10 JAN 2007 Every day, a day in school

10 JAN 2007 Every day, a day in school

Ah yes, midnight in the Wounded Warrior computer lounge. My fingers again caress the familiar keyboard, because there is nothing else in the hospital that they ought to be caressing! I'm smiling because I know that no matter what they do to me, they can't stop the clock! There is also ample reason to smile today because we were fortunate to see very few wounded pass through our doors in need of comfort and care. After reporting my list of patients from my 24-hr shift, I attended to the needs of a sweaty body that had been in the same clothes for 24 hours, and made a deep dive for slumber land. My friend Laparoscopic Surgeon S. knocked on my door to tell me that yet another little child needed a tracheostomy. I returned to the hospital to give him a secure tube for breathing and a tube for feeding. His skull was fractured in an explosion a few days ago and he is still in a coma. Don't any of you count him out. It is a great gift of nature that children have great chances to recover from head injuries. We'll be watching him for good things.

Vascular Surgeon M. was manning the helm as SOD today and with the help of today's BSOD Surgical Oncologist J., they had two other tracheostomies to do on adults. It is not a particularly joyful operation to do because it is acknowledging that their mind's function is clouded severely enough by injury that they can not reliably breath or eject their phlegm. However in some ways it is a hopeful operation. It means that they have gotten past the initial drama of the sudden devastating effects of major trauma. It means that they are strong enough to tolerate a little semi-elective maintenance operation and survive the few seconds when transitioning from tube in the mouth to tube in the throat without completely decompensating. And putting the effort of placing the surgical breathing tube into the person in the first place signifies to me that I am embracing the idea that they will be among the living long enough to stay in the habit of breathing for a while.

Today was a happy package day. I got yet another offering of great DVD's from a generous friend in the Books for Soldiers programs. She has been kind enough to offer to help out other troops at the hospital seeking books or movies to get them to the other side. I got some tasty ginger spice cookies from my Mom. I knew when I told her that I liked the last batch she wouldn't fail to send more! I know that she would drive here in her Mustang and pick me up if she could! Since she can't, I'm happy that she feels compelled to keep up the Italian method of loving children: stuffing them with food! Vascular Surgeon M. also had a happy mail day. He received some high tech medical equipment that he had requested from beyond the sea. It is amazing to be part of a medical staff that can bring the most modern and high-tech practices in medicine here to the middle of the war zone. It makes me feel like an old meatballer, but I do know that people feel a little easier when a little injured baby comes in because they know that they have me around. To be honest, they do so well taking care of kids without any help from me. I think that I'm serving mainly as a confidence booster!

Now if you will pardon a completely unpardonable change in tone, I'd like to make my feeble attempt to share a little knowledge. One of the most important duties of a physician to society through the ages has been to serve as educator. A topic surfaced today upon which I though I could shed a little light.I recently got a very interesting question independently from BagBlog and madtom, who have been kind enough to visit here from time to time. (Click on their names to read their blogs. Do it!) They both asked me my thoughts about an article that came out in the BBC today, reporting that British soldiers treated in Iraq at US military facilities received blood that was (potentially) contaminated. this was news to me so I read the article which you can find here.

As the article reports, British officials have identified 18 soldiers and 6 contractors from the UK who have received blood using a technique called fresh whole blood transfusion. As this is a topic with which I have much experience through my two deployments, I'm happy to provide my thoughts (which of course are mine and not in any way to be construed as official Department of Defense communication.) I have no contact or specific knowledge of the 24 individuals involved, but I can speak in general about the technique. If you have no interest in blood transfusion or if you wish to be awake three minutes from now, STOP HERE!

One of the deadliest killers of our injured troops, as well as civilians, in the theater of war is exsanguinating hemorrhage. This fancy term means that all of a person's blood came out of them, and they died. It is nothing new to the war in Iraq, it has been a threat to soldiers in the line of fire probably as long as men have taken to the activity of killing each other. War has been a cruel but efficient teacher, and we have adopted techniques to try and keep these injured individuals alive after they have suffered bleeding wounds. One of the best methods, an old one, is to place a tight tourniquet on the limbs of the injured to stop the leakage of blood until they come to the care of a surgeon. Another which has proved so effective, and allowed us to save many a troop who might not have made it home otherwise, is placing a surgeon in the theater of war, and quickly transporting the injured troop to that surgeon's operating table. But even with quick surgery, we cannot keep a body alive if it has been emptied of blood. Blood lets the body move oxygen to all its parts, and blood transfusion gives this ability back to an injured person. Banked blood is blood that has been collected before the injury, is tested, stored, and is then available when the injured need it. Fresh whole blood is collected from a donor at the time of injury and is given to the person needing it at that moment.

