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Experience With Procurement, Storage, and Distribution of Blood From Local Sources in the Early Days of the Korean War

Medical Science Publication No. 4, Volume 1

EXPERIENCE WITH PROCUREMENT, STORAGE, AND DISTRIBUTION OF BLOOD FROM LOCAL SOURCES IN THE EARLY DAYS OF THE KOREAN WAR*

COLONEL R. L. HULLINGHORST, MC

As indicated in the title, this paper will not be concerned with the important aspect of utilization of blood, but with a brief presentation of some difficulties encountered in establishing a blood program in a military theater faced with sudden conversion from occupation duties to active warfare. This requires a brief historical account of the general situation before proceeding to a discussion of the specific problems of: (a) formulating a general blood policy, (b) organizing the blood bank, (c) estimating requirements, and (d) reacting to critical supply shortages.

Prior to the onset of hostilities in Korea only the Tokyo Army and Osaka Army Hospitals maintained blood banks and these were sufficient only to meet their own needs. The sudden invasion of the Republic of Korea on 25 June 1950, was a shock to both tactical and logistic elements of the Far East Command.

During the following week it became obvious that medical field units were being formed within the Eighth Army in expectation of the decision by the United Nations to actively oppose the aggressors. The need for whole blood in the care of expected casualties became apparent and on 3 July the Commanding Officer of the 406th Medical General Laboratory was assigned the responsibility for establishing a blood program. Four days later, blood was delivered to the first hospital unit arriving in Korea. From that time on, no active hospital in Korea was ever without blood.

Formulating a General Blood Policy. All combat and many supporting units were being alerted. This left only a small number of service troops, military dependents, foreign businessmen and diplomats as the donor reservoir, since theater policy prohibited the receipt of blood donations from the Japanese population in the early phases. Concentration of potential donors in the Tokyo-Yokohama area, and marked depletion of troops in the vicinity of existing hospitals else-


*Presented 20 April 1954, to the Course on Recent Advances In Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.


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where required a central collecting agency to provide blood not only to Korea, but also to those hospitals in Japan which would be receiving casualties evacuated from field units.

Only group O blood would be supplied for use in Korea. Blood of high titer was to be used for group O recipients, conserving that of low titer for administration to wounded of other blood groups. Compatibility by Rh type was to be disregarded provided the blood was acceptable in the routine cross-match.

Hospitals in Japan were expected to use blood compatible as to group and Rh factor, and were to be supplied with the necessary amount of eight basic varieties of blood.

A 21-day expiration policy was adopted, and standards of donor acceptability were those of recognized authorities (1, 2, 3), with modifications. As an example of such modifications, a set of tables was later prepared establishing the volume of blood to be collected from persons of small stature in order to deviate from the limitation of 200 cc. as the maximum blood donation approved by the Japanese Medical Association.

Organizing the Blood Bank. The importance of excellent public relations in the procurement and handling of donors was recognized early. Fortunately there emerged a full-time American Red Cross volunteer who proved competent and invaluable. The full cooperation of Armed Forces Station, the FECOM newspaper Stars and Stripes and of the other local newspapers (both English speaking and Japanese) was readily obtained. A corps of part-time volunteer workers were organized as receptionists, nurse's aids, clerks and chauffeurs in support of donor service. These were later supplemented by a similar staff obtained with the aid of the Japanese Red Cross when permission to accept Japanese donors was obtained.

From the assigned laboratory personnel plus three attached officers of the Army Nurse Corps there were formed a central collecting and processing unit, mobile collecting teams and a storage and courier section. An advanced blood bank depot was established in southern Japan from which local hospitals were supplied, and from which couriered deliveries were made to hospitals in the Pusan bridgehead by air as called for.

By mid-August the 8090 Blood Bank Laboratory Detachment was activated and attached to the Medical General Laboratory although qualified personnel for this supplementary unit were acquired only gradually. The Commanding Officer of the General Laboratory, however, remained the one responsible for the entire theater blood program. This position warranted the full-time utilization of a senior officer and assistant to plan and direct procurement, supervise distribution and instruct in the proper utilization of blood and blood substi-


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tutes. These important responsibilities were never satisfactorily handled as additional duties.

