CHAPTER IX
The Military Blood Program
Time is crucial in the collection, delivery, and distribution of whole bloodfor large numbers of traumatic casualties. From 1965 forward, the stimulusbehind the plans for a whole blood distribution program to support U.S. forcesin the war in Vietnam was the need for speed. Blood is perishable, and itsuseful life is short. From donor to patient, liquified whole blood has a lifeexpectancy of 21 days. Still, the most desirable blood for transfusion is thefreshest blood available of the group and type specific for the recipient,completely and accurately processed and cross matched-a combination ofperfections difficult to achieve in war.
Evolution of the System
The dominant conviction of the early blood program planners in USARPAC andUSARV was that whole blood requires professional surveillance in handling fromthe moment it is drawn from the donor until the moment it is administered to thepatient. Contaminated blood can be lethal.
By 1965 and the buildup of forces in Vietnam, the time had come to move withhaste. Fortunately for the planners, requirements for whole blood increasedslowly in 1965 and not with the same explosive force experienced at thebeginning of the Korean War. Another asset was the substantial number ofdirectives and guides already written and the existence of the Military BloodProgram Agency.
Colonel Neel, Surgeon, USMACV, Major (later Colonel) Frank W. Kiel, MC,Commanding Officer, 406th Mobile Medical Laboratory, Vietnam, and Colonel JosephF. Metzger, MC, Commanding Officer, 406th Medical Laboratory, Japan, in late1965, were guided by three major principles based on experience gained thus farin the collection, processing, handling, and distribution of blood for troops inVietnam. These medical officers, however, could not envision that requirementsfor whole blood would climb slowly but steadily from less than 100 units permonth in 1965 to 8,000 units by February 1966, skyrocket to more than 30,000units per month by 1968, peak at 38,000 units in February 1969, and fall rapidlyto less than 15,000 units by mid-1970. (Chart 12)
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CHART 12-UNITS OF BLOOD AVAILABLE IN SOUTH VIETNAM, BYMONTH,
JANUARY 1965-DECEMBER 19701
The first guiding principle was that a source of whole blood outside Vietnamand the Pacific Command was essential. Donor resources in the Pacific could notmeet the demands for whole blood during the buildup. Second was theestablishment of a central depot in Saigon where all whole blood shipped fromJapan could be received, transshipped, and distributed for use in the field.Third was the need for a system of forward mobile blood storage subdepotsoperated by the Army and colocated with hospitals and medical units in the Army,Navy, and Air Force along the South Vietnam coast.
A single American hospital in Vietnam, the 8th Field Hospital, administeredall whole blood transfusions until the spring of 1965. Every 10 days, 10 unitsof universal donor low titer group O blood were shipped to the hospital fromJapan to meet the small demand for transfusions. Seldom did the demand for bloodexceed the supply, and even during the surprise attacks by the Vietcong at QuiNhon and Pleiku, in February 1965, the 406th Mobile Medical Laboratory bledlocal donors to supply the needed 123 units of whole blood. After the 3d FieldHospital arrived in Saigon in May 1965, it became the central blood depot inVietnam, and the 406th Mobile Medical Laboratory, a satellite of the 406thMedical Laboratory in Japan, was charged with distributing whole blood to allU.S. forces in Vietnam.
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In the meantime, with the expanding need for blood, reorganization of thewhole blood program for PACOM (Pacific Command) was underway. Colonel Metzgerwas also designated Blood Program Officer, PACOM, with direct responsibility toCINCUSARPAC (Commander in Chief, U.S. Army, Pacific) for the co-ordination andintegration of plans, policies, and procedures to insure blood for all areas inUSARPAC, including USARV.
The embryonic whole blood distribution system in Vietnam continued to expandand by 1967 was serving all Free World forces in Vietnam, excluding the RVN Armywhich met its own blood needs. The responsibility for supervising and operatingthe central blood bank in Vietnam came under the technical direction of ColonelHinton J. Baker, MC, Commanding Officer, 9th Medical Laboratory, 3d FieldHospital, Saigon. The USARV Central Blood Bank operated under the parentlaboratory's 9th Medical Laboratory Detachment and was supported by personnelfrom the 3d and 51st Field Hospitals, and five subdepots in the blooddistribution system: the 406th, 528th, and 946th Mobile Medical Laboratories atNha Trang, Qui Nhon, and Long Binh, respectively; the Naval Support ActivityHospital, Da Nang; and the 96th Evacuation Hospital, Vung Tau.
