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Chapter 11

Chapter 11

The Blood Program in the Korean War

Lieutenant Colonel Arthur Steer, MC, USA
Colonel Robert L. Hullinghorst, MC, USA
Colonel Richard P. Mason, MC, USA

Although there was no established blood bank in the Far East Command when the Korean War began, whole blood from an operating blood bank was available to the first medical field installation when it began to receive patients. Thereafter, regardless of the fortunes of war, blood was always available in adequate amounts to meet the requirements of the combat forces. This paper will describe the organization and establishment of a functioning blood bank under emergency conditions, the difficulties encountered, the policies established, the storage and distribution practices, the problem of estimating blood requirements, an analysis of the amount of blood issued, the amount actually used, and the use of group "O" blood for all patients in the field. Certain recommendations will be made based on experience during the period July 1950 to July 1953.

Organization and Mission of the Blood Bank

On 3 July 1950, responsibility for collecting and distributing blood in the Far East Command was assigned to the 406th Medical General Laboratory in Tokyo and on 7 July blood was delivered to the first hospital unit arriving in Korea. To accomplish this, personnel were diverted from other laboratory activities, available supplies and bleeding sets were obtained from depots, base and mobile bleeding sections were established, additional refrigerators were obtained, and an intensive publicity campaign to obtain donors was initiated. In August 1950, the 8090 Blood Bank Laboratory Detachment was activated and attached to the 406th Medical General Laboratory although it was long before qualified personnel were acquired. By September 1950, a more realistic appraisal of the "police action" in Korea had indicated that blood sources in Japan were not sufficient and group "O" blood was being supplied from the continental United States.

The mission of the Tokyo Blood Bank was to supplement shipments of group "O" blood from the Zone of Interior, to furnish blood of all


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groups and types to hospitals in Japan, to act as a blood-distributing center for the theater, to investigate blood storage, distribution and use policies and practices, and especially to furnish sufficient blood to meet emergency requirements during the time increased shipments were in transit from the United States.

Difficulties

During the early months of the war, operation of the blood bank was plagued by shortages of critical supplies. Vacuum bottles were not available in sufficient amount and it did not appear that a sufficient supply could be obtained immediately from the United States because of the high priority given to other supplies. Under close technical direction and controlled by rigid laboratory testing, selected Japanese firms produced ACD vacuum bottles, as well as disposable donor and recipient sets, which met American standards. Even pyrogen-free water became critically short, the emergency being met by continuous operation of an improvised distillation system.

Few of the staff had had prior blood bank experience but were trained as they worked. They were assisted by a group of devoted part-time volunteer workers mainly from the American Red Cross and later from the Japanese Red Cross also. These volunteers served as receptionists, nurses' aides, clerks, and in many other capacities. Certain of the volunteers conducted much of the publicity and public relations work which was so important in obtaining donors. In this activity the radio and press facilities under military and Japanese control cooperated wonderfully, as did most of the prominent visitors to Japan.

Disposal of outdated blood was a constant problem. No method was found for maintaining a reserve of a perishable agent such as blood in amounts sufficient to meet expected requirements without an appreciable portion becoming outdated. Of course this is true even in fixed civilian hospitals where the requirements for blood transfusion are much more stable than on the battlefield.1 This was further complicated in periods of military pressure when local blood collection facilities were being strained to meet a sudden increase in blood requirements. At such times widespread appeals for group "O" donors produced many volunteers of other blood groups who could not be dissuaded from donating blood without antagonizing them and injuring the intensive drive for donors. In such periods depot stocks of groups "A" and "B" would exceed desired levels. The blood bank was directed to send the outdated group "O" blood and excess blood of other groups to Korean depots. Some of it was used apparently without harm as supportive therapy for patients with tuberculosis and


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prior to elective surgery in base hospitals. When Korean military hospitals were established further forward, blood approaching the outdating limit, and later fresher blood, was sent to these hospitals.

During 1952 when the combat situation was relatively stable, the usual daily shipment of blood to Korea consisted of 240 bottles of blood. During the frequent short periods of combat activity, it was not unusual to send up to 800 units of blood daily to Korea and then to send none during the lull in activity which often followed. Despite a definite informational effort to acquaint donors collectively and individually with these facts, the flow of donors could not be cut off too sharply at such times without many being offended and thus jeopardizing a favorable response to subsequent emergency appeals. Also previously increased shipments from the United States continued to arrive for a brief period after such a lull even with the earliest possible notification of reduced needs. On a few occasions persons in high authority scheduled the bleeding of large units for its publicity value to the national blood program despite the fact that there was little need for the blood at the time. With these wide fluctuations in requirements and supply, there were wild fluctuations in the amount of blood in reserve in Tokyo ranging from almost none to over 2,000 units.

