​acute_​​hemolytic_​​transfusion_​​reaction_​​​(Spinella_​​et_​​al._​​2009)_​._​​If_​​this

happens,_​​the_​​host_​​bodies_​​have_​​antibodies_​​IgG_​​and_​​IgM_​​that_​​would_​​attach_​​and_​​destroy_​​the_​​donor's red_​​blood_​​cells._​​A_​​systemic_​​immune_​​reaction_​would_{​ ​​}occur_​​and_​​the_​​complement_​​system_​​would_​​be activated._​​The_​​"enemy"_​​cells_​​would_​​be_​​lysed_​and_{​ ​​}macrophages_​​would_​​clean_​​up_​​the_​​mess_​​by phagocytosis_​​and_​​by_​​releasing_​​cytokines_​​and_​interleukins._{​ ​​}The_​​cytokines_​trigger_{​ ​​}the_​​release_​​of tissue_​​factor_​​which_​​would_​​activate_​​the_​​intrinsic_​​and_​​extrinsic_​​coagulation_​pathways_{​ ​​​}(Mitra_​​et_​​al. 2012)_​._​​Previous_​​research_​​and_​​publications_​​demonstrate_​​that_​​whole_​​blood_​with_{​ ​​}low_​​anti-A_​​and anti-B_​​IgM_​​titers_​​present_​​a_​​low/negligible_​risk_{​ ​​}of_​​a_​catastrophic_{​ ​​}acute_​​hemolytic_​​transfusion reaction_​​when_​​given_​​to_​individuals_{​ ​​}that_​​are_​​not_​​of_​​the_​​same_​​blood_​​group_​​​(Bassett_​​et_​​al._​​2016)_​.

Limitations

During_​​combat_​​situations_​​blood_​​bank_​​capacity_​of_{​ ​​}forward_​​surgical_​units_{​ ​​}and_​​combat_​​field hospitals_​​is_​​frequently_​​overwhelmed._​​The_​​75th_​Ranger_{​ ​​}Regiment's'_​​Ranger_​O_{​ ​​}Low_​​Titer_​​(ROLO) Whole_​​Blood_​​Program_​​was_​​the_​​winner_​​of_​the_{​ ​​}annual_​​Army's_​​Greatest_​​Innovation_​​Award_​​at_​​the Association_​​of_​​the_​​United_​​States_​​Army_​Global_{​ ​​}Warfare_​​Symposium._​The_{​ ​​}program_​​identified_​​all blood_​​group_​​O_​​members_​​of_​​the_​​unit_​​and_​​then_​​tests_​​them_​​to_​​determine_​possible_{​ ​​}donors_​​to_​​be_​​used at_​​the_​​point_​​of_​​injury._​​After_​​laboratory_​​confirmation_​​of_​​blood_​​type,_​​the_​​team_​​medic_​​will_​​maintain a_​​roster_​​of_​​blood_​​types_​​for_​​each_​​Type_​​O_​​individual_​​on_​​his_​​team._​The_{​ ​​}blood_​​products_​​have_​​a 35-day_​​shelf_​​life_​​when_​​stored_​​at_​​1_​​to_​6_{​ ​​}degrees_​​Celsius._​​Typically,_​2-4_{​ ​​}units_​​are_​​collected_​​24hrs prior_​​to_​​a_​​mission.

Collection_​​of_​​the_​​blood_​​products_​​are_​conducted_{​ ​​}by_​​Blood_​Support_{​ ​​}Detachment_​​located_​​in overseas_​​military_​​theaters_​​when_​​the_​​Soldier_​​first_​​arrives._​​The_​​donors_​for_{​ ​​}this_​​blood_​​have

completed_​​the_​​unit’s_​​preparation,_​​screening_​​and_​vaccination_{​ ​​}program_​​and_​have_{​ ​​}been_​​included_​​in

an_​​established_​​“walking_​​blood_​​bank”_​​​(Bassett_​​et_​al._{​ ​​}2016)_​._​​The_​​walking_​​blood_​​banks_​​identify specific_​​blood_​​types_​​of_​​all_​​the_​​Soldiers_​​prior_​​to_​​military_​​operations,_​​so_​​they_​​will_​​their_​​specific blood_​​type_​​transfused_​​if_​​needed_​​​(Bassett_​​et_​​al._​2016)_{​ ​}._​​Blood_​​type_​​for_​​every_​​Soldier_​​is_​​usually displayed_​​on_​​a_​​velcro_​​patch._​​Early_​​activation_​of_{​ ​​}the_​​walking_​​blood_​​bank_​​based_​​on_​​prehospital mechanism_​​of_​​injury_​​reduce_​​the_​​time_​​to_​​FWB_​​transfusion_​​​(Bassett_​​et_​​al._​​2016)_​._​​The_​​preferred method_​​used_​​when_​​performing_​​a_​​transfusion_​​is_​to_{​ ​​}give_​​the_​​exact_​​type_​​between_​​donor_​​and recipient,_​​but_​​in_​​times_​​when_​​the_​​environment_​​is_​not_{​ ​​}controlled,_​​type_​​O_​may_{​ ​​}be_​​used_​​as_​​the universal_​​donor_​​​(Ho_​and_{​ ​​}Leonard_​​2011)_​.