As troop strength grew and combat casualties increased, the task ofdistributing whole blood, plasma, and related products in South Vietnamdeveloped into the largest blood distribution system ever undertaken by a singleorganization.
Colonel James E. McCarty, MC, became Blood Program Officer, PACOM, in June1968 and commander of the 406th in Japan at the same time. He and hispredecessor, Colonel Metzger, visited South Vietnam regularly, conferred withthe surgeon, and inspected blood facilities throughout the country.
Initial Sources of Whole Blood
The primary source for whole blood used in South Vietnam until July 1966 wasthe 406th Medical Laboratory in Japan. Mobile bleeding teams were dispatchedfrom the laboratory to donor resources in Japan, Korea, Okinawa, and Taiwan. Avery valuable donor resource was found in the Yokosuka Naval Base when thePacific fleet came in, and reserve donor resources also existed in Hawaii, Guam,and the Philippines. With vigorous command support and the dedicated work ofblood-drawing teams, supply kept pace with demand until June 1966. Bloodcollections in PACOM rose from 201 units in January 1965 to 7,426 in January1966 and 12,984 in June 1966.
Blood collected in PACOM was processed and shipped from the 406th in Japan tolarge troop concentrations along the coast of South
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Vietnam at Saigon, Nha Trang, Qui Nhon, and Da Nang. By 1965, it was apparentthat this plan would not work because aircraft could not be scheduledeconomically from Japan to each of the four areas regularly enough to keep thesupply levels of blood at the proper level. Communications between Japan and thecoastal cities were poor, and shipments of blood often arrived in Vietnamwithout the knowledge of those persons handling it. Planners had also becomesharply aware that blood could not be handled as a routine supply item even in adedicated medical supply system.
In short, by 1965 it was clear in PACOM that the whole blood distributionsystem should consist of a central depot in Saigon with several small mobilesubdepots located in areas of high troop intensity.
Agencies for Expansion of Blood Supply
The Military Blood Program Agency
In June 1966, the need for whole blood in Vietnam became urgent. Blood donorresources in PACOM had been exceeded, and the blood program officer estimatedthat 1,000 units of low titer group O blood per week would be needed.CINCUSARPAC sent a request to the MBPA (Military Blood Program Agency) to shipthe needed blood to the 406th.
Four years earlier, in May 1962, responsibility for implementing and co-ordinatingthe whole blood program in CONUS was delegated to the Secretary of the Army bythe Secretary of Defense. Hence, The Surgeon General of the Army established theMBPA on 17 July 1962 to support emergency requirements for whole blood in war.The agency, staffed by medical officers of the three services, maintained closeworking relationships with the U.S. Public Health Service, the Office ofEmergency Planning, Executive Office of the President, and the American RedCross.
Armed Services Whole Blood Processing Laboratory
The MBPA incorporated the donor collection and processing capabilities of thethree military departments. Blood was collected by 42 donor centers designatedby The Surgeons General of the Army, Navy, and Air Force and shipped by air tothe triservice ASWBPL (Armed Services Whole Blood Processing Laboratory),McGuire Air Force Base. (Chart 13) All group O blood was titered, andafter a thorough inspection and verification of groups, Rh types, and otheressentials, blood was flown via Elmendorf Air Force Base, Alaska, to Yokota AirForce Base in Japan. At each point, shipments were re-iced, if necessary, andflown to the 406th Medical Laboratory in Japan. From Japan, whole blood was
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flown to the 9th Medical Laboratory, Saigon, and distributed from there tosubdepots in South Vietnam.
The first shipment of whole blood, 2,036 units, arrived in Japan from theUnited States in July 1966.
From July 1966 to 1967, two shipments of 1,500 to 2,500 units of whole bloodwere received from CONUS each week. To boost blood needs, Colonel Metzgerrecommended in 1967 that daily shipments to total 5,000 units each week be madefrom CONUS to arrive in Japan early in the morning, from Mondays throughFridays. Daily shipments began in mid-August 1967. The total number of units ofblood collected and shipped to Vietnam are shown in Table 9.
