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Chapter VIII

Contents

CHAPTER VIII

Transportation and Refrigeration

PRELIMINARY SPECIFICATIONS

The question of how blood should be transported and refrigerated came up early in the blood-plasma program. At a meeting of the Subcommittee on Blood Procurement on 18 August 1941 (1), it was formally recommended that the bottles of blood be precooled with Dry Ice before they were shipped and should be shipped under thermostatically controlled temperatures, well below 50 F. (10 C.). Rous and Turner (2) had shown in 1916 that the rate of hemolysis was much greater when blood was stored at 68 F. (20 C.) rather than at 41 F. (5 C.). The lower temperature was, of course, as important as the upper. Later, when metabolic processes were more clearly understood, it was realized that the metabolism of the red blood cells was reduced at a lower temperature and that they therefore needed less nourishment, which meant that the nutrition supplied by the dextrose in preservative solutions was more fully utilized.

In a discussion of refrigeration for the transportation of blood at the December 1943 meeting of the American Society of Refrigerating Engineers (3)-when movement of blood by air had begun to be considered-the following points were made:

1. Whole blood, to be useful and safe, must be maintained at a constant temperature of about 39 to 43 F. (4 to 6 C.).

2. This is not a problem in most hospital units since, when they are operational, electric current is available for refrigeration. The problem arises when blood must be transported.

3. One of the requirements, therefore, in a refrigerator used for blood for military purposes is a compressor capable of maintaining the temperatures just specified when the refrigerator is in transportation as well as when it is plugged into regular power outlets. This requirement means that any refrigerator which is used must be capable of operation from a small generator which can develop one-third to one-half kilowatt of power and can also provide 110-volt, 60-cycle alternating current.

4. The refrigerator selected must be sturdy and well insulated, so that the temperature in it will remain at the desired level when it is used in climates in which the ambient temperature may rise to 130 F. (54 C.). The cabinet must be about 3.5 to 4 cu. ft., to accommodate 40-50 bottles of blood. Because of the weight limitation on cargo for planes, even of the largest type, it is desirable that the box should not weigh over 80 pounds.


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A refrigerator which met these specifications for the air transport of blood was not developed by the Army during World War II (p. 208). The program for providing whole blood for oversea theaters did not become a complete reality, however, until, in addition to the development of equipment for collecting and administering blood, means of refrigeration had been developed for its storage and preservation during the airlift (p. 214).

TRANSPORTATION IN THE ZONE OF INTERIOR

Railway Shipments

The original arrangements were that blood should be shipped from Red Cross donor centers in various cities to the processing laboratories by the Railway Express Agency, Inc., in Church containers (4). These refrigerated containers (fig. 55) had been devised by Maj. Elihu Church, president of the Church Co., for food. From the standpoint of safe transportation and refrigeration, they proved admirably adapted for the rail transportation of blood in the Zone of Interior. They had certain disadvantages, however, including their cost, their excessive weight, and their limited number.

By March 1943 (4), shortages of Church containers had become critical. Schedules of shipment of the containers between laboratories and centers were not being maintained, especially on the east and west coasts, even though more than 300 of the 450 Church containers then in use had been assigned to the blood-plasma program. The Red Cross considered it essential that a pool sufficient for at least one day's supply of blood be maintained at each donor center.

Action was taken to improve the situation at a meeting in the main (New York City) office of the Railway Express Agency on 5 March 1943, attended by the chief of the eastern division of the agency; Major Church; Dr. (later Major, MC) Earl S. Taylor, representing the American Red Cross; and Col. Charles F. Shook, MC, representing The Surgeon General. All district managers of the agency were informed of the urgency of the situation and were instructed to give first priority to blood shipments and to expedite the return of empty containers. Arrangements were also made to expedite the repair of damaged containers.

At this time, 100 additional containers were in process of manufacture. Later, the shortage of containers was called to the attention of a representative of the War Production Board, with special emphasis on the urgent necessity of refrigeration of the blood, particularly during long hauls.

By the end of 1943, all but 37 of all the Church containers in the country were being used by the American Red Cross. By the middle of 1944, enough were available to transport all the bloods being procured each week. Adequate reserves were maintained at strategic points, and repair parts were also in adequate supply.