The Japanese medical profession seldom used transfusions and there had never been a blood bank program on an appreciable scale. Nevertheless, many Japanese individuals, social groups, and labor unions volunteered as donors even before publicity was aimed at them specifically. A complication which arose was a restriction against collecting more than 200 ml. of blood from any of these donors. With the support of the Japanese Medical Association, the 200 ml. limit was replaced by a table of comparative values which established the volume of blood to be collected from persons of small stature. The relatively lower incidence of group "O" and the invariable presence of the Rh factor limited somewhat the full applicability of this large donor group to recipients whose distribution of blood group and Rh type was somewhat different.

Policies

The general policy was established that only group "O" blood would be sent to Korea. The antibody titer was indicated on the label in order that high-titer blood would be used on "O" recipients only, while that of low titer could be used for all patients. Although all blood was labeled as to Rh type, no attempt was made in Korea to determine the recipient's Rh factor, it being felt that serious reactions on the basis of Rh incompatibility were unlikely in battle casualties. The calculated risk obviated the need for maintaining separate supply levels and recognized the emergency nature of the use of blood in com-


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bat surgery. The hospitals in Japan determined the group and type of all patients prior to transfusion and used compatible blood which was further checked by crossmatch.

Storage

Blood was considered to be outdated 21 days after collection, and this expiration date was printed on the label. Investigation late in 1952 indicated that blood deteriorated fairly slowly during the first 10 to 14 days of storage and thereafter more rapidly. Even before this, measures had been instituted to get fresher blood to the patient. When it was pointed out to them, medical supply officers at the depots quickly recognized that the usual supply practice of "first in, first out" did not apply to blood because that practice resulted in putting fresh blood on the shelves while old blood was sent to the hospitals. However, the attempt to give fresher blood aggravated the problem of trying to reduce the amount of blood becoming outdated and at the same time maintaining reserves for emergencies. This problem was further complicated by the establishment of multiple reserve depots (see below). Early in 1952, the blood on the average was 18 or more days old when it was given to the patient, but by the end of the year, this had dropped to about 14 days.

The necessity for maintaining blood at a constant low temperature was recognized at all installations. At first, batteries of miscellaneous small refrigerators had to be used. Later, large walk-in refrigerators became available at major depots. All installations maintained a close watch for fluctuation of temperatures in the refrigerators by frequent periodic inspections of thermometers in the refrigerators or the use of constant recording thermometers. Despite this, there were two or three instances when the entire reserve at an installation was destroyed because thermostat failure resulted in freezing overnight.

Refrigeration During Shipment

Various expedients were used to maintain refrigeration during shipment of blood. In all methods, wet ice was placed in a separate metal container in close proximity to the bottles of blood. At first, standard "marmite" food containers were used. These were bulky, heavy, could hold only a few bottles of blood and were seldom recovered from the receiving unit in the field. Later, insulated plywood boxes with hinged tops, metal racks for 16 bottles of blood, and a central metal container for ice were used. These withstood moderately well the rigors of exposure to weather and rough handling, and were not well suited for other purposes so that almost all were returned. Temperature below 10 C. was maintained in these boxes for at least 24 hours


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with one filling of the ice container, which was easy to reach if re-icing was necessary. These containers were used for the shipment of blood to all depots and medical using agencies within the theater. More elaborate but similar trunklike containers were developed in the United States for the shipment of blood to the Far East Command.

Distribution

The blood bank in Tokyo was responsible for the distribution of all blood in the theater. It, therefore, maintained a large reserve to meet any contingency. Routine shipments of blood were received six times a week from the United States, one of the shipments being twice as large as any of the others. Although, in emergency, additional blood could be obtained from the Zone of Interior within 48 hours, it was assumed for planning purposes that 4 days would elapse between the time a cable was sent to the Armed Services Blood and Blood Derivatives Group for additional blood and the arrival of the blood in Tokyo. During this time, the blood bank, by using its reserves in Tokyo and by increasing activity of the bleeding teams, was responsible for providing the required blood. It was estimated that the Tokyo depot could send to Korea 3,500 units of blood during the 4-day maximum waiting period for increased shipments to arrive from the United States.

