CHAPTER VIII
Transportation and Refrigeration
PRELIMINARY SPECIFICATIONS
The question of how blood should be transported andrefrigerated came up early in the blood-plasma program. At a meeting of theSubcommittee on Blood Procurement on 18 August 1941 (1), it was formallyrecommended that the bottles of blood be precooled with Dry Ice before they wereshipped and should be shipped under thermostatically controlled temperatures,well below 50? F. (10? C.). Rous and Turner (2) had shown in 1916 thatthe rate of hemolysis was much greater when blood was stored at 68? F. (20?C.) rather than at 41? F. (5? C.). The lower temperature was, of course, asimportant as the upper. Later, when metabolic processes were more clearlyunderstood, it was realized that the metabolism of the red blood cells wasreduced at a lower temperature and that they therefore needed less nourishment,which meant that the nutrition supplied by the dextrose in preservativesolutions was more fully utilized.
In a discussion of refrigeration for the transportation ofblood at the December 1943 meeting of the American Society of RefrigeratingEngineers (3)-when movement of blood by air had begun to be considered-thefollowing points were made:
1. Whole blood, to be useful and safe, must be maintained ata constant temperature of about 39? to 43? F. (4? to 6? C.).
2. This is not a problem in most hospital units since, whenthey are operational, electric current is available for refrigeration. Theproblem arises when blood must be transported.
3. One of the requirements, therefore, in a refrigerator usedfor blood for military purposes is a compressor capable of maintaining thetemperatures just specified when the refrigerator is in transportation as wellas when it is plugged into regular power outlets. This requirement means thatany refrigerator which is used must be capable of operation from a smallgenerator which can develop one-third to one-half kilowatt of power and can alsoprovide 110-volt, 60-cycle alternating current.
4. The refrigerator selected must be sturdy and wellinsulated, so that the temperature in it will remain at the desired level whenit is used in climates in which the ambient temperature may rise to 130? F.(54? C.). The cabinet must be about 3.5 to 4 cu. ft., to accommodate 40-50bottles of blood. Because of the weight limitation on cargo for planes, even ofthe largest type, it is desirable that the box should not weigh over 80 pounds.
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A refrigerator which met these specifications for the airtransport of blood was not developed by the Army during World War II (p. 208).The program for providing whole blood for oversea theaters did not become acomplete reality, however, until, in addition to the development of equipmentfor collecting and administering blood, means of refrigeration had beendeveloped for its storage and preservation during the airlift (p. 214).
TRANSPORTATION IN THE ZONE OF INTERIOR
Railway Shipments
The original arrangements were that blood should be shippedfrom Red Cross donor centers in various cities to the processing laboratories bythe Railway Express Agency, Inc., in Church containers (4). Theserefrigerated containers (fig. 55) had been devised by Maj. Elihu Church,president of the Church Co., for food. From the standpoint of safetransportation and refrigeration, they proved admirably adapted for the railtransportation of blood in the Zone of Interior. They had certain disadvantages,however, including their cost, their excessive weight, and their limited number.
By March 1943 (4), shortages of Church containers hadbecome critical. Schedules of shipment of the containers between laboratoriesand centers were not being maintained, especially on the east and west coasts,even though more than 300 of the 450 Church containers then in use had beenassigned to the blood-plasma program. The Red Cross considered it essential thata pool sufficient for at least one day's supply of blood be maintained at eachdonor center.
Action was taken to improve the situation at a meeting in themain (New York City) office of the Railway Express Agency on 5 March 1943,attended by the chief of the eastern division of the agency; Major Church; Dr.(later Major, MC) Earl S. Taylor, representing the American Red Cross; and Col.Charles F. Shook, MC, representing The Surgeon General. All district managers ofthe agency were informed of the urgency of the situation and were instructed togive first priority to blood shipments and to expedite the return of emptycontainers. Arrangements were also made to expedite the repair of damagedcontainers.