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FIGURE 55.- Shipping room of American Red Cross Blood Donor Center, Louisville, Ky., showing Church container used to transport blood from centers to processing laboratories.

An article published in the General Electric News was intended to stimulate the interest of the workmen making the Church containers by explaining their own vital role in the blood-plasma program. Major Church had reprints of the article made for distribution to all employees of the Railway Express Agency who had any connection with the shipments of blood from the centers to the processing laboratories.

Truck Shipments

In June 1944, Dr. Milton V. Veldee complained to Maj. Frederic N. Schwartz, MAC, in the Office of The Surgeon General, and to Dr. G. Canby Robinson and Major Taylor of the American Red Cross that blood was being shipped from certain donor centers to the processing laboratories by truck


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instead of by Railway Express and sometimes had to be iced two and three times along the way (5). The laboratories had complained of the arrangement and Dr. Veldee objected to it on several grounds:

1. A great deal of experimentation had gone into the development of the Church container, which had proved, on the whole, very acceptable for both summer and winter shipments. Before any new arrangements could be accepted, it would be necessary to study the physical condition of the blood shipped under them in all weather conditions, which would require at least a year. Meantime, the National Institute of Health specifications, which had been somewhat liberalized since the start of the program, must be observed.

2. The Red Cross should not lend itself to scrapping a well organized and smoothly functioning service in favor of a new and untried method, which involved factors with such high war priorities and critical shortages as gasoline, trucking equipment, and manpower.

3. While there was probably no legal, contractual reason why the Red Cross should not cancel its agreement with the American Railway Express Agency, Inc. and the Church Co., both had given splendid cooperation.

As a result of Dr. Veldee's protest, all blood donor centers reverted to the original arrangements for transportation and refrigeration, and they remained in effect until the end of the war.

Refrigeration in the Zone of Interior of blood designed for the oversea airlift is discussed under that heading.

STATUS OF REFRIGERATION, 1943-AUGUST 1944

Airlift Requirements

After attending a conference in the Aero-Medical Laboratory at Wright Field, Dayton, Ohio, on 25 October 1943, Maj. (later Col.) Douglas B. Kendrick, MC, recommended (6) that a refrigerator developed by the Airtemp Division, Chrysler Corp., Dayton, Ohio, for the transportation of frozen biologicals in airplanes be modified for the similar transportation of blood (fig. 56). The Chrysler representatives did not think it would be possible to make the refrigerator specified by the Medical Department (1 cu. ft., 80 lb.), and an attempt at development would take 4-6 months. The Chrysler box was already in production. No action had been taken on Colonel Kendrick's recommendation when the airlift to Europe began in August 1944.

Field Requirements

Standard refrigeration was satisfactory for the storage of blood in hospitals and was part of authorized equipment. A refrigerator for use in the field, however, had to be operated by a gasoline generator as well as by the usual power outlets, to provide for the time it was being transported in trucks. The Division of Surgical Physiology, Army Medical School, working in conjunction with Mills Industries, Inc., Chicago, developed an electric refrigerator of 4-cu. ft. capacity, which held 50 bottles of blood. It operated on 110-volt,


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FIGURE 56.-Lightweight aluminum refrigerator (Chrysler) developed by the Army Air Forces. A. Refrigerator open. B. Refrigerator closed. C. Compressor.


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60-cycle A.C. current supplied by the usual power outlets or by a 750-watt (1 hp.) generator.

On 23 November 1943, Mills Industries was given a letter of intent for the purchase of this whole blood cabinet, to be delivered within 4 weeks (7). On 25 May 1944, in response to a letter from the Director, Technical Division, Office of The Surgeon General, Colonel Kendrick (8) recommended that this refrigerator (with other transfusion equipment) be standardized. The recommendation was approved, but at this time, less than 2 weeks before D-day, only a prototype existed. This box was later produced in quantity and is still (1962) in use.