Until the early months of 1951, the hospitals in Japan received patients who had been wounded only a few hours or days before. During this time, these hospitals required large amounts of blood. Two sub-depots were established to meet these needs. One supplied the hospitals in Southern Japan and served as an emergency depot for the Pusan area while the other served the hospitals in the Osaka area. These sub-depots received their blood from Tokyo by rail, a baggage car having been equipped with refrigerators for this purpose.

The blood sent daily by air to Korea was accompanied by a courier who, at first, made delivery direct to hospitals. Later, the shipments were taken to the medical supply depot which then assumed responsibility for proper storage and distribution in the combat zone. This in turn made the depot commander responsible for the availability of an adequate supply of blood, forcing him to maintain reserves of blood to meet emergency situations. After the landing at Inchon and the break-through from the Pusan area, independent depots were maintained in Pusan and Seoul. The Seoul depot subsequently established two sub-depots which in turn maintained reserve supplies.

Blood from Tokyo reached Seoul 8 to 12 hours after being requested. The sub-depots in the Eighth Army area could receive blood from Seoul in 2 hours if weather permitted air transport, with a maximum of 8 hours under adverse weather conditions. The hospitals could


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obtain blood from the sub-depots in an hour or less. As the time required for receiving blood decreased, smaller reserve stocks were maintained. However, there was a limiting factor which was related to the psychology of preparedness. There was always the realization that although excess amounts of blood were undesirable, inadequate amounts were disastrous. Just as the soldier who has used his tenth grenade on a combat patrol will not willingly carry less on his next foray, so the commander who has seen 100 units of blood administered in a single influx of casualties will not decrease a high blood reserve until assured that active combat has definitely subsided and will not suddenly re-appear.

Estimating Blood Requirements

When the blood bank was first established, a search was made for a method of estimating blood requirements. The single reference available2 reported that the British, based on experience in the Middle East, recommended using 0.1 unit per soldier wounded in action (WIA); that the data from U. S. Forces in the Mediterranean Theater indicated that 0.45 unit was used per WIA; that the whole Blood Committee of the European Theater of Operations utilized for planning purposes 0.2 unit of blood per casualty (type not stated). Experience during the first 5 weeks of the war in Korea indicated that 0.8 unit of blood per WIA was required, a much higher figure than any previous estimate but due to rise even higher.

In view of the build-up in troop strength in Korea projected for the period August 1950-February 1951, a long-term estimate of casualties was attempted. It was assumed that heavy combat losses would continue until UN Forces gained tactical superiority; losses would then be at a moderate rate but still increasing for an additional period as the size of our forces continued to grow. Finally, enemy resistance would be overcome, guerilla and police action might continue, and noncombat injury would become of relatively greater importance. Applying the factor 0.8 pint/WIA, blood requirements for the 6-month period could be expected to increase gradually with a maximum to be reached in October 1950. These estimated requirements far exceeded the estimated 100 units per day which could be collected over a prolonged period by repeated donations from the 20,000 potential donors in the Tokyo-Yokohama area. A request was therefore made that group "O" blood be sent from the United States and this request was promptly honored.

As the war progressed, it became increasingly difficult to plan blood bank activities on the basis of daily intelligence reports. The changing tactical situation was accompanied by changes in the medical support program. Hospitals in Japan lengthened their evacuation


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policy and more frequently used blood for treatment of nonbattle casualties and disease. Medical organizations in Korea insisted on maintaining high stock levels of blood. Since these could be depleted as readily by outdating as by use, requests for additional blood did not always reflect battle activity. Throughout the war, there was a constant and progressive increase in the percentage of battle casualties transfused and in the amount of blood used in the treatment of war wounds.

In 1952 and 1953 local actions, probing attacks, and defense of strong points characterized the fighting. There were few offensives and these were limited and of short duration. Often it was the enemy who determined the combat area and severity of the fighting. Consequently, short-term prognostications of the number of combat casualties to be expected became less reliable.