SOF_​​medics_​​prevent_​​transfusion_​​reactions_​​with_​the_{​ ​​}use_​​of_​blood_{​ ​​}cards_​​that_​​consistently provide_​​blood_​​type_​​in_​​less_​​than_​​10_​minutes_{​ ​​}with_​​the_​​FDA_​​approved_​​the_​​ABORhcard_​​​(Bowling and_​​Pennardt_​​2010)_​._​​Viral_​​infections_​​such_​​as_​​hepatitis_​​B_​​and_​​C_​​can_​​be_​​screened_​​with_​​rapid immunoassays,_​​but_​​these_​​tests_​​are_​​not_​​FDA_​​approved_​​for_​​donor_​settings_{​ ​​​}(Bowling_​​and_​​Pennardt 2010)_​._​​A_​​challenge_​​with_​​blood_​​transfusions_​​is_​​equipping_​​designated_​personnel_{​ ​​}with_​​the_​​proper equipment_​​and_​​training,_​​but_​​SOF_​​personnel_​utilized_{​ ​​}their_​​training_​learned_{​ ​​}at_​​the_​​Special Operations_​​Combat_​​Medic_​​Skills_​​Sustainment_​Course_{​ ​​​}(Bowling_​​and_​​Pennardt_​​2010)_​.

The_​​operational_​​situation_​​is_​​changing._​​With_​​the_​​reduction_​​of_​​troops_​and_{​ ​​}decrease_​​in_​​true combat_​​missions,_​​the_​​SOF_​are_{​ ​​}being_​​relied_​​on_​​more_​​now_​​than_​​ever_​​before._​​​​The_​​areas_​​are_​​more remote_​​and_​​austere_​​than_​​ever_​​before_​​​(Keenan_​​and_​Riesberg_{​ ​​}2017)_​._​​They_​​do_​​not_​​enjoy_​​the_​​support of_​​a_​​large_​​medical_​​infrastructure_​​that_​​regular_​​army_​​units_​​have._​Medical_{​ ​​}evacuation_​​to_​​definitive care_​​is_​​measured_​​in_​​days,_​​not_​​hours._​There_{​ ​​}aren't_​​enough_​​surgical_​​and_​​critical_​​care_​​resources. CASEVAC’s_​​are_​​constrained_​​by_​​landing_​strips,_{​ ​​}weather,_​​and_​​unreliable_​​political_​​permissions (Keenan_​​and_​​Riesberg_​​2017)._​​​With_​​the_​​past_​​robust_​​medical_​​support_​​available_​​during_​​the_​​war,_​​the

Special_​​Operations_​​Medics_​​had_​​a_​​de-emphasis_​​on_​​their_​​prolonged_​​field_​​care_​​for_​​the_​​sake_​​of_​​point of_​​injury_​​trauma_​​care._​​With_​​the,_​limitations_{​ ​​}in_​​equipment_​and_{​ ​​}transportation,_​​Operational_​​context was_​​defined_​​by_​“Ruck,_{​ ​​}Truck,_​​House,_​​Plane”_​​​(Keenan_​​and_​​Riesberg_​​2017)_​._​​Medical_​​support plans_​​would_​​be_​​developed_​​based_​​on_​​this_​​aspect._​​​​Prolonged_​​Field_​care_{​ ​​}includes_​​surgical_​​skills, fresh_​​whole_​​blood_​​transfusions,_​​ventilator_​​management,_​​advanced_​​pain_​​management,_​​and anesthesia_​​skills._​​Teleconsultation_​​and_​​real_​​time_​​Ultrasound_​​are_​​being_​​considered_​​​(Keenan_​​and Riesberg_​​2017)_​.

New_​​Technology

A_​​study_​​was_​​conducted_​​by_​​Boscarino_​et_{​ ​​}al_​​measured_​the_{​ ​​}biochemical_​​and_​​biomechanical markers_​​affected_​​by_​​changes_​​such_​​as_​​heat,_​​agitation,_​​and_​​pressure_​changes_{​ ​​}on_​​pRBC._​​Even though_​​FWB_​​was_​​not_​​used_​​in_​​this_​​study,_​​the_​​same_​​changes_​​would_​​happen_​to_{​ ​​}the_​​RBC_​​within_​​the FWB_​​​(Boscarino_​​et_​​al._​​2014)_​._​​He_​​measured_​​physical_​​and_​​chemical_​changes_{​ ​​}during_​​a_​​simulated HALO_​​(High_​​Altitude_​​Low_​​Opening)_​​airborne_​operation_{​ ​​}followed_​​by_​a_{​ ​​}12-hour_​​foot_​​patrol (Boscarino_​​et_​​al._​2014)_{​ ​}._​​HALO_​​airborne_​​operations_​​are_​​conducted_​by_{​ ​​}Special_​​Operation_​​Forces (SOF)_​​who_​​jump_​​from_​the_{​ ​​}aircraft,_​​free-fall_​​for_​​a_​​period_​​of_​​time_​​at_​​​terminal_​​velocity_​,_​​and_​​open their_​​parachute_​​at_​​a_​​low_​​altitude._​​​​This_​helps_{​ ​​}defeat_​​identification_​​via_​​radar_​​and_​​reduces_​​the amount_​​of_​​time_​​a_​​parachute_​​might_​​be_​​visible_​​to_​​ground_​​observers,_​​enabling_​​a_​​stealthy_​​insertion_​.

The_​​blood_​​samples_​​were_​​stored_​​in_​​the_​​Series_​​4-EMT_​​Golden_​Hour_{​ ​​}cooling_​​containers_​​for the_​​duration_​​of_​​the_​​experiment._​​The_​containers_{​ ​​}remained_​​between_​2.3-3.8_{​ ​​}degrees_​​Celsius_​​which is_​​in_​​accordance_​​with_​​the_​​American_​Association_{​ ​​}Blood_​​Bank_​standards_{​ ​​}for_​​transport_​​​(Boscarino et_​​al._​​2014)_​._​​During_​​the_​​HALO_​​drop,_​​the_​​pH_​​did_​​not_​​significantly_​​change._​​Lactate_​​and_​​Potassium