At this time, 100 additional containers were in process ofmanufacture. Later, the shortage of containers was called to the attention of arepresentative of the War Production Board, with special emphasis on the urgentnecessity of refrigeration of the blood, particularly during long hauls.
By the end of 1943, all but 37 of all the Church containersin the country were being used by the American Red Cross. By the middle of 1944,enough were available to transport all the bloods being procured each week.Adequate reserves were maintained at strategic points, and repair parts werealso in adequate supply.
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An article published in the General Electric News wasintended to stimulate the interest of the workmen making the Church containersby explaining their own vital role in the blood-plasma program. Major Church hadreprints of the article made for distribution to all employees of the RailwayExpress Agency who had any connection with the shipments of blood from thecenters to the processing laboratories.
Truck Shipments
In June 1944, Dr. Milton V. Veldee complained to Maj.Frederic N. Schwartz, MAC, in the Office of The Surgeon General, and to Dr. G.Canby Robinson and Major Taylor of the American Red Cross that blood was beingshipped from certain donor centers to the processing laboratories by truck
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instead of by Railway Express and sometimes had to be icedtwo and three times along the way (5). The laboratories had complained ofthe arrangement and Dr. Veldee objected to it on several grounds:
1. A great deal of experimentation had goneinto the development of the Church container, which had proved, on the whole,very acceptable for both summer and winter shipments. Before any newarrangements could be accepted, it would be necessary to study the physicalcondition of the blood shipped under them in all weather conditions, which wouldrequire at least a year. Meantime, the National Institute of Healthspecifications, which had been somewhat liberalized since the start of theprogram, must be observed.
2. The Red Cross should not lend itself toscrapping a well organized and smoothly functioning service in favor of a newand untried method, which involved factors with such high war priorities andcritical shortages as gasoline, trucking equipment, and manpower.
3. While there was probably no legal,contractual reason why the Red Cross should not cancel its agreement with theAmerican Railway Express Agency, Inc. and the Church Co., both had givensplendid cooperation.
As a result of Dr. Veldee's protest, all blood donorcenters reverted to the original arrangements for transportation andrefrigeration, and they remained in effect until the end of the war.
Refrigeration in the Zone of Interior of blood designed forthe oversea airlift is discussed under that heading.
STATUS OF REFRIGERATION, 1943-AUGUST 1944
Airlift Requirements
After attending a conference in the Aero-Medical Laboratory atWright Field, Dayton, Ohio, on 25 October 1943, Maj. (later Col.) Douglas B.Kendrick, MC, recommended (6) that a refrigerator developed by theAirtemp Division, Chrysler Corp., Dayton, Ohio, for the transportation of frozenbiologicals in airplanes be modified for the similar transportation of blood(fig. 56). The Chrysler representatives did not think it would be possible tomake the refrigerator specified by the Medical Department (1 cu. ft., 80 lb.),and an attempt at development would take 4-6 months. The Chrysler box wasalready in production. No action had been taken on Colonel Kendrick'srecommendation when the airlift to Europe began in August 1944.
Field Requirements
Standard refrigeration was satisfactory for the storage ofblood in hospitals and was part of authorized equipment. A refrigerator for usein the field, however, had to be operated by a gasoline generator as well as bythe usual power outlets, to provide for the time it was being transported intrucks. The Division of Surgical Physiology, Army Medical School, working inconjunction with Mills Industries, Inc., Chicago, developed an electricrefrigerator of 4-cu. ft. capacity, which held 50 bottles of blood. It operatedon 110-volt,
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FIGURE 56.-Lightweight aluminum refrigerator(Chrysler) developed by the Army Air Forces. A. Refrigerator open. B.Refrigerator closed. C. Compressor.
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60-cycle A.C. current supplied by the usual power outlets orby a 750-watt (1 hp.) generator.