As a result of the interplay of these various factors, attempts to prognosticate needs for blood on the basis of expected combat activity were largely abandoned. They were replaced by a policy of obtaining sufficient blood to meet requests and maintaining a reserve in Tokyo of 800 to 1,200 units of blood. On the few subsequent occasions when blood was obtained in anticipation of requirements, results were quite poor. However, it is still believed that planning for blood requirements is a logical method of blood bank operation and that, under a different situation and with due allowance for the modern more liberal use of blood in treating battle casualties, this method would be successful.

The desirability of giving patients blood as fresh as possible complicated the attempts at estimating blood requirements and maintaining a blood reserve. In theory, the Tokyo Blood Bank would extract about 50 units of blood from the amount received each day, putting these units in the reserve and replacing them with blood 15 or 16 days old. This group of fresh and old blood would be sent to the depots in Korea where the old blood would be used to replace reserve blood which had become outdated, while the fresh blood would be given to patients. In practice, the need for blood was rarely constant, but rose and fell like great and unpredictable tidal waves. It was necessary not only to record the amount of blood on hand but also the expiration date of every unit to guard against the possibility that the entire reserve would become outdated at one time if it had accumulated during a quiet period.

Issue of Blood

In 1950 and the first half of 1951 recently wounded patients often received first definitive care in hospitals in Japan. During a 3-month period in 1950, 77 per cent of battle wounded were evacuated to


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Japan while during a similar period at the end of 1951, 48 per cent were evacuated to Japan. It is not known what percentage of the blood sent to hospitals in Japan was used for the treatment of battle casualties but an indication that much of it was not used for the immediate treatment of the battle wounded is seen in the fact that these hospitals requested almost as much blood in the first half of 1952 when casualties were lowest as in the second half when twice as many casualties occurred (Fig. 1). In the 3 years covered by this report, approximately 18 per cent of the blood distributed by the Tokyo Blood Bank went to hospitals in Japan.

FIGURE 1. Blood supplied to hospitals in Japan in relation to wounded in action-United Nations Forces 
less those of Republic of Korea (UN less ROK).

In Korea, during 1950, most of the field hospitals were in the Pusan area, and of necessity primarily served to render casualties transportable as soon as possible to Japan. Throughout most of 1951 the hospitals of Eighth Army were more numerous, widely dispersed, and played a larger role in the care of wounded. By 1952 the hospitals in the southern part of Korea played a less prominent role in the care of battle casualties. In August 1952, the southern three-fourths of the Republic of Korea (ROK) was designated a communications zone and the northern portion was assigned to Eighth Army as a combat zone.


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In Figure 2, the blood sent to all of Korea in 1950 and 1951 was considered as sent for the treatment of battle casualties while thereafter only the blood sent to Eighth Army was so considered.

It was not possible to determine from the available information what portion of the blood issued was actually used for the treatment of battle casualties. However, it is of greater importance for blood bank operations to determine how much blood must be supplied per battle casualty. Unfortunately even this simple calculation could not be made accurately, because, after 1951, increasing numbers of Korean troops were assigned to U. S. forces and received treatment in U. S.

FIGURE 2. Blood supplied to Korea in relation to wounded in action (UN less ROK through December 1951; total UN thereafter).

hospitals and at the same time blood was sent to some but not all of the ROK field hospitals. Korean doctors did not use blood as liberally as American doctors, and they did not make direct requests for blood but received available blood which was in excess of the requirements of U. S. hospitals. Consequently, inclusion of all ROK casualties to whom blood was not always available decreased the ratio of blood supplied per casualty while omission of ROK casualties removed a significant number who received such treatment. During a 2-week survey in 1952, 29 per cent of blood transfusions in American hospitals in Korea were given to Korean troops most of whom were attached to American units; during this time 70 per cent of all casualties were Koreans. It has been estimated that from 20 to 30 per cent of the blood received by Eighth Army depots in 1952 and 1953 was sent to


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ROK hospitals and approximately 50 per cent of the blood sent to Eighth Army was used for the treatment of ROK casualties. However, a firm policy for supply of blood for Korean casualties was never established. Some blood was requested with the intent of sending it to ROK hospitals but much of the blood sent to Eighth Army was originally requested for U. S. Army hospitals and would have been destroyed because of outdating if not sent to the ROK hospitals.

Omitting the build-up phase of 1950 as not representative, between 2.10 and 3.39 units of blood were supplied to the combat zone for each casualty incurred (January 1951 to July 1953). Even the lower of these two figures is greatly in excess of rates of actual use of blood to be discussed later.

