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MILITARY MILITARY
MEDICINE MEDICINE

Trauma in this whole blood collaborative. Further, a collection, delivery and protocol. Careful monitoring for transfusion reactions and hypother-

rotation schedule were created to achieve best practice utilization of
mia has shown no transfusion reactions above normal and no other
product resources. South Texas Blood and Tissue Center standardized
complications. After 14 days, the whole blood products that have not
Care to the same low-titer value as our military partners. Only male donors been utilized in the prehospital setting are exchanged from the heli-
are used in the program because of the risk of transfusion-related acute
copter and brought to the hospital to be used in trauma patients before
expiration at 35 days. Waste of whole blood is less than 1% with this
lung injury from female donors. STBTC has tested more than 10,000
individual donors, 85% of whom met the low-titer qualification for in- rotational scheme and is unique to Southwest Texas..

IN MILITARY MEDICINE clusion in the program. Community involvement was a key element in Emergency Department and Prehospital Transfusion
initiating this program. It required cooperation and encouragement of
community leaders, the medical community, as well as improved out- In the four years since the inception of the program, between several
By Susannah E. Nicholson, MD, MS, FACS
reach to potential donors. A grant was awarded from the San Antonio rural/critical-access hospitals, EMS agencies and both the University and
Brooke Army Medical trauma centers, nearly 4,000 injured patients have
T rauma is a leading cause of death both globally and in the product line. To recruit the necessary additional donors, STBTC de- received nearly 8,000 units of whole blood. No other place on planet
Medical Foundation to decrease the cost of development of this new
United States. Approximately half of all trauma mortalities are
earth has such a comprehensive program with the experience gained in
veloped the “Brothers in Arms” branded program with specific “Broth-
a consequence of hemorrhage, and most of these patients die
within six hours of injury. Trauma patients in hemorrhagic shock have ers in Arms” messaging to enlist and prepare potential donors for the civilian sector. Only the United States Military has more experience
with whole blood. The importance of the collaboration of these multiple
inclusion in the program.
shown improved survival with the implementation of the massive trans- agencies has been paramount to the success of this program.
fusion protocols (MTP). The United States military relied on whole Prehospital Transfusion Protocol Mortality, in preliminary study, is lower than the blood component
blood (straight from the donor without extensive processing or sepa- The STRAC serves 22 counties, over 26,000 square miles. There are era of resuscitation and those that die of their injuries live, on average,
ration into components of red blood cells, plasma and platelets) from five helicopter agencies (over 12 helicopter bases) within this region four more hours than the historical control. The program benefits chil-
1917 through the Vietnam War. A resurgence of whole blood use, by that provide up to two units of whole blood to trauma patients prior dren, women who are pregnant, non-trauma relate hemorrhage condi-
necessity due to the dispersed military treatment facilities across South- to arrival to a Level I trauma facility. Over 20 ground EMS agencies tions (e.g., gastrointestinal bleeding), vascular and transplant surgery
west Asia and the Middle East, prompted further study of safety and carry one unit of whole blood. All personnel administering products patients and has been used successfully throughout the COVID-19
efficacy and began to infiltrate the civilian health care system in the Preparation of Resources received whole blood training by STRAC via creation of a transfusion pandemic. Further uses of whole blood are being investigated and the
United States. We sought to characterize MTP patients cared for at The Southwest Texas Regional Blood Resuscitation program was de- military-civilian collaboration has never
University Hospital by UT Health San Antonio surgeons, nurses and veloped based on the recommendations of the Trauma, Hemostasis been stronger or more meaningful in the
blood bankers in a study to better understand how Rh status of whole and Oxygenation Research (THOR) network: an international com- modern era of injury care and management.
blood in our prehospital transfusion program might affect our trauma munity of civilian and military stakeholders specializing in emergency
patient population. medical services, trauma, anesthesia, blood banking and basic/transla- Susannah E. Nicholson, MD,
Our preliminary data, collected over the span of one and a half years tional science. The THOR network is dedicated to the development MS, FACS is the Director of
(presented at the Military Health System Research Symposium in and implementation of best practices in resuscitation from hemor- Trauma Research at the Univer-
2017), consisted of 63 patients who received massive transfusion on ar- rhagic shock. The longstanding relationship between South Texas sity of Texas Health Science Center at San
rival at our American College of Surgeons Level I trauma center. Mor- Blood and Tissue Center (STBTC), UT Health San Antonio, UT Antonio. She is a member of the Bexar
tality was 76% (n = 48). This has been the case in most trauma centers Health Military Health Institute, University Hospital, San Antonio County Medical Society.
in this country and this high mortality rate raised a concern that perhaps Military Medical Center, Institute for Surgical Research and Southwest Contributing authors to this article include
there was more we could do to improve survival in severely injured pa- Texas Regional Advisory Council for Trauma (STRAC) provided basis Brian Eastridge, MD; Ronald Stewart, MD;
tients. Realizing that in our data set, most hemorrhage-related deaths for providing whole blood on helicopters and ground ambulances. Donald Jenkins, MD; Micah Wright, PhD;
after arrival had less than a 30-minute prehospital time (from time of Low-titer cold-stored O RhD-positive whole blood is a licensed blood Byron Hepburn, MD; James Bynum, PhD;
injury to hospital arrival), prehospital transfusion appeared to be a po- product, so there were no issues related to Food and Drug Adminis- Andre Cap, MD, PhD and Eric Epley. Spe-
tential strategy to decrease mortality in the MTP patient. tration approval. This product has a 35-day shelf life and was created cial thanks to the UT Health San Antonio
As we developed a prehospital transfusion program, we decided on in consultation with military partners including the Institute for Sur- Department of Surgery, UT Health San An-
the use of whole blood for a variety of reasons. Whole blood is a supe- gical Research, the Army Blood Program and the Mayo clinic Low tonio Military Health Institute, United States
rior resuscitation therapy compared with saline or albumin; whole Titer O Whole Blood (LTOWB) team. The overall donor base was Army Institute of Surgical Research and
blood administration is also an easier task than transfusion of multiple evaluated, and donor testing was performed to find a cadre of low an- Southwest Texas Regional Advisory Council
components. We decided on the use of low titer cold-stored O RhD- tibody titers O+ donors. All processes and supplies used in collection, for Trauma.
positive whole blood (LTO+WB). labeling and transporting of LTO+ WB were validated by the STBTC

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