TABLE 9.-NUMBER OF UNITS OF BLOOD COLLECTED AND SHIPPED, BYYEAR, TO THE CENTRAL BLOOD BANK IN VIETNAM BY THE 406TH MEDICAL LABORATORY, U.S.ARMY, JAPAN
| Year | Units collected1 | Units shipped |
|
|
| |
1966 | 130,308 | 115,869 |
1967 | 222,534 | 213,022 |
1968 | 399,724 | 351,519 |
1969 | 385,883 | 348,409 |
19702 | 73,109 | 59,175 |
|
|
|
|
1The total figures for each year include bloodshipped to the 406th Medical Laboratory in Japan by CONUS and that collected inPACOM by the 406th.
2Excludes blood collected and shipped in December 1970. Decemberstatistics were not available.
Source: Report, Administrative Division, 406th Medical Laboratory, USAMC,Japan, 1970.
From 1969, whole blood was flown by MATS C-141 Starlifter to Japan. Thisblood, plus fresh frozen plasma and whole blood obtained by the 406th, was flownby commercial airline to the USARV Central Blood Bank in Saigon and after June1969 to Cam Ranh Bay, the new location of the blood bank. (Map 5) Bloodwas approximately 7 days old by this time. Most of it went forward by C-130fixed wing aircraft to one of the six subdepots at Long Binh, Nha Trang, QuiNhon, Pleiku, Chu Lai, and Da Nang. From these subdepots, blood of all types andfresh frozen plasma were sent by fixed wing aircraft, helicopter, or ambulanceto the various field, evacuation, and surgical hospitals. Low titer group
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O positive blood was shipped from the subdepots to division clearing stationsby helicopter.
The Department of Defense, and thus MBPA, felt that blood quotas should beassigned according to available donor resources. The military departmentsoriginally felt that quotas should be assigned according to
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An Overview of the New Central Blood Bank atCam Ranh Bay, June 1969
their blood requirements. Fortunately, this problem was resolved early andessentially the following distribution prevailed:
|
Relocation of the Central Blood Bank
After the Tet Offensive in 1968, military officials feared that another suchoffensive would interrupt the supply of blood from the USARV Central Blood Bankin Saigon, or that the airfield at Tan Son Nhut might be seized. Plans wereinitiated to construct a new central blood bank at Cam Ranh Bay on the groundsof the 6th Convalescent Center. The new laboratory was completed in June 1969and the USARV Central Blood Bank moved there in July 1969.
The building, with 1,000 square feet of laboratory floor space and 600 squarefeet of cement under cover, accommodated a 1,800 cubic foot walk-inrefrigerator. The neat new structure was considered to be in a more secure areaat Cam Ranh Bay than in Saigon, and air transportation from Japan was readilyavailable. (See Map 5.) Maximum flexibility was achieved by therelocation of the central blood bank. The
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3d Field Hospital, redesignated a subdepot, could quickly revert to a centralblood bank if an emergency arose, and the subdepot at Da Nang, after expansion,was fully capable of serving as a central blood bank.
Group and Type-Specific Blood
In early 1965, it was decided that only universal donor low titer group Oblood would be shipped to Vietnam, and that the use of group and type-specificblood would be confined to the offshore hospitals in Japan and in thePhilippines. The great advantage of universal donor blood is that it isimpossible to give a patient the wrong group of blood. As the requirements forblood increased, and as hospitals in Vietnam became more sophisticated, bloodprogram officials decided to utilize fully the available donor population. Lessthan 45 percent of the donor population had group O low titer blood, and 55percent of the donor population was not being bled.
The first shipments of group A blood arrived in Vietnam in December 1965, andshipments with random blood group distribution, groups A, AB, B, and O, withoutselection, arrived in January 1966. The clearing companies and forward surgicalhospitals continued to use only group O low titer blood because they could notcross match, but evacuation hospitals began to give other type-specifictransfusions almost exclusively.