Estimating Blood Requirements. Efforts to obtain data from World War II experience for planning blood requirements were relatively unsuccessful. The single reference available (4) stated that British experience in the Middle East had recommended 0.1 pint per soldier wounded in action (WIA); data from United States Forces in the Mediterranean Theater showed 0.45 pint/WIA; for planning purposes, the Whole Blood Committee of the European Theater of Operations utilized 0.2 pint per casualty (type not stated). From the 20,000 potential donors in the Tokyo-Yokohama area it was felt that at least 100 pints per day could be collected over a prolonged period-using a program of repeat bleeding at 10-week intervals (this assumption proved sound in that 60,191 pints were collected in the next 18 months).

Utilizing such planning data, it was expected that these resources would be ample for the small number of casualties expected initially from the "police action." With growing realization that a relatively major effort would be required for solution of the Korean situation, a re-evaluation became necessary. Using daily G1 strength reports, it was obvious that our forces were incurring 2.5 WIA per thousand per day. Experience during the first 5 weeks indicated that blood had been required at a ratio of 0.8 pint/WIA. Applying these factors (fig. 1) to the projected buildup of troop strength in Korea and assuming that gradually increasing military superiority would be reflected in diminishing casualty rates for our troops in November and December, a peak requirement of 420 pints per day would be required by 30 October. Based on this estimate a request was made for periodic shipment from the continental United States of that amount in excess of the 100 pints per day to be procured locally. This local procurement was continued (fig. 2) in order to provide an easily controlled cushion for sudden fluctuation in requirements. It also provided the specific types of blood for hospitals in Japan, since shipment of blood other than group O from the United States did not seem feasible.

This long-term estimate of blood requirements was subjected to frequent revision as the variations of military favor and disfavor affected our troops. The short-term casualty estimates required for a continuing evaluation of blood requirements are, unfortunately, not a recognized function of either Army or theater staffs. An attempt was made to foresee major fluctuations by daily review of theater G2 and G3 summaries. This was of some value although ultimately dependence was placed on daily reports from the medical supply depot in Korea. A sudden request for increased shipments such as from 200 to 800 pints daily was met with the 2-day reserve maintained in


158

FIGURE 1.

Tokyo plus increased local collections. The increase in shipments from the United States could always be expected 48 hours later.

As regards factors concerned with blood related to casualty rates, there occurred a gradual increase in this ratio throughout the first 18 months of operation (table 1). Exclusive of the early months of the campaign, a sound figure appears to have been 2.4 pints/WIA, three-fourths of this amount having been supplied to the combat zone, the remaining one-fourth to hospitals in what could be considered the communications zone (Japan).

Supply Shortages Affecting the Blood Program. In any sudden and unexpected conversion of an occupation force to full-scale combat, certain supply shortages are to be expected. Constant readiness, careful planning and relatively massive stockpiling must be resorted to in order to avoid this. Critical shortages which affected the local blood program were those of disposable transfusion sets, vacuum bottles for blood collection, and pyrogen-free water.

The limited number of disposable recipient sets were reserved for use in field units in Korea. As a result it was possible to see a direct relationship between use of disposable sets and relative freedom from pyrogenic reactions.


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Table 1. Relation of Blood Supply to Wounded in Action in Korean War

Month

Units of blood supplied

Wounded in action

Units per WIA

July 1950

1,036

1,872

0. 55

August

2,923

4,412

0. 66

September

7,347

10,543

0. 69

October

8,240

2,678

3. 07

November

5,893

3,542

1. 67

December

9,449

6,253

1. 52

January 1951

7,284

2,789

2. 61

February

11,724

4,731

2. 48

March

12,217

4,834

2. 53

April

14,240

4,853

2. 93

May

15,906

4,507

3. 53

June

12,834

3,436

3. 74

July

11,661

1,628

7. 16

August

9,776

1,707

5. 72

September

12,438

6,539

1. 90

October

20,206

9,968

2. 03

November

14,999

2,647

5. 67

December

12,335

1,147

10. 75

 


190,508


78,086


2. 04

This necessary reuse of transfusion apparatus accelerated the developing shortage of pyrogen-free water. Hospitals in Japan were forced to modify standard procedures (5) using triple-distilled water only as a final rinse in preparing transfusion equipment. The requirements of the Blood Bank for sufficient pyrogen-free water to permit reprocessing of donor sets were met only by continuous 24-hour operation of an improvised triple-distillation system (6), furnishing over 1,000 liters of a product meeting USP specifications (7).

