ugust 2005 marked the second anniversary of the founding of the Uniformed Services Society of Anesthesiologists (USSA) as a component society of ASA. This component society was created to provide a venue for anesthesiologists in the armed forces to actively participate as members of ASA. Over the past two years, we have worked to increase our active members (now more than 80) and expand tri-service coordination of programs in the Army, Navy and Air Force. While our goals are to accomplish more within the military community and ASA, progress in the last two years has been hindered by the high rate of deployments.

Over the past two years, we have seen more than 50 percent of all active-duty anesthesiologists deployed overseas for three to 12 months (six-month median); and those not deployed pick up the workload with the help of activated reservists, many of whom also have been deployed overseas. This year we were fortunate enough to reach out and establish ties with many of those who have served on active duty before us. In Atlanta we hosted an evening reception that brought together nearly 100 active-duty and 50 former active-duty anesthesiologists. Updates were provided on two tri-service anesthesia initiatives regarding the implementation of regional anesthesia for pain management in injured soldiers and the pending air-worthiness approval for the first patient-controlled analgesia device for use on aircraft.

Because we are unable to cover all the accomplishments of those taking care of the combat casualties, this update will focus on the work of two of our anesthesiologists in a remote area of Iraq. There is a lot of information available in the news and on the Internet regarding injuries and deaths in this conflict. One of the most remarkable numbers is the low rate in which injured soldiers die after being wounded and receiving medical care [(DOW) died of wounds]. In the Civil War, 14 percent of injured soldiers who did not die on the battlefield eventually died from complications of their wounds. This number has fallen consistently in major conflicts as medical care has improved. In World War I, the DOW rate was 8.1 percent, and by the end of Vietnam, the number had fallen to 3.7 percent. Currently in the conflict in Iraq, the DOW rate is 1.6 percent. While some, if not the majority, of the credit must be given to body armor and the skills of our combat medics, it is the daily dedication, skill and professionalism of all the health care workers that contribute to saving lives.

The following excerpt details the work of these unsung heroes and the challenges they face working out of tents to save the lives of severely injured soldiers.

Walking Blood Bank in Combat Trauma Resuscitation

LCDR Jeffrey D. McGuire, M.D., MC USN
CDR Michael E. Compeggie, M.D., MC USN
On Deployment in Iraq


n our area of operations in Iraq, the U.S. Marine Corps (USMC) Force Service Support Group (FSSG) provides combat service support to USMC units and a number of Army units integrated into this joint command. On any given day, numerous convoys and security patrols arrive and depart the base. It was one of these security patrols that was attacked by an improvised explosive device (IED) within two kilometers of the main gate.

The patrol was fortunate in that casualties were limited to one soldier. He was a machine gunner on an armored Humvee who was found slumped in his harness, hemorrhaging severely from a shoulder wound caused by an IED fragment. The unit’s medic quickly applied his first-aid skills to temporarily control the hemorrhage. This treatment was the first of a series of events that would be necessary to save this soldier’s life. In order to survive, this soldier also would need effective, timely volume resuscitation and surgical repair.

Jeffrey D. McGuire, M.D., an anesthesiologist at Naval Medical Center in Portsmouth, Virginia (center, at the head of the bed), administers anesthesia to an injured soldier. By his side is Michael B. Compeggie, M.D., a staff anesthesiologist at Naval Medical Center, Camp Lejune, North Carolina.

The Surgical Shock Trauma Platoon (SSTP) of the FSSG is one of the forward treatment facilities in the Marine Expeditionary Force area of operations. The mission of the SSTP is to provide life- or limb-saving interventions. The unit is a mobile, tent-based trauma center consisting of a small emergency department, three operating rooms, a ward with limited holding capability as well as extremely limited laboratory and X-ray resources. Included is a 40-unit blood bank that is limited to packed red blood cells. In addition a walking blood bank has been established to supplement the blood-replacement capacity.

Upon arrival at the SSTP, the soldier was found to be in severe hemorrhagic shock. Immediate resuscitation was initiated, and he was moved to the operating room. The patient was reassessed, standard monitors placed, rapid-sequence induction with cricoid pressure performed, and the patient’s airway was secured without difficulty. Simultaneously, central access, arterial pressure monitoring and additional peripheral access with a rapid infusion catheter were obtained as the operating room staff prepared for surgery.