One of the reasons for the apparent issue of blood to Korea in excess of the amount used is the need for maintaining reserves. Without changing the reserve level, there are many more units of blood per casualty in reserve when the casualties are few than when the number of WIA is large. Further, when there are many casualties there is a much more rapid turnover of blood in stock, the reserves are used more efficiently, and there is little outdating of blood. At such times, consequently, a greater proportion of the blood is actually used for the treatment of casualties.

When the combat zone data are charted monthly (Fig. 3), an inverse proportion is evident between the number of casualties and the issue

FIGURE 3. Blood issue factor in relation to wounded in action by month (UN less ROK).


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factor of bottles of blood per casualty (B/WIA). This emphasizes that it was the maintenance of reserves at a high level which determined the amount of blood issued to Korea and that during periods of activity only a relatively small additional amount was needed.

Three factors determined the reserve level. One, already mentioned, is the psychological attitude that the maximum amount of blood required at any time must always be available. The second factor is the time required for replenishing the blood reserve. The possibility that bad weather will increase the time required for transportation of blood is an important consideration in determining how much blood must be available. The third factor is the number of organizations maintaining reserves of blood. There were as many as five stores of blood between the donor in the U. S. and the wounded soldier in Korea: the processing center in California, the blood bank in Tokyo, the depot in Seoul, the sub-depot in the corps area, and the surgical hospital blood bank. Each of these maintained reserves for emergencies. The amount of blood which would have been destroyed because of outdating would have been great were it not for the fact that the California depot could divert unneeded blood to fractionation centers and the depots in the Far East Command could give it to the ROK hospitals that needed it. The magnitude of this problem is indicated by the fact that during a period of intense combat activity there was available in the theater more than 12 times the average daily amount given to casualties other than ROK and more than 5 times the maximum amount given these casualties on any one day. Under other circumstances, the multiplicity of stores of blood would have been inefficient and wasteful.

Use of Blood

It is difficult, during combat, to determine how much blood is actually being given to the war wounded. Detailed records are not maintained and are often inaccurate when large numbers of casualties are received. The amount of blood given a wounded soldier depends not only on the severity of his injury but on the type of medical installation. The surgical hospitals give more blood per patient than do the division medical units or the evacuation hospitals.

During 1950 and part of 1951 recently wounded soldiers were treated in hospitals both in Korea and Japan. No estimate is available concerning blood use during the early part of this period. Applying the best data available during the period 1 April-31 August 1951, 0.6 unit was used in Korea per battle casualty admitted to hospitals.

In 1952 a survey of blood distribution and use was conducted in Korea during a 2-week period when our forces were experiencing the largest number of casualties received during the year. Information


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was obtained in two ways. The medical units listed the number of casualties received and the number of units of blood given to patients who were identified by name, rank and serial number. At the same time machine records casualty reports were studied which listed by name, rank, serial number and organization, all U. S Army casualties during this period. Two months later the status of each of these patients was reviewed. With this information, it was possible to determine (1) how blood was used in medical installations at different levels in Korea, (2) the amount of blood given to Korean troops treated in U. S. Army hospitals, (3) the amount of blood given to casualties in relation to the duration of disability as a measure of the severity of injury, (4) the average amount of blood actually used in the treatment of battle casualties, (5) the tendency to use low-titer blood in preference to high-titer blood, and (6) incidence of transfusion reactions.

For the purpose of this survey, the Mobile Army Surgical Hospital (MASH) was considered as a Corps unit and the evacuation hospital as an Army unit. One of the evacuation hospitals was also the Renal Failure Center, and used a proportionally larger amount of blood because of this function.

The survey indicated that approximately 20 per cent of all wounded in action received blood transfusions at an average rate of 4.3 bottles per transfused patient or 0.9 bottle per total U. S. wounded. In Table 1 this information is given for the medical installations at different levels and for Eighth Army as a whole, based on casualty reports of U. S. Army war wounded only.

Table 1. Blood Use Factors by Echelon of Medical Care
 

 

Per Cent of WIA Transfused

No. of Bottles Per WIA

No. of Bottles Per Patient Transfused

Division level

2.0

0.09

4.4

Corps level

29.3

0.99

3.4

Army level

5.4

0.15

2.7

Total 8th Army*

20.2

0.9

4.3

*Corrected for admission to and transfusion in more than one unit.

