Medical Science Publication No. 4, Volume 1
EXPERIENCE WITH PROCUREMENT, STORAGE, AND DISTRIBUTIONOF BLOOD FROM LOCAL SOURCES IN THE EARLY DAYS OF THE KOREAN WAR*
COLONEL R. L. HULLINGHORST,MC
As indicated in the title, this paper will not be concerned with theimportant aspect of utilization of blood, but with a brief presentationof some difficulties encountered in establishing a blood program in a militarytheater faced with sudden conversion from occupation duties to active warfare.This requires a brief historical account of the general situation beforeproceeding to a discussion of the specific problems of: (a) formulatinga general blood policy, (b) organizing the blood bank, (c) estimating requirements,and (d) reacting to critical supply shortages.
Prior to the onset of hostilities in Korea only the Tokyo Army and OsakaArmy Hospitals maintained blood banks and these were sufficient only tomeet their own needs. The sudden invasion of the Republic of Korea on 25June 1950, was a shock to both tactical and logistic elements of the FarEast Command.
During the following week it became obvious that medical field unitswere being formed within the Eighth Army in expectation of the decisionby the United Nations to actively oppose the aggressors. The need for wholeblood in the care of expected casualties became apparent and on 3 Julythe Commanding Officer of the 406th Medical General Laboratory was assignedthe responsibility for establishing a blood program. Four days later, bloodwas delivered to the first hospital unit arriving in Korea. From that timeon, no active hospital in Korea was ever without blood.
Formulating a General Blood Policy. All combat and many supportingunits were being alerted. This left only a small number of service troops,military dependents, foreign businessmen and diplomats as the donor reservoir,since theater policy prohibited the receipt of blood donations from theJapanese population in the early phases. Concentration of potential donorsin the Tokyo-Yokohama area, and marked depletion of troops in the vicinityof existing hospitals else-
*Presented 20 April 1954, to the Course on Recent Advances In Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.
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where required a central collecting agency to provide blood not onlyto Korea, but also to those hospitals in Japan which would be receivingcasualties evacuated from field units.
Only group O blood would be supplied for use in Korea. Blood of hightiter was to be used for group O recipients, conserving that of low titerfor administration to wounded of other blood groups. Compatibility by Rhtype was to be disregarded provided the blood was acceptable in the routinecross-match.
Hospitals in Japan were expected to use blood compatible as to groupand Rh factor, and were to be supplied with the necessary amount of eightbasic varieties of blood.
A 21-day expiration policy was adopted, and standards of donor acceptabilitywere those of recognized authorities (1, 2, 3), with modifications.As an example of such modifications, a set of tables was later preparedestablishing the volume of blood to be collected from persons of smallstature in order to deviate from the limitation of 200 cc. as the maximumblood donation approved by the Japanese Medical Association.
Organizing the Blood Bank. The importance of excellent publicrelations in the procurement and handling of donors was recognized early.Fortunately there emerged a full-time American Red Cross volunteer whoproved competent and invaluable. The full cooperation of Armed Forces Station,the FECOM newspaper Stars and Stripes and of the other local newspapers(both English speaking and Japanese) was readily obtained. A corps of part-timevolunteer workers were organized as receptionists, nurse's aids, clerksand chauffeurs in support of donor service. These were later supplementedby a similar staff obtained with the aid of the Japanese Red Cross whenpermission to accept Japanese donors was obtained.
From the assigned laboratory personnel plus three attached officersof the Army Nurse Corps there were formed a central collecting and processingunit, mobile collecting teams and a storage and courier section. An advancedblood bank depot was established in southern Japan from which local hospitalswere supplied, and from which couriered deliveries were made to hospitalsin the Pusan bridgehead by air as called for.
By mid-August the 8090 Blood Bank Laboratory Detachment was activatedand attached to the Medical General Laboratory although qualified personnelfor this supplementary unit were acquired only gradually. The CommandingOfficer of the General Laboratory, however, remained the one responsiblefor the entire theater blood program. This position warranted the full-timeutilization of a senior officer and assistant to plan and direct procurement,supervise distribution and instruct in the proper utilization of bloodand blood substi-
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tutes. These important responsibilities were never satisfactorily handledas additional duties.