THE AIRLIFT TO THE EUROPEAN THEATER

The Decision to Fly Blood Unrefrigerated in Flight

When the airlift of blood to the European theater ceased to be academic in August 1944 and became a matter of extreme urgency, two matters had to be settled immediately. The first was the preservative solution to be used (p. 224). The second was the possible risk of flying blood, even if refrigerated again immediately before enplanement and refrigerated immediately after deplanement, without refrigeration in transit. One problem was intimately related to the other.

At this time, no action had been taken on the Chrysler refrigerator recommended in November 1943 for use in transportation of blood in planes (6). The Division of Surgical Physiology, Army Medical School, had been working with Engineers' Development Laboratory, Armed Services Medical Procurement Agency, Fort Totten, N.Y., on a fiberboard container for this purpose, but it was not ready for use. It is hard to explain why, long after an efficient insulated box was in use in the Mediterranean theater (p. 417), and long after blood was being flown to the Pacific Ocean Areas by the Navy in an efficient insulated box (p. 213), the Army was flying blood to Europe without refrigeration. Furthermore, the Navy was using ACD (acid-citrate-dextrose) solution as a preservative, which materially reduced the space occupied by each bottle, while the Army was still using Alsever's solution, which was not so effective a preservative and which required considerably more space for each bottle.

When the question of flying blood to Europe came up in August 1944 (about 8 months after the proposal had previously been rejected (p. 465)), those responsible for the blood program in the Zone of Interior were faced with an extremely difficult decision: Would the urgent need for whole blood in the European theater be more adequately met by sending 450 pints of blood daily under refrigeration, or by sending 900 pints daily without refrigeration during the flight period of transportation? Military necessity often forces undesirable compromises, and here there was never any question that the wiser decision was to send the larger amounts.


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It is easy to say, long after the end of the war, that the decision should never have had to be made. That is entirely true. On the other hand, the plan was not adopted either recklessly or hastily. There was ample evidence to support the belief that while lack of refrigeration in flight was an undesirable alternative, it was a perfectly safe plan (p. 211). If 600-cc. bottles had been available and if ACD solution had been approved then, the plan employed would not have been adopted. At the time, however, it was the only reasonable solution, and it was safe within the framework of the methods employed.

There was no question in the minds of those who had to make the decisions that (1) fresh blood was best for wounded casualties and (2) that blood kept under refrigeration at every stage until it was used was more desirable than blood not constantly under refrigeration. A condition, however, not a theory, was confronting those responsible for getting the blood to Europe, and their decision was:

1. That if blood were put in Alsever's solution and were kept refrigerated until it was placed aboard the plane, it could safely be flown across the ocean unrefrigerated during the 16-24 hours, or sometimes longer, taken for the flight.

2. That if the blood were then replaced under refrigeration, it could be safely used for 21 days from the date of collection. Later, after the program had become so efficient that the blood became available in Europe within 4-6 days after it had been collected, or even earlier, this interval was reduced to 18 days.

Objections to the Plan

At a conference held in the Office of The Surgeon General on 15 August (9) and attended by Col. (later Brig. Gen.) Elliott C. Cutler, MC, Col. William F. MacFee, MC, 2d Evacuation Hospital, and Maj. Robert C. Hardin, MC, these officers stated that they considered sending blood overseas without refrigeration an unsafe practice, which they were unwilling to accept. They were given the following explanation of, and justification for, the plan:

1. The blood would be delivered in 1,000-cc. bottles containing 500 cc. of blood and 500 cc. of Alsever's solution. The bottles would be refrigerated before and immediately after the blood was collected and would remain under refrigeration until they were placed on board the plane. They would be refrigerated at Prestwick, shipped by air to the Continent in refrigerated cans, refrigerated again at the blood depot, and then delivered to forward areas in refrigerated cans. Thus, the only time the blood would not be under refrigeration would be during the Atlantic crossing.

2. Blood collected in Alsever's solution had been shipped without refrigeration from the Army Medical School to Prestwick and back to the school; there, tests showed that the supernatant plasma contained no more than 28 mg. of hemoglobin per 100 cc. Blood in the same solution had been shipped unrefrigerated to Bermuda, Los Angeles, and Hawaii and had been off refrigeration for as long as 5 days. At the end of this period, the supernatant plasma


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contained no more than 25 mg. of hemoglobin per 100 cc. No reactions of any kind had followed transfusions with this blood on three separate patients.