At the time of the survey, divisional medical units used little blood proportionately, possibly because the large influx of casualties did not permit extended care of severely wounded at that level. An exception, not included above, was the Medical Battalion of the Marine Division whose medical companies function in a manner comparable to a MASH. It was understandable, therefore, why 29 per cent of casualties admitted to such USMC installations were transfused. Most of


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the blood in the combat zone was used by MASH's in keeping with the primary mission of these hospitals to provide resuscitation and initial surgery to nontransportable, severely wounded. In fact, the more severely wounded frequently were flown directly by helicopter from the battalion aid station to the MASH, by-passing other division medical units. Although all of the severely wounded patients were sent ultimately to the evacuation hospitals, this generally was not effected until resuscitation and immediate surgery had been accomplished. For this reason and because of the number of transportable, less severely wounded moved directly from clearing station to evacuation hospital, a much lower percentage of those admitted to the latter installations required transfusion.

During the period of this survey, more than 1,500 U. S. Army troops were wounded in battle. Analysis revealed that 21 per cent were seriously wounded and 79 per cent lightly wounded. When records on these patients were analyzed 2 months later (Table 2), 3 per cent of the wounded had died, another 3 per cent originally considered seriously wounded had been returned to duty, and 15 per cent also seriously wounded were still hospitalized. At the same time 34 per cent of the wounded were still hospitalized despite an original categorization as lightly wounded. The amount of blood given with relation to severity of injury is given in Table 2.

Table 2. Blood Use by Severity of Wound
 

Category

Per Cent of Total WIA

Per Cent of Category Transfused*

Units of Blood Per WIA

Units of Blood Per Patient Transfused

Died of wounds (DOW)

2.8

**55.1

7.0

12.7

Seriously wounded

15.1

69.0

3.1

4.4

Seriously wounded returned to duty

3.4

13.6

0.4

3.0

Lightly wounded

34.1

17.8

0.5

2.6

Lightly wounded returned to duty

44.5

3.8

0.08

2.2

All cases

 

20.2

0.9

4.3

*Corrected for admission to more than one medical unit.
**20% DOW known not to have received blood and 25% DOW may have received blood but not identified by name on any transfusion records.

The large amount of blood given to 69 per cent of the seriously wounded is not surprising but that almost 4 per cent of the lightly wounded returned to duty should get an average of 2.2 units of blood indicates how freely transfusions of whole blood were given.


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During the period of survey, there was a definite tendency to use low-titer blood for all patients although this in part was regulated by the amount of low-titer blood locally available. Thus 72 per cent to 82 per cent of Koreans whose blood type was unknown were given low-titer blood while 60 per cent to 80 per cent of U. S. troops whose blood type was recorded on blood tags were given low-titer blood. If there was excess blood at an installation, it was the high-titer blood which was retained in the reserve.

The survey also showed that under combat conditions, very little attention was paid to the possibility of transfusion reaction. Only 2.5 per cent of the patients transfused were reported to have had reactions and these were all of the minor urticarial or febrile type. One hospital which treated only 7.5 per cent of the patients transfused reported 58 per cent of these reactions. Although serious transfusion reactions often cannot be detected in patients in severe shock or under anesthesia, the general evidence based on autopsy studies, postoperative hospital course, reactions in lightly wounded casualties and the investigations at the Renal Failure Center all indicate that little hazard was attendant on the use of group "O" blood for all casualties.3 The advantage of having blood immediately available for resuscitation without the necessity for waiting for a laboratory procedure more than outweighed the potential hazard.

Discussion

Adequate prior plans had not been prepared for the unexpectedly sudden attack on South Korea and our precipitate involvement under United Nations urging. Such a situation may recur and with the possibility of atomic attack, our medical concern may well be with our homeland. Since it is not feasible to maintain on a stand-by basis military units such as blood bank laboratory detachments or blood bank bleeding detachments, the alternative would be to assign the responsibility for the emergency establishment and operation of a regional blood program to a suitable medical unit in each overseas command and at strategic locations within the continental United States. Each responsible medical unit should be required to formulate appropriate plans, and to ascertain that sufficient supplies and equipment are available at a known depot. Such an emergency function cannot be continued indefinitely, however, and plans should extend to the rapid mobilization of the proper units capable of assuming blood program responsibilities.