On 23 November 1943, Mills Industries was given a letter ofintent for the purchase of this whole blood cabinet, to be delivered within 4weeks (7). On 25 May 1944, in response to a letter from the Director,Technical Division, Office of The Surgeon General, Colonel Kendrick (8) recommendedthat this refrigerator (with other transfusion equipment) be standardized. Therecommendation was approved, but at this time, less than 2 weeks before D-day,only a prototype existed. This box was later produced in quantity and is still(1962) in use.
THE AIRLIFT TO THE EUROPEAN THEATER
The Decision to Fly Blood Unrefrigerated in Flight
When the airlift of blood to the European theater ceased to beacademic in August 1944 and became a matter of extreme urgency, two matters hadto be settled immediately. The first was the preservative solution to be used(p. 224). The second was the possible risk of flying blood, even if refrigeratedagain immediately before enplanement and refrigerated immediately afterdeplanement, without refrigeration in transit. One problem was intimatelyrelated to the other.
At this time, no action had been taken on the Chryslerrefrigerator recommended in November 1943 for use in transportation of blood inplanes (6). The Division of Surgical Physiology, Army Medical School, hadbeen working with Engineers' Development Laboratory, Armed Services MedicalProcurement Agency, Fort Totten, N.Y., on a fiberboard container for thispurpose, but it was not ready for use. It is hard to explain why, long after anefficient insulated box was in use in the Mediterranean theater (p. 417), andlong after blood was being flown to the Pacific Ocean Areas by the Navy in anefficient insulated box (p. 213), the Army was flying blood to Europe withoutrefrigeration. Furthermore, the Navy was using ACD (acid-citrate-dextrose)solution as a preservative, which materially reduced the space occupied by eachbottle, while the Army was still using Alsever's solution, which was not soeffective a preservative and which required considerably more space for eachbottle.
When the question of flying blood to Europe came up in August1944 (about 8 months after the proposal had previously been rejected (p.465)), those responsible for the blood program in the Zone of Interior werefaced with an extremely difficult decision: Would the urgent need for wholeblood in the European theater be more adequately met by sending 450 pints ofblood daily under refrigeration, or by sending 900 pints daily withoutrefrigeration during the flight period of transportation? Military necessityoften forces undesirable compromises, and here there was never any question thatthe wiser decision was to send the larger amounts.
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It is easy to say, long after the end of the war, that thedecision should never have had to be made. That is entirely true. On the otherhand, the plan was not adopted either recklessly or hastily. There was ampleevidence to support the belief that while lack of refrigeration in flight was anundesirable alternative, it was a perfectly safe plan (p. 211). If 600-cc.bottles had been available and if ACD solution had been approved then, the planemployed would not have been adopted. At the time, however, it was the onlyreasonable solution, and it was safe within the framework of the methodsemployed.
There was no question in the minds of those who had to makethe decisions that (1) fresh blood was best for wounded casualties and (2) thatblood kept under refrigeration at every stage until it was used was moredesirable than blood not constantly under refrigeration. A condition, however,not a theory, was confronting those responsible for getting the blood to Europe,and their decision was:
1. That if blood were put in Alsever's solution and werekept refrigerated until it was placed aboard the plane, it could safely be flownacross the ocean unrefrigerated during the 16-24 hours, or sometimes longer,taken for the flight.
2. That if the blood were then replaced under refrigeration,it could be safely used for 21 days from the date of collection. Later, afterthe program had become so efficient that the blood became available in Europewithin 4-6 days after it had been collected, or even earlier, this interval wasreduced to 18 days.
Objections to the Plan
At a conference held in the Office of The Surgeon General on15 August (9) and attended by Col. (later Brig. Gen.) Elliott C. Cutler,MC, Col. William F. MacFee, MC, 2d Evacuation Hospital, and Maj. Robert C.Hardin, MC, these officers stated that they considered sending blood overseaswithout refrigeration an unsafe practice, which they were unwilling to accept.They were given the following explanation of, and justification for, the plan:
1. The blood would be delivered in 1,000-cc. bottlescontaining 500 cc. of blood and 500 cc. of Alsever's solution. The bottleswould be refrigerated before and immediately after the blood was collected andwould remain under refrigeration until they were placed on board the plane. Theywould be refrigerated at Prestwick, shipped by air to the Continent inrefrigerated cans, refrigerated again at the blood depot, and then delivered toforward areas in refrigerated cans. Thus, the only time the blood would not beunder refrigeration would be during the Atlantic crossing.