As with distilled water, blood donor bottles were too space-consuming to be supplied from the United States by airlift during this early critical period. Fortunately certain Federal Security Specifications were furnished by the Preventive Medicine Consultant. Using these as a guide, close technical supervision and careful laboratory testing allowed local procurement from Japanese manufacturers of acceptable blood-collectitig bottles and later disposable donor and recipient sets.

Throughout the early period of the war, the only blood substitute available was dried plasma. In September 1950 even this item became critical when the theater was notified to suspend from issue the available stocks from two major biologic producers. At the same time information was received that plasma-processing capacity in the


160

FIGURE 2.

United States would be inadequate to meet theater requirements for at least 2 months. Hospitals in Japan and Korea were advised to use blood or other substitute in lieu of plasma wherever feasible. This allowed preservation of precious plasma stores for use by division medical units, but undoubtedly was a factor in stimulating greater readiness to use whole blood for resuscitation.

Utilization of Blood. As has been mentioned above, supervision and advice in the use of blood and blood substitutes were lacking. This may account for the unbelievably small amounts of plasma and albumin generally used by medical installations receiving blood. Another possible example of the desirability of closer supervision of the program became apparent in the disappearance in 1951 of a reasonable relationship between blood requisitions and numbers of casualties. The answer was found related to the psychology of preparedness. The soldier who has used his tenth grenade on a combat patrol will not willingly carry a lesser number on his next foray. Similarly, the


161

hospital commander who has seen 100 pints of blood consumed in a single influx of battle casualties will not decrease his high level of blood on hand until assured active combat has definitely subsided and will not suddenly reappear. Likewise at a theater level there is always realization that excess amounts of blood are undesirable, but inadequate amounts are disastrous.

It is felt only proper to state that a survey conducted in the closing months of 1951 showed that in the first 18 months of the Korean War only two-thirds of blood supplied was actually used in our hospitals in both Japan and Korea.

These facts naturally lead to the problem of disposal of outdated blood. Proposals which were considered were: (a) an additional laboratory unit for a fractionation program, (b) development of Japanese facilities for local fractionation on a contract basis, and (c) return of outdated blood to the Zone of Interior for fractionation. Each of these proposals was carefully evaluated before rejection. Of necessity, and realizing the danger of adverse publicity, circumspect methods of destruction were utilized. Coincidentally a cautious education of the unduly curious was begun. Later, all blood which had passed the 21-day expiration date was turned over to Korean medical authorities who maintained it was quite satisfactory for use. This is not particularly suggested as a pattern for the future, however.

Summary

1. A brief historical account is given of the development of a blood program for a combat theater of limited size.

2. A method is described for planning blood requirements, but it should be remembered that the factors derived may not pertain to other situations.

3. It is suggested that the amount of blood used is possibly more than necessary or available in a military situation of larger scope.

4. The need is stated for a full-time director of a theater blood program who also could serve as an active consultant on the use of blood and blood substitutes.

References

1. Kilduffe, R., A., and DeBakey, M.: The Blood Bank and the Technique and Therapeutics of Transfusions. C. V. Mosby Company, St. Louis, 1942.

2. Strumia, M. M., and McGraw, J. J.: Blood and Plasma Transfusions. F. A. Davis Company, Philadelphia, 1949.

3. DeGowin, E. L., Hardin, R. C., and Alsever, J. B.: Blood Transfusion. W. B. Saunders Company, Philadelphia, 1949.

4. Mason, J. P.: Planning for the ETO Blood Bank. Military Surgeon 102: 460 (June), 1948.


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5. TB Med 204: Complications of Blood Transfusion. Department of Army Technical Bulletin, Washington, D.C., 24 October 1945.

6. Cook, F. E., et al.: Remington's Practice of Pharmacology, 8th Edition, pp. 1651-1652, 1942.

7. Pharmacopeia of the United States, 13th Revision, pp. 606-607, 1947.