Unfortunately, random shipments resulted in excessive amounts of group Ablood in the depots in Vietnam. With the institution of shipments from CONUS byMBPA in July 1966, the numbers of units of universal donor group O low titerblood shipped to Vietnam increased, and by 1967, shipments exceeded requirementsby 65 percent. As more and more Vietnamese were cared for in U.S. militaryhospitals, with the Vietnamization of the combat role, a new problem with bloodgroup distribution arose. The requirements for group B increased in proportionto the number of Vietnamese admitted to American military hospitals. Theapproximate percentage blood group distribution for American and Vietnamesepopulations in the following tabulation readily show that Vietnamese requiredmore group B blood:
| Specific blood types | |||
| A | AB | B | O | |
American troops..percent.. | 39 | 3 | 14 | 44 |
Vietnamese troops..percent.. | 21 | 6 | 31 | 42 |
Transfusion Reactions
Hemolytic and Nonhemolytic Transfusion Reactions
Between March 1967 and June 1969, approximately 364,900 transfusions wererecorded. During that period, 38 hemolytic and 979 nonhemolytic transfusionreactions were reported, or about 1 hemolytic,
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transfusion reaction per 9,600 transfusions and one nonhemolytic reaction per370 transfusions. Causes of the nonhemolytic reactions are unknown and whilethey never threatened life, these reactions were considered detrimental to thewell-being of the severely wounded patient. The cause of these reactions isexceedingly complex, and much research is needed in this neglected field.
The Coagulopathies
Bleeding problems, called variously the oozing syndrome, tomato juicesyndrome, or red ink syndrome, were frightening to the most experienced battlesurgeon. To see a patient suddenly begin to bleed profusely from every orificeand wound just as heroic surgery appeared to be successful was a dramaticexperience.
Coagulopathies may be divided into two groups, if it is remembered that thedivision is an oversimplification. Since coagulopathies usually occur incombinations and rarely in the pure form, study under field conditions is almostimpossible. Coagulopathies that respond well to fresh blood are attributed todeficiencies of platelets or deficiencies of coagulation principles other thanplatelets. The latter principles respond well to fresh frozen plasma or freshblood. Coagulopathies that do not respond well to fresh blood may be attributedto circulating anticoagulants, disseminated intravascular coagulation, orcirculating intravascular fibrinolysins.
While physicians generally recognized the classification of coagulopathies,there was little agreement about the proper treatment. One group of physicianstreated all coagulation problems with fresh blood while others differentiatedthe various syndromes and used more specific treatments, such as fresh blood,fresh frozen plasma, cortisone, heparin, epsilon, aminocaproic acid-or prayer.Fortunately the number of patients suffering from coagulation problems wassmall, but the threat after massive transfusions and surgery was ever present.
Fresh Frozen Plasma
In April, 1968, fresh frozen plasma was introduced in Vietnam as a means forcontrolling coagulopathies following surgery and massive transfusions. Theavailability of fresh frozen plasma resulted in a decrease in the quantity offresh whole blood drawn in Vietnam. Fresh plasma is obtained at the 406thMedical Laboratory in Japan by the process of plasmapheresis from a limitedgroup of donors of the AB group-the ideal donors for fresh plasma. Thesedonors may be bled every week or every other week. Blood from them is spun down,plasma rises to the top, and red cells settle at the bottom. While plasma isdrawn off in satellite bags and frozen immediately, red cells are returned tothe donor.
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A 2.5-Cubic Foot Freezer in Which Fresh FrozenPlasma is Stored
Since plasma proteins are replenished rapidly, each donor may contribute 2units weekly for as long as 2 years without effects.
Donors in the AB group have no isoantibodies in their plasma and it may begiven to patients of any blood type-a real breakthrough.
Wastage of Blood
The amount of whole blood outdated because it was not used in 21 days wasfrequently significant and occasionally, during lulls in the fighting, reached50 percent of the blood in Vietnam per month. The average amount of outdatingwas approximately 29 percent with extremes of 9 percent and 50 percent.
Use of whole blood was best during periods of greatest military activity.While much speculation and discussion transpired about this significant problem,the simple facts are that blood was usually from 4 to 7 days old before itarrived in Vietnam. Outdating was difficult to eliminate because fillingrequisitions instantly for subdepots throughout Vietnam was impossible. Somewaste of blood was the price that h ad to be paid to assure that not one fightingman would die for the want of blood.
Most blood 21 to 31 days old was shipped to ARVN hospitals for local use andfor Free World forces if they desired it. During the early days of the buildup,31-day-old blood was destroyed, but as the war progressed, blood was convertedto plasma lyophilized by the vacuum system.