So why would we use fresh whole blood? It has some benefits and some risks. First of all, when there is an overwhelming onslaught of wounded, we run out of blood in the blood bank and have no other choice. Secondly, when a person has lost a very large amount of blood, giving them banked blood restores the volume to their veins, but doesn't provide all of the ingredients in blood. Stored blood loses tiny cells called platelets that help stop up leaks in injured arteries. Stored blood is also missing some of the proteins in blood that help form a healthy blood clot, like a person would need to stop a nose bleed. As stored blood gets older, the cells start to break and they release high levels of potassium which can be harmful to a person's heart rhythm if levels in the body get too high. Also, stored blood has a chemical called EDTA added to it to reduce the level of calcium, which can cause the stored blood to clot in the bag. This ETDA can cause a person's calcium level to drop after a large transfusion. These aspects of stored blood probably don't matter if a person only receives a small transfusion. However, if they receive large volumes of blood as high as the person's whole body content of blood, or even greater, these abnormal levels of platelets and minerals can become dangerous.

Some of these deficits of whole blood can be compensated for, such as giving a person a matching transfusion of plasma or isolated platelets for each transfusion of blood the receive. But some facilities that store blood may not also store components such as plasma or platelets. They require a colder freezer and a more complicated method of collection, called apheresis.
When I worked in Balad in 2005, we gave fresh whole blood many times. Often were the times that we received numerous casualties in quick succession and depleted our blood bank. At that time, our tent hospital did not have the capability for platelet apheresis and was dependent upon delivery of platelets that had to be ordered from another hospital in the country. For these reasons, we called for rapid donations of fresh whole blood many times, and I believed that we saved lives that otherwise we couldn't have been saved. In fact, after returning home after my last deployment, I was able to meet a troop to whom I had donated a unit of blood. His arm had been nearly torn off in a vehicle crash and he had lost a terrible amount of blood. My colleague Vascular surgeon T. reconnected the severed blood vessels in his arm in a precise and painstaking operation. When the call came for blood, I answered with other troops and we rolled up our sleeves. This reservoir of blood in the veins of the men and women working on this base is referred to as the "walking blood bank". If the call for donation goes out, I know that we will have more volunteers than we need in a matter of minutes. I know that to be true because twice on this 2007-2008 deployment that call has gone out. It is far less frequent than my previous deployment because several factors have changed. Thankfully, we see the occurrence of an overwhelming mass casualty event far less frequently this time. We are nearly always able to keep ahead of the demand for transfusion in our blood bank. Secondly, we now have the ability to perform apheresis on site, which allows us to treat people who are short not just on blood but also on the platelets that help them stop the bleeding.

As I mentioned, there are risks. One risk is that a person will get blood that does not match their type. For this reason we test blood for a match against the wounded before it is given. When circumstances are too dire to wait for that, we give "universal donor" blood of type O negative, which is accepted by all blood types. There is a risk of getting an infection (HIV, hepatitis, Human lymphocyte virus) from a transfusion. For banked blood, the blood has been tested for infection before it is released for use. When life-threatening situations require the speed, volume, and component content of fresh whole blood, there isn't the luxury of holding out on the dying person until the tests are done. We do however take measures to reduce the risk as much as possible. First off, all military members in this theater of war have been tested yearly for HIV infection and have been immunized against hepatitis B. At the time of fresh whole blood donation, donors answer health risk questions to exclude those whose circumstances put them at risk for undiagnosed infection. This questionnaire is subject to honesty, but it is still a powerful method of selecting a potentially safer donor pool. When a troop donates blood, test specimens are collected at the same time. For every donor, a rapid 20 minute test for HIV, hepatitis B, and hepatitis C infection is performed. Often this test is complete before the blood gets to the patient. For every donor, test specimens are sent to the US Army Blood program for definitive testing. All results are reported to our hospital. Additionally, our hospital will track any recipient of whole blood, regardless of their nationality to monitor for complication.

So you can see that we take the safety of whole blood transfusion very seriously, as we do all of the therapies we offer at our little hospital. It is a dreadful responsibility to know that the decisions we make here may determine the difference between life and death. It gives me a sense of pride and honor to be part of a broad and varied team of professionals who take this responsibility to heart every day. I've listed below a few more in depth resources below if you aren't completely sick of the topic!

Be well, and keep an eye out for me! I've reached the point in the rotation where I refuse to do anything new. If I've come this far running over my familiar, well-travelled deer paths, there is no way I'm going to change now!

Warm regards,

Chris

Outside resources:

Here is a quick PowerPoint presentation by Rice that illustrates some of the motivation for whole blood transfusion in the battle environment.

An extremely informative paper on the use of fresh whole blood transfusion in Operation Iraqi Freedom by trauma surgeon Dr. Holcomb and colleagues.

A more up to date article (abstract only) by my friend and colleague, Dr. Spinella.