3. When blood collected in Alsever's solution and kept off refrigeration for periods ranging up to 72 hours was tested for hemolytic change, it was found that it could be stored safely for up to 8 days, against safe periods of 21 days with refrigeration.1

4. For the past year, liquid plasma prepared at the Blood Research Division, Army Medical School, had been obtained from unrefrigerated blood, kept at room temperatures, 70 to 90 F. (21 to 32 C.). When the unrefrigerated red blood cells, which were resuspended in isotonic sodium chloride solution, were used after 5 days' storage, the reaction rate was comparable to, or lower than, the rate after transfusion with refrigerated red blood cells. The increase in the recipient's red blood cell count and hemoglobin level was also comparable to the increase observed after the use of refrigerated red blood cells.

5. Although it was granted that proof of safety would be obtained only after actual experience with large amounts of blood, the proposal to fly blood unrefrigerated to Europe during flight was considered safe because the only difference between using unrefrigerated blood and red cells in the Zone of Interior and using them abroad would seem to be the conditions to which the blood would be subjected during flight.

Other Studies on Refrigeration

Numerous studies made before the war, particularly at the State University of Iowa (p. 220), on the effects of refrigeration on blood have been mentioned in other connections. One or two other studies might be cited:

Bushby and his associates (10) studied storage of blood at various temperature levels. They showed that rapid cooling of the blood immediately after collection was not harmful but that undue delay in refrigeration (up to 24 hours) had deleterious effects; that cooling to 32 F. (0 C.) for 2 days before storage at 39 F. (4 C.) did no harm, nor did warming to room temperature after 4 days' storage at this level; and that it was apparently safe to remove a bottle of blood from the refrigerator, let it warm, and then store it again.

At the Conference on Blood Preservation on 19 January 1945 (11), when blood was already being flown to Europe without refrigeration en route, Dr. J. G. Gibson, 2d, reported observations on 10 blood specimens shipped by air under refrigeration. The amount of free hemoglobin in the plasma was 8-13 mg. percent, and survival of the red cells after transfusion was excellent. In contrast, blood shipped by plane to Paris and return, without refrigeration either way, was found greatly deteriorated; it had been 11 days in transit.

1It should be emphasized that these tests were made simply to determine the theoretic safety of keeping blood unrefrigerated for certain periods of time if logistic restrictions proved overriding and it became necessary to use this method. It was clearly understood, by all concerned with the program, that blood should be kept at a constant temperature.


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At this same conference, Lt. Cdr. Eugene L. Lozner, MC, USN, reported observations on transfusions carried out with blood collected in ACD solution in Washington and on the west coast, shipped to Guam in Navy refrigerated boxes, and then shipped back to the Naval Medical School in Washington. Filtration through the recipient apparatus was good. Blood in which less than 2 percent of the red cells were hemolyzed produced no untoward reactions. Recipients who were given blood more than 28 days old showed bilirubinemia but no hemoglobinemia.

STUDIES ON UNREFRIGERATED BLOOD FLOWN TO THE EUROPEAN THEATER

Numerous studies were made on blood flown unrefrigerated across the Atlantic, beginning with samples from the first shipments (12). Tests at the blood bank at Salisbury showed that the fragility of the red blood cells and the amount of free hemoglobin released compared very favorably with the same tests on blood collected in the European theater.

Temperatures on the transocean flight-A formal test on the temperatures of blood in transit without refrigeration was made in January 1945 by Capt. John Elliott, SnC, Assistant in the Division of Surgical Physiology, Army Medical School. He reported to Brig. Gen. Fred W. Rankin, through the Director of the School, on 1 February 1945, as follows (13):

A shipment of blood collected in Washington and Baltimore on 12 January 1945 was accompanied to Paris and observed along the way. The total time in transit was 6 days and 12 hours. The scheduled flight time from the United States to Paris was 28 hours, but all crews questioned agreed that it was not unusual during the winter for planes to be delayed en route for 1 to 5 days.