2. Blood collected in Alsever's solution had been shippedwithout refrigeration from the Army Medical School to Prestwick and back to theschool; there, tests showed that the supernatant plasma contained no more than28 mg. of hemoglobin per 100 cc. Blood in the same solution had been shippedunrefrigerated to Bermuda, Los Angeles, and Hawaii and had been offrefrigeration for as long as 5 days. At the end of this period, the supernatantplasma
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contained no more than 25 mg. of hemoglobin per 100 cc. Noreactions of any kind had followed transfusions with this blood on threeseparate patients.
3. When blood collected in Alsever's solution and kept offrefrigeration for periods ranging up to 72 hours was tested for hemolyticchange, it was found that it could be stored safely for up to 8 days, againstsafe periods of 21 days with refrigeration.1
4. For the past year, liquid plasma prepared at the BloodResearch Division, Army Medical School, had been obtained from unrefrigeratedblood, kept at room temperatures, 70? to 90? F. (21? to 32? C.). When theunrefrigerated red blood cells, which were resuspended in isotonic sodiumchloride solution, were used after 5 days' storage, the reaction rate wascomparable to, or lower than, the rate after transfusion with refrigerated redblood cells. The increase in the recipient's red blood cell count andhemoglobin level was also comparable to the increase observed after the use ofrefrigerated red blood cells.
5. Although it was granted that proof of safety would beobtained only after actual experience with large amounts of blood, the proposalto fly blood unrefrigerated to Europe during flight was considered safe becausethe only difference between using unrefrigerated blood and red cells in the Zoneof Interior and using them abroad would seem to be the conditions to which theblood would be subjected during flight.
Other Studies on Refrigeration
Numerous studies made before the war, particularly at theState University of Iowa (p. 220), on the effects of refrigeration on blood havebeen mentioned in other connections. One or two other studies might be cited:
Bushby and his associates (10) studied storage ofblood at various temperature levels. They showed that rapid cooling of the bloodimmediately after collection was not harmful but that undue delay inrefrigeration (up to 24 hours) had deleterious effects; that cooling to 32? F.(0? C.) for 2 days before storage at 39? F. (4? C.) did no harm, nor didwarming to room temperature after 4 days' storage at this level; and that itwas apparently safe to remove a bottle of blood from the refrigerator, let itwarm, and then store it again.
At the Conference on Blood Preservation on 19 January 1945 (11),when blood was already being flown to Europe without refrigeration en route,Dr. J. G. Gibson, 2d, reported observations on 10 blood specimens shipped by airunder refrigeration. The amount of free hemoglobin in the plasma was 8-13 mg.percent, and survival of the red cells after transfusion was excellent. Incontrast, blood shipped by plane to Paris and return, without refrigerationeither way, was found greatly deteriorated; it had been 11 days in transit.
1It should be emphasized that these tests were made simply to determine the theoretic safety of keeping blood unrefrigerated for certain periods of time if logistic restrictions proved overriding and it became necessary to use this method. It was clearly understood, by all concerned with the program, that blood should be kept at a constant temperature.
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At this same conference, Lt. Cdr. Eugene L. Lozner, MC, USN,reported observations on transfusions carried out with blood collected in ACDsolution in Washington and on the west coast, shipped to Guam in Navyrefrigerated boxes, and then shipped back to the Naval Medical School inWashington. Filtration through the recipient apparatus was good. Blood in whichless than 2 percent of the red cells were hemolyzed produced no untowardreactions. Recipients who were given blood more than 28 days old showedbilirubinemia but no hemoglobinemia.