Technical Research and Innovations
Lengthening the Life of Blood
Efforts were constantly made to extend the shelf life of blood. One of themost promising was the addition of small amounts of the amino acid adenine whichincreased the shelf life of whole blood to 40 days. Blood with such an additivewas tried on a limited basis in Vietnam during 1969. The blood was transfused topatients admitted to the hospitals at Long Binh, and no adverse effects werefound in numbers of clinical tests. As soon as the oxygen-carrying capacity ofadenine-treated red cells can be improved, adenine may well be added to allunits of
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liquid preserved blood used in combat military blood banking. Experimentsindicate that the oxygen-carrying capacity of treated red cells may be increasedby adding small amounts of inosine.
Freezers for Fresh Frozen Plasma
The freezing compartment of an ordinary refrigerator is not cold enough tokeep fresh frozen plasma for more than a week or two. Factor V, the mostcritical of all clotting factors, is present in the plasma, and it deterioratesslowly at temperatures above -20?C. A small freezer, used by constructionengineers to cool steel rivets, was ideal for storing fresh frozen plasma. Steelrivets contract when cooled and expand to give a snug fit as they warm up. Afterdiligent searching, enough of these freezers were found for all hospitals inVietnam. By July 1969, a newly designed 4-cubic foot freezer, similar to theconstruction engineer's freezer, was issued in Vietnam.
The Styrofoam Blood Box
While the war in South Vietnam will be remembered by most military men as thewar in which air mobility came of age, it will be remembered by many people,both Vietnamese and American, as the war of the white styrofoam blood box. Thestyrofoam blood box was introduced in late 1965 and was without question one ofthe most important technical advancements to come out of the blood distributionprogram. Major William S. Collins II, director of the blood bank at the 406thMedical Laboratory, suggested modifying the standard disposable blood box byreplacing the cardboard divide insert with a styrofoam insert which he haddevised. The new insert, when placed in a cardboard shipping container,permitted shipment of blood at the required temperature regardless of outsidetemperatures. The shipping container is easier to handle and was lesssusceptible to damage or destruction. Major Collins received $935 for hissuggestion, and his innovation resulted in a first-year savings of $56,000 and anew flexibility in military blood banking.
The Collins box, which occupies only 3 cubic feet and weighs only 40 poundswhen filled with 18 units of whole blood and wet ice, replaced the Hollinger box which occupies 8 cubic feet and weighs 115 pounds when filled with 24 unitsof blood and wet ice. In addition to weighing less, the Collins box offers otherequally important advantages: it costs only $1.40, or $98.60 less than the $100Hollinger box; it is expendable and does not have to be returned through thesystem to Japan. The Collins box maintains an adequate ice level for 48 hours,twice as long as the Hollinger box. The castoff Collins styrofoam blood boxeswere
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grabbed by American servicemen and Vietnamese civilians to be used as privateiceboxes in hot and dusty Vietnam.
Significant Problems
Wet icemaking machines used to manufacture ice for blood shipments plaguedtheir users at all blood depots with maintenance problems. Research to resolvethe problem was started by the USARV blood program officer.
Another significant question concerned how much universal donor group O lowtiter whole blood could be given to a casualty before he would have a reactionto his hereditary specific type and group. At least one important experiment wasdone at Walter Reed Army Medical Center on a small group of men who had receivedfrom 21 to 44 units of universal donor group O blood, but results wereinconclusive.
The Donor System
For the first time in U.S. military history, every unit of whole blood usedto support the war was donated free of charge by military personnel, theirdependents, and civilians employed at military installations.
Donors were not motivated by profit. No high-pressure advertising programswere permitted, yet nearly a million and a half volunteers gave blood. Not oncewas it necessary to initiate contracts for blood to be supplied by the AmericanRed Cross or the American Association of Blood Banks. Even in the most difficulttimes, when blood requirements reached 38,000 units a month, the civilian bloodcollection system was not upset by the additional military requirements tosupport an ongoing war.
Most of the credit for donor recruitment must go to the young officers andthe sergeants. These dedicated individuals instilled such confidence in theirmen that the fear of giving blood and the social pressures against the war wereovercome.