Estimating Blood Requirements. Efforts to obtain data from WorldWar II experience for planning blood requirements were relatively unsuccessful.The single reference available (4) stated that British experiencein the Middle East had recommended 0.1 pint per soldier wounded in action(WIA); data from United States Forces in the Mediterranean Theater showed0.45 pint/WIA; for planning purposes, the Whole Blood Committee of theEuropean Theater of Operations utilized 0.2 pint per casualty (type notstated). From the 20,000 potential donors in the Tokyo-Yokohama area itwas felt that at least 100 pints per day could be collected over a prolongedperiod-using a program of repeat bleeding at 10-week intervals (this assumptionproved sound in that 60,191 pints were collected in the next 18 months).
Utilizing such planning data, it was expected that these resources wouldbe ample for the small number of casualties expected initially from the"police action." With growing realization that a relatively majoreffort would be required for solution of the Korean situation, a re-evaluationbecame necessary. Using daily G1 strength reports, it was obvious thatour forces were incurring 2.5 WIA per thousand per day. Experience duringthe first 5 weeks indicated that blood had been required at a ratio of0.8 pint/WIA. Applying these factors (fig. 1) to the projected buildupof troop strength in Korea and assuming that gradually increasing militarysuperiority would be reflected in diminishing casualty rates for our troopsin November and December, a peak requirement of 420 pints per day wouldbe required by 30 October. Based on this estimate a request was made forperiodic shipment from the continental United States of that amount inexcess of the 100 pints per day to be procured locally. This local procurementwas continued (fig. 2) in order to provide an easily controlled cushionfor sudden fluctuation in requirements. It also provided the specific typesof blood for hospitals in Japan, since shipment of blood other than groupO from the United States did not seem feasible.
This long-term estimate of blood requirements was subjected to frequentrevision as the variations of military favor and disfavor affected ourtroops. The short-term casualty estimates required for a continuing evaluationof blood requirements are, unfortunately, not a recognized function ofeither Army or theater staffs. An attempt was made to foresee major fluctuationsby daily review of theater G2 and G3 summaries. This was of some valuealthough ultimately dependence was placed on daily reports from the medicalsupply depot in Korea. A sudden request for increased shipments such asfrom 200 to 800 pints daily was met with the 2-day reserve maintained in
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Tokyo plus increased local collections. The increase in shipments fromthe United States could always be expected 48 hours later.
As regards factors concerned with blood related to casualty rates, thereoccurred a gradual increase in this ratio throughout the first 18 monthsof operation (table 1). Exclusive of the early months of the campaign,a sound figure appears to have been 2.4 pints/WIA, three-fourths of thisamount having been supplied to the combat zone, the remaining one-fourthto hospitals in what could be considered the communications zone (Japan).
Supply Shortages Affecting the Blood Program. In any sudden andunexpected conversion of an occupation force to full-scale combat, certainsupply shortages are to be expected. Constant readiness, careful planningand relatively massive stockpiling must be resorted to in order to avoidthis. Critical shortages which affected the local blood program were thoseof disposable transfusion sets, vacuum bottles for blood collection, andpyrogen-free water.
The limited number of disposable recipient sets were reserved for usein field units in Korea. As a result it was possible to see a direct relationshipbetween use of disposable sets and relative freedom from pyrogenic reactions.
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Table 1. Relation of Blood Supply to Woundedin Action in Korean War
Month | Units of blood supplied | Wounded in action | Units per WIA |
July 1950 | 1,036 | 1,872 | 0. 55 |
August | 2,923 | 4,412 | 0. 66 |
September | 7,347 | 10,543 | 0. 69 |
October | 8,240 | 2,678 | 3. 07 |
November | 5,893 | 3,542 | 1. 67 |
December | 9,449 | 6,253 | 1. 52 |
January 1951 | 7,284 | 2,789 | 2. 61 |
February | 11,724 | 4,731 | 2. 48 |
March | 12,217 | 4,834 | 2. 53 |
April | 14,240 | 4,853 | 2. 93 |
May | 15,906 | 4,507 | 3. 53 |
June | 12,834 | 3,436 | 3. 74 |
July | 11,661 | 1,628 | 7. 16 |
August | 9,776 | 1,707 | 5. 72 |
September | 12,438 | 6,539 | 1. 90 |
October | 20,206 | 9,968 | 2. 03 |
November | 14,999 | 2,647 | 5. 67 |
December | 12,335 | 1,147 | 10. 75 |
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This necessary reuse of transfusion apparatus accelerated the developingshortage of pyrogen-free water. Hospitals in Japan were forced to modifystandard procedures (5) using triple-distilled water only as a finalrinse in preparing transfusion equipment. The requirements of the BloodBank for sufficient pyrogen-free water to permit reprocessing of donorsets were met only by continuous 24-hour operation of an improvised triple-distillationsystem (6), furnishing over 1,000 liters of a product meeting USPspecifications (7).