STUDIES ON UNREFRIGERATED BLOOD FLOWN TO THE EUROPEANTHEATER
Numerous studies were made on blood flown unrefrigerated acrossthe Atlantic, beginning with samples from the first shipments (12). Testsat the blood bank at Salisbury showed that the fragility of the red blood cellsand the amount of free hemoglobin released compared very favorably with the sametests on blood collected in the European theater.
Temperatures on the transocean flight-A formal test onthe temperatures of blood in transit without refrigeration was made in January1945 by Capt. John Elliott, SnC, Assistant in the Division of SurgicalPhysiology, Army Medical School. He reported to Brig. Gen. Fred W. Rankin,through the Director of the School, on 1 February 1945, as follows (13):
A shipment of blood collected in Washington and Baltimore on12 January 1945 was accompanied to Paris and observed along the way. The totaltime in transit was 6 days and 12 hours. The scheduled flight time from theUnited States to Paris was 28 hours, but all crews questioned agreed that it wasnot unusual during the winter for planes to be delayed en route for 1 to 5 days.
The first crew turned on the heat in the plane immediatelyafter it took off from Washington. This crew, like the second, which took overat the Azores, stated that their instructions were to maintain a temperatureabove freezing but that they had had no information about a safe upper limit.The blood was transported during the entire trip at a temperature below 54? F.(12? C.), with the lower limit 46? F. (8? C.), except for a single period of6 hours, during which the range was 61? to 81? F. (16? to 27? C.). Duringthe first 4 hours of the flight, time temperature range was 46? to 54? F. (8?to 12? C.) except for 2 hours on the ground at Bermuda, when it rose to 81? F.(27? C.). At Saint Mawgan, England, where the plane was delayed for almost 5days, the outside temperature was between 32? and 46? F. (0? and 8? C.) andthe blood was kept aboard.
During the stop at Saint Mawgan, Captain Elliott was able todiscuss the transportation of whole blood with several crews from Army planesand from Transworld and American Airlines planes. Army pilots had instructionsto maintain temperatures between 37? and 48? F. (3? and 9? C.); one of themhad the instructions posted in the cabin. Commercial pilots had no writteninstructions but had been told verbally to maintain temperatures above
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freezing. These data were confirmed by crews questioned onthe return trip.
According to Captain Elliott's information, only oneshipment of blood had been delayed at Bermuda during the operation of theprogram to date. During December and January, 12 shipments had been delayed atthe Azores, and during December, 19 had been held over at Saint Mawgan. Noinformation could be secured concerning delays at Stephenville, Newfoundland, orPrestwick, Scotland.
The commanding officers at the hospital in Bermuda and thedispensary in the Azores and the flight medical officer at Saint Mawgan had allbeen told to offload blood and store it under refrigeration if a plane was to beheld more than 2 hours. There was ample refrigerating capacity at all of thesestations, and the excellent cooperation of priorities, traffic, and medicalofficers insured the proper handling of the blood while the planes were on theground.
Refrigeration in the European theater-The 400 to 500bottles of blood collected daily by the blood bank at the 152d Station Hospitalat Salisbury were flown to Paris in iced marmite cans (fig. 120, p. 534).Refrigeration facilities there, at the continental section of the blood bank,were practically unlimited. The 300 to 400 bottles of blood collected locallyand the blood received from the Zone of Interior were sent forward inrefrigerators mounted on trucks. The blood from Salisbury was shipped in themarmite cans in which it was received; these cans held sufficient wet ice tomaintain desired temperatures for 24 hours or more.
Though the Paris operation was a very large one-up to 31December 1944, the bank had received 28,974 bottles of blood from the Zone ofInterior, and, for the first 25 days of January, it had received 21,677 bottles-therehad been no losses from lack of refrigeration.