The wound penetration site indicated an intrathoracic injury in the region just inferior to the midclavicular area. Surgical exposure to the posterior clavicle was obtained through a trap door sternotomy. Operative findings indicated that the IED fragment had transected the proximal subclavian artery and vein. The hemorrhage was controlled through ligation of the vessels. During the operation, the work of the anesthesia team was complicated by the rapid ongoing blood loss. However, continuing aggressive resuscitation through the central and peripheral access with the aid of a fluid warmer sustained blood pressure and normothermia with a minimal base deficit.

Over the course of the procedure, the patient received 20 liters of crystalloid, one liter of hetastarch, 24 units of packed cells and 16 units of whole blood. In addition, the patient received 4.8 mg of recombinant factor VIIa and three doses of calcium chloride. After the patient was stabilized, at a final hematocrit of 28, he was evacuated to a Combat Support Hospital where he received a definitive repair of his subclavian artery. Two weeks later, we received a picture of the patient in his stateside hospital bed giving the “thumbs up” with his injured extremity.

The Armed Services Blood Program’s technical manual by convention limits forward surgical facilities to packed red blood cells. Major hospital units are the first medical units where platelets and fresh frozen plasma are available. Frequently combat trauma patients require massive blood transfusion, and this invariably leads to a dilutional and consumptive coagulopathy. In the absence of blood component therapy, some of these patients would die if a walking blood bank were not available. In our experience with trauma patients in Iraq, when we were administering a hemorrhaging surgical patient a seventh unit of packed cells, it was time to activate the walking blood bank. The decision to activate the walking blood bank at our facility is a joint decision between the surgical and anesthesia teams. Once activated, prescreened walking blood bank donors are notified via radio and e-mail message alerts of the need for whole blood. Within 10 minutes of activation, the first donors arrive on site.

Preparing a walking blood bank is the first step in providing this service to injured soldiers. When we set up operations, our Army primary care colleagues supplied us with a voluntary roster of 500 soldiers. This was essentially their entire unit as a ready “quick reaction force” for our walking blood bank. Our donors, however, were not limited to this one unit; many other volunteer donors came from the USMC as well as other Navy and Army units at the site. The proximity as well as their enthusiastic participation would prove instrumental in saving this injured soldier’s life.

While some of the initial volunteers also included civilian contractors, we limited donors to active-duty U.S. military. Blood screening for infectious agents as we know it in the United States is not possible. By limiting our donors to active-duty military soldiers who receive hepatitis B vaccination with verified titers, HIV screening and urine drug screening, infectious risks should be minimal. In forward units such as ours, this low risk is weighed against the additional time to transport the soldier to facilities with additional resources. In this situation, this patient would have died at our facility without whole blood, and he probably would have died in transport to a more distant facility with blood component therapy.

Despite an enthusiastic donor system, our early efforts were constrained by a lack of equipment. Initially this prevented us from drawing more than one unit at a time. This rate-limiting step was overcome when a medic wrote home to the Oklahoma Blood Institute. In response they sent seven blood scales and other necessary equipment. After sharing three of these scales with a sister unit, we were still able to simultaneously draw blood from four donors at one time.

Once the walking blood bank is activated, 40 minutes are required to provide the first unit of whole blood to the operating team. Blood is typed for ABO and Rh antigens and then is crossmatched between the donor and the recipient. All units of transfused blood also are crossmatched with the previous whole blood donor units. Post transfusion and the patient is followed up with antibody testing for infectious complications at the 90-, 180- and 360-day mark.

Providing life- and limb-saving resuscitation and surgery is the mission of forward surgical units in the Iraqi theater. Among many other factors, availability of adequate and appropriate blood products is imperative to saving combat trauma patients in hemorrhagic shock. It is a sobering and heartwarming experience to step out of the operating room for a moment and see dozens of dusty, sweaty and tired Marine, Army, and Navy service members lined up to donate life-giving blood to their fallen comrades in arms. There is no doubt that the walking blood bank at forward surgical units saves lives and better enables the entire medical team to accomplish the missions of saving life and limb of combat trauma patients. It is a privilege to serve with such people.

Paul D. Mongan, M.D., is Associate Professor and Chair, Department of Anesthesiology, The Uniformed Services University, Bethesda, Maryland. He is a Colonel in the U.S. Army.