As with distilled water, blood donor bottles were too space-consumingto be supplied from the United States by airlift during this early criticalperiod. Fortunately certain Federal Security Specifications were furnishedby the Preventive Medicine Consultant. Using these as a guide, close technicalsupervision and careful laboratory testing allowed local procurement fromJapanese manufacturers of acceptable blood-collectitig bottles and laterdisposable donor and recipient sets.
Throughout the early period of the war, the only blood substitute availablewas dried plasma. In September 1950 even this item became critical whenthe theater was notified to suspend from issue the available stocks fromtwo major biologic producers. At the same time information was receivedthat plasma-processing capacity in the
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United States would be inadequate to meet theater requirements for atleast 2 months. Hospitals in Japan and Korea were advised to use bloodor other substitute in lieu of plasma wherever feasible. This allowed preservationof precious plasma stores for use by division medical units, but undoubtedlywas a factor in stimulating greater readiness to use whole blood for resuscitation.
Utilization of Blood. As has been mentioned above, supervisionand advice in the use of blood and blood substitutes were lacking. Thismay account for the unbelievably small amounts of plasma and albumin generallyused by medical installations receiving blood. Another possible exampleof the desirability of closer supervision of the program became apparentin the disappearance in 1951 of a reasonable relationship between bloodrequisitions and numbers of casualties. The answer was found related tothe psychology of preparedness. The soldier who has used his tenth grenadeon a combat patrol will not willingly carry a lesser number on his nextforay. Similarly, the
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hospital commander who has seen 100 pints of blood consumed in a singleinflux of battle casualties will not decrease his high level of blood onhand until assured active combat has definitely subsided and will not suddenlyreappear. Likewise at a theater level there is always realization thatexcess amounts of blood are undesirable, but inadequate amounts are disastrous.
It is felt only proper to state that a survey conducted in the closingmonths of 1951 showed that in the first 18 months of the Korean War onlytwo-thirds of blood supplied was actually used in our hospitals in bothJapan and Korea.
These facts naturally lead to the problem of disposal of outdated blood.Proposals which were considered were: (a) an additional laboratory unitfor a fractionation program, (b) development of Japanese facilities forlocal fractionation on a contract basis, and (c) return of outdated bloodto the Zone of Interior for fractionation. Each of these proposals wascarefully evaluated before rejection. Of necessity, and realizing the dangerof adverse publicity, circumspect methods of destruction were utilized.Coincidentally a cautious education of the unduly curious was begun. Later,all blood which had passed the 21-day expiration date was turned over toKorean medical authorities who maintained it was quite satisfactory foruse. This is not particularly suggested as a pattern for the future, however.
Summary
1. A brief historical account is given of the development of a bloodprogram for a combat theater of limited size.
2. A method is described for planning blood requirements, but it shouldbe remembered that the factors derived may not pertain to other situations.
3. It is suggested that the amount of blood used is possibly more thannecessary or available in a military situation of larger scope.
4. The need is stated for a full-time director of a theater blood programwho also could serve as an active consultant on the use of blood and bloodsubstitutes.
References
1. Kilduffe, R., A., and DeBakey, M.: The Blood Bank andthe Technique and Therapeutics of Transfusions. C. V. Mosby Company, St.Louis, 1942.
2. Strumia, M. M., and McGraw, J. J.: Blood and PlasmaTransfusions. F. A. Davis Company, Philadelphia, 1949.
3. DeGowin, E. L., Hardin, R. C., and Alsever, J. B.:Blood Transfusion. W. B. Saunders Company, Philadelphia, 1949.
4. Mason, J. P.: Planning for the ETO Blood Bank. MilitarySurgeon 102: 460 (June), 1948.
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5. TB Med 204: Complications of Blood Transfusion. Departmentof Army Technical Bulletin, Washington, D.C., 24 October 1945.
6. Cook, F. E., et al.: Remington's Practice ofPharmacology, 8th Edition, pp. 1651-1652, 1942.
7. Pharmacopeia of the United States, 13th Revision, pp.606-607, 1947.