Recommendations
In the report of this tour of inspection, Captain Elliottmade the following recommendations, based on his observations:
1. All shipments of blood from the UnitedStates should be accompanied by a numbered manifest stating the time and placethe blood was collected, the storage temperature at the airport, the time ofdeparture from the United States, temperature readings at 2- or 3-hour intervalsduring the crossing, storage temperatures during delays on the ground, and anyother pertinent information containing temperature and storage conditions.
With these data, the Paris Blood Bank wouldhave a record of the temperatures at which the blood had been maintained fromcollection to delivery and, depending upon the length of time optimumtemperatures had been maintained, could determine whether the present 16-daydating period could be safely extended to 21 days. Major Hardin hoped that thissystem would be instituted as soon as possible.
2. All plane crews should be given uniforminstructions concerning the proper temperatures to be maintained in planesflying blood.
3. Refrigeration during transportation shouldbe provided as soon as possible.2
2Captain Elliott recommended an immediate 5-percent increase in the daily airlift to Paris and also recommended, in view of an imminent request to increase shipments by 20 percent, that plans be set in train at once to implement this increase.
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On 1 February 1945, Maj. John J. McGraw, Jr., MC, ActingChief Division of Surgical Physiology, Army Medical School, made the followingcomments on this report, through the Director, Army Medical School, to theChief, Overseas Branch, Issue Section, Supply Division, Office of The SurgeonGeneral, and to General Rankin (14):
On the basis of this report, there was no doubt that the AirTransport Command was carrying out a most efficient operation in the airlift ofblood to Europe. To increase the efficiency and safety of the operation, it wasrecommended:
1. That Captain Elliott's recommendations concerning themaintenance of a temperature chart for the airlifted blood be instituted at onceand that the chart originate with the center collecting the blood.
2. That the responsibility for handling blood be fixed at allstages en route and that those responsible be instructed to keep thetemperatures of the blood as far as possible between 39? and 50? F (4? and10? C.).
These recommendations were put into effect on 17 February1945.
EXPENDABLE REFRIGERATION CONTAINERS FOR THE
OVERSEA AIRLIFTS
One highly favorable circumstance in the program of blood forEurope was that shipments began in late August and most of the bloods flownacross the Atlantic without refrigeration were moved during the coldest part ofthe year, when overheating of the blood was unlikely. During this interim,active work continued on an expendable iced container, which was ready in thespring, when warmer weather began. Also during this period, the Navyaccumulated sufficient experience flying blood to the Pacific in ACD solution toproduce statistical evidence of its safety. The use of this solution permitted areduction of 400 cc. in the size of the bottle, which largely compensated forthe additional space occupied by the iced containers.
Containers
Navy container.-The Navy expendable refrigerated boxwas put into use as soon as the Navy airlift of blood to the Pacific began inNovember 1944. Trial runs began in September. When the insulated chests weredemonstrated by Capt. Lloyd R. Newhouser, MC, USN, at the Conference on BloodPreservation on 19 January 1945 (11), about 19,000 bloods had beenshipped in them by plane from San Francisco to Pearl Harbor, re-iced there, andthen flown on to Guam, and thence to more forward points. The overall rate ofdiscard had been 1.7 percent, and the reaction rate in about 6,000 transfusionshad been 2.7 percent.
The Navy chest (fig. 140, p. 612) was made of plywoodinsulated with 3 inches of Fiberglass. It weighed 87 pounds packed and occupied5.9 cubic feet. Inside, a galvanized iron receptacle contained a centralcanister filled
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with 15 pounds of ice and had space for sixteen 600-cc.flasks of blood in ACD solution.
Testing had been rigorous and had included parachute drops,without damage. The observations of Lt. (later Lt. Cdr.) Henry S. Blake, MC, USN,on a test shipment had shown that temperatures within the chest were maintainedat 45.5? to 48? F. (7.5? to 9? C.).