The Korean War was not one of the major military operations from the standpoint of size in this century of world wars. Accordingly, it is not surprising that adequate amounts of blood were always avail-


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able. In World War II rationing of blood was necessary on occasion,2, 4 and in future catastrophes it may again be necessary. In such an event it is essential that one individual be responsible to the area surgeon for the adjustment of supply of blood to demand by control of collection, requisition, storage and distribution.

Experience in the Korean War suggests that a blood program of greater efficiency would have resulted had responsibility for the entire area been assigned to one organization under the command of a medical officer qualified to supervise blood collection, storage, distribution and use. It is furthermore felt that then any limitation on availability of blood would have been charged properly to that individual rather than to the medical depot commander, whose responsibility would appear to be limited more reasonably to providing refrigerated holding facilities for the blood.

The centralization of all blood collection within the theater was dictated initially by supply problems and limited donor sources. Later, large hospitals in the rear areas should have been encouraged to organize their own blood program with locally available donors and facilities. Assistance and some continuing supervision would doubtless have insured satisfactory operation. Further exploitation of local resources by use of multiple collecting centers or by means of a railway collecting unit was considered, and could have been used to meet total requirements. This would have greatly increased the role of the supervising and coordinating agency, however. Such plans were not put into use because of the lack of a suitable means of plasma salvage within the theater, and because of the desirability of continued integration with the national blood program.

In many hospitals in Korea surgeons held that fresh blood that was type specific was greatly to be desired over stored blood from universal donors. Under combat conditions in the field, however, this is not only hazardous but impractical, the feasibility of satisfying such a desire disappearing rapidly within an army zone. In addition, it was conclusively demonstrated that type-specific blood, such as group "A", should not be given to a patient of that type if he had recently received multiple transfusions of group "O" blood in forward hospitals.5

It is evident that the trend is towards more liberal use of blood. When indicated, blood transfusions are of great value in the treatment of the wounded. However, indiscriminate and excessive use of blood as a sort of harmless medical insurance is not without danger because, despite all efforts, there is the possibility of human error in typing and labeling blood and because of the possibility of immunizing the recipient unnecessarily through Rh or other factors in the blood.

Consideration of future situations entailing a shortage of blood


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emphasizes the need for improved methods of preservation of blood, for improved plasma expanders, and for a re-evaluation of the minimum amount of whole blood required for resuscitation. Plastic blood containers, given preliminary evaluation in Korea, appear highly promising and are being constantly improved. They could materially alleviate part of the logistic problem described.

Conclusions

1. In each overseas major command plans must exist for immediate implementation of a blood program. This should include designation of a specific unit as responsible for the planning and emergency operation of this activity including estimation of requirements, and methods of collection, storage and distribution.

2. For planning purposes, 0.9 unit of blood per WIA per day times the number of days required to replenish stocks appears to be a reasonable supply level for an overseas theater. Whether this amount can be met will depend on the size of the military operation, education in the use of blood substitutes, and over-all national requirements.

3. With a perishable commodity such as blood plus the suddenness with which daily requirements may vary, local resources should be developed to a maximum degree.

4. The distribution system for blood should be based on the most direct system of supply feasible with a minimum number of storage centers.

5. A continuing program in professional education and supervision of the use of blood and plasma expanders should exist within the theater.

References

1. a. Editorial: Blood Salvage. New England J. Med. 251: 80, 1954.
b. Statement Massachusetts Medical Society: Human Serum Albumin and Plasma Salvage. Ibid.

2. Mason, J. B.: Planning for the ETO Blood Bank. Military Surgeon 102: 460, 1948.

3. Crosby, W. H., and Akeroyd, J. H.: Some Immunohematologic Results of Large Transfusions of Group O Blood in Recipients of Other Blood Groups; a Study of Battle Casualties in Korea. Blood 9: 103, 1954. (Chapter 7, this volume.)

4. Mason, J. B.: The Role of ADSEC in the Supply of Whole Blood to the Twelfth Army Group. Military Surgeon 103: 9, 1948.

5. Crosby, W. H., and Howard, J. M.: The Hematologic Response to Wounding and to Resuscitation Accomplished by Large Transfusions of Stored Blood; a Study of Battle Casualties in Korea. Blood 9: 439, 1954. (Chapter 6, this volume.)

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