Army container-The Army container (fig. l82, p. 762),as finally developed, was made of reinforced (double) cardboard, insulated withaluminum foil and cotton batting. It was both flameproof and moistureproof. Likethe Navy box, it occupied 5.9 cubic feet. It was fitted with wire racks whichheld 24 recipient sets and twenty-four 600-cc. bottles of blood in ACD solution.The compartment for ice held 19 pounds, and both icing and re-icing were simple.The empty box weighed 35 pounds and, with its contents, about 105 pounds. Theshipping weight per bottle was thus only 4 pounds, against 5? pounds per bottlefor the Navy container.
The date and hour of packing were recorded on theinstruction sheet on the lid of the box. Also recorded were the date and hour(about 48 hours later) when re-icing would be necessary if the box had notarrived at its destination.
Ice was supplied to the bleeding centers at Boston, New York,and Washington in the amount of about 1,000 pounds each per day. The blood wasrefrigerated as soon as it was collected, and the containers were re-iced asnecessary before they were placed on the oversea planes and again after theywere removed. Re-icing en route was cared for, by arrangement, by the AirTransport Command and the Naval Air Transport Service.
Specific instructions were given to all bleeding centers forthe correct handling of the insulated boxes and the new solution bottles.
These containers proved entirely satisfactory throughout theremainder of the airlift. They also proved useful to oversea organizations, suchas clearing stations, which had no refrigeration, as well as to installations inwhich refrigerating space was limited. The only real objection to them concernedtheir original color, a light, glossy tan. On occasion, stacks of empties in thefield attracted enemy planes on strafing missions, particularly on moonlightnights. Advanced blood banks in the European theater quickly learned that theseboxes must be camouflaged or destroyed. The same complaint was made about Navyboxes in the Pacific. Later, all containers were painted olive-drab.
Changeover to Refrigerated Containers and ACD Solution
The Reynolds Metal Co., without waiting for a formal order,provided six insulated sample containers, and they were shipped to Paris, two aday, on 26, 27, and 28 February. Each contained 24 bottles of blood.Observations en route and at the Paris Blood Bank indicated an entirelysatisfactory per-
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formance (15). The temperature was at all times withinthe required range (39? to 50? F., 4? to 10? C.), and refrigeration lastedlonger than the period set forth in the specifications for the containers. Atthe end of the longest run, 64? hours, the box still contained 10-12 pounds ofice, and all the bloods in it were in excellent condition.
Meantime, arrangements were made in the Zone of Interior forrequisitioning the necessary containers and also for the changeover from Alsever'sto ACD solution. All changes had to be carefully integrated with each other: Theblood had to be flown to Europe daily; it could not be held over. Most centersdid not have storage facilities for more than a 3-day supply of containers.Orders for the larger bottles of blood, containing Alsever's solution, had tobe canceled, but only just in time for the bottles containing ACD solution to beready in correlation with the delivery of the containers.
On 24 March 1945, Maj. Gen. Paul R. Hawley made the urgentrequest of The Surgeon General that, beginning at once, all blood shipped to theEuropean theater be refrigerated and be put up in ACD solution (16). Alsever'ssolution, he said, had been satisfactory in respect to cell survival in therecipient within the age limits used, but the pressing need for refrigerationmade it advisable to change to ACD solution, to reduce the volume of shipmentsbut permit shipment of the same amount of blood. The theater experience with ACDsolution had been too small for valid comparison with Alsever's solution, buthe was willing to accept the NRC (National Research Council) pronouncement thatit was at least as satisfactory.
When General Hawley made this request, practically everythingin the Zone of Interior was ready for the changeover to ACD solution and theuse of expendable insulated containers. In fact, a radiogram had already beensent to him on 19 February 1945, from the Office of The Surgeon General,informing him that the 1,200 bloods delivered daily to Paris unrefrigerated andin 1,000-cc. bottles in Alsever's solution would shortly be replaced by thesame number in 600-cc. bottles in ACD solution and in insulated, expendablecontainers. The total weight requirement of each shipment would be 5,000 poundsand the total space requirement 320 cu. ft.
The new plans were put into effect on 1 April 1945, and thefirst blood was flown from the east coast to Europe under these arrangements on9 April 1945.
Flying chilled blood to Europe on planes withoutrefrigeration was a highly successful expedient. That it succeeded does not makethe plan either wise or desirable. All future programs for the use of wholeblood should include provisions for constant, reliable refrigeration.
On the other hand, this unrefrigerated blood saved an untoldnumber of lives that would have been lost if, because refrigeration was lacking,no blood at all had been flown to Europe.
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References
1. Minutes, meeting of Subcommittee on Blood Procurement,Division of Medical Sciences, NRC, 18 Aug. 1941.
2. Rous, P., and Turner, J. R.: The Preservation of Living RedBlood Cells in Vitro. I. Methods of Preservation. J. Exper.Med. 23: 219-237, February 1916.
3. Kendrick, D. B.: Refrigeration Applications for BloodPlasma and Biologicals. Refrigerating Engineering 47: 33-39, January 1944.
4. Memorandums and correspondence on transportation of bloodin Church containers, 5 Mar. 1943-15 Dec. 1943. [On file,Historical Unit, U.S. Army Medical Service, Walter Reed Army Medical Center,Washington, D.C.]
5. Memorandums and correspondence on shipment of blood bytrucks, 9 June 1944-8 Aug. 1944. [On file, Historical Unit, U.S. Army MedicalService, Walter Reed Army Medical Center, Washington, D.C.]
6. Memorandum, Lt. Col. Douglas B. Kendrick, MC, to Chairman,Medical Department, Technical Committee, Office of The Surgeon General, 15 Nov.1943, subject: Military Characteristics of Refrigerator for Frozen Biologicals.
7. Letter of Intent, Lt. Col. Douglas B. Kendrick, MC, toMills Industries, 23 Nov. 1943, subject: Purchase of"Whole Blood Cabinet."
8. Memorandum, Lt. Col. Douglas B. Kendrick, MC, for Director,Technical Division, Surgeon General's Office, 24 May 1944, subject: BloodTransfusion Equipment, Field.
9. Memorandum, Lt. Col. D. B. Kendrick, MC, for Brig. Gen.Fred W. Rankin, 23 Aug. 1944, subject: Conference on Supply of Whole Blood forthe ETO.
10. Bushby, S. R. M., Kekwick, A., Marriott, H. L., and Whitby, L. E. H.: Survival of Stored Red Cells After Transfusion. Lancet 2:414-417, 5 Oct. 1940.
11. Minutes, Conference on Blood Preservation, Division ofMedical Sciences, NRC, 19 Jan. 1945.
12. Kendrick, D. B., Elliott, J., Reichel, J., Jr., and Vaubel,E. K.: Supply of Preserved Blood to European Theater of Operations. Bull. U.S.Army M. Dept. No. 84, pp. 66-73, January 1945.
13. Memorandum, Capt. John Elliott, SnC, to Chief, SurgicalConsultants Division, Office of The Surgeon General, through Director, ArmyMedical School, 1 Feb. 1945, subject: Transportation ofBlood from the U.S. to the ETO Blood Bank in Paris.
14. Memorandum, Maj. John J. McGraw, Jr., MC, for Chief,Overseas Branch of Issue Division, Supply Section, Office of The SurgeonGeneral, 1 Feb. 1945, subject: Report of Trip to ETO Blood Bank.
15. Memorandum, Capt. Leslie H. Tisdall, MC, for Chief,Development Branch, Office of The Surgeon General, 8 Mar. 1945, subject: TestShipment of Refrigerated Blood.
16. Memorandum, Maj. Gen. Paul R. Hawley to The SurgeonGeneral, 24 Mar. 1945, subject: Refrigeration of Blood for Trans-AtlanticShipment.