The first crew turned on the heat in the plane immediately after it took off from Washington. This crew, like the second, which took over at the Azores, stated that their instructions were to maintain a temperature above freezing but that they had had no information about a safe upper limit. The blood was transported during the entire trip at a temperature below 54 F. (12 C.), with the lower limit 46 F. (8 C.), except for a single period of 6 hours, during which the range was 61 to 81 F. (16 to 27 C.). During the first 4 hours of the flight, time temperature range was 46 to 54 F. (8 to 12 C.) except for 2 hours on the ground at Bermuda, when it rose to 81 F. (27 C.). At Saint Mawgan, England, where the plane was delayed for almost 5 days, the outside temperature was between 32 and 46 F. (0 and 8 C.) and the blood was kept aboard.

During the stop at Saint Mawgan, Captain Elliott was able to discuss the transportation of whole blood with several crews from Army planes and from Transworld and American Airlines planes. Army pilots had instructions to maintain temperatures between 37 and 48 F. (3 and 9 C.); one of them had the instructions posted in the cabin. Commercial pilots had no written instructions but had been told verbally to maintain temperatures above


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freezing. These data were confirmed by crews questioned on the return trip.

According to Captain Elliott's information, only one shipment of blood had been delayed at Bermuda during the operation of the program to date. During December and January, 12 shipments had been delayed at the Azores, and during December, 19 had been held over at Saint Mawgan. No information could be secured concerning delays at Stephenville, Newfoundland, or Prestwick, Scotland.

The commanding officers at the hospital in Bermuda and the dispensary in the Azores and the flight medical officer at Saint Mawgan had all been told to offload blood and store it under refrigeration if a plane was to be held more than 2 hours. There was ample refrigerating capacity at all of these stations, and the excellent cooperation of priorities, traffic, and medical officers insured the proper handling of the blood while the planes were on the ground.

Refrigeration in the European theater-The 400 to 500 bottles of blood collected daily by the blood bank at the 152d Station Hospital at Salisbury were flown to Paris in iced marmite cans (fig. 120, p. 534). Refrigeration facilities there, at the continental section of the blood bank, were practically unlimited. The 300 to 400 bottles of blood collected locally and the blood received from the Zone of Interior were sent forward in refrigerators mounted on trucks. The blood from Salisbury was shipped in the marmite cans in which it was received; these cans held sufficient wet ice to maintain desired temperatures for 24 hours or more.

Though the Paris operation was a very large one-up to 31 December 1944, the bank had received 28,974 bottles of blood from the Zone of Interior, and, for the first 25 days of January, it had received 21,677 bottles-there had been no losses from lack of refrigeration.

Recommendations

In the report of this tour of inspection, Captain Elliott made the following recommendations, based on his observations:

1. All shipments of blood from the United States should be accompanied by a numbered manifest stating the time and place the blood was collected, the storage temperature at the airport, the time of departure from the United States, temperature readings at 2- or 3-hour intervals during the crossing, storage temperatures during delays on the ground, and any other pertinent information containing temperature and storage conditions.

With these data, the Paris Blood Bank would have a record of the temperatures at which the blood had been maintained from collection to delivery and, depending upon the length of time optimum temperatures had been maintained, could determine whether the present 16-day dating period could be safely extended to 21 days. Major Hardin hoped that this system would be instituted as soon as possible.

2. All plane crews should be given uniform instructions concerning the proper temperatures to be maintained in planes flying blood.

3. Refrigeration during transportation should be provided as soon as possible.2

2Captain Elliott recommended an immediate 5-percent increase in the daily airlift to Paris and also recommended, in view of an imminent request to increase shipments by 20 percent, that plans be set in train at once to implement this increase.


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On 1 February 1945, Maj. John J. McGraw, Jr., MC, Acting Chief Division of Surgical Physiology, Army Medical School, made the following comments on this report, through the Director, Army Medical School, to the Chief, Overseas Branch, Issue Section, Supply Division, Office of The Surgeon General, and to General Rankin (14):

On the basis of this report, there was no doubt that the Air Transport Command was carrying out a most efficient operation in the airlift of blood to Europe. To increase the efficiency and safety of the operation, it was recommended:

1. That Captain Elliott's recommendations concerning the maintenance of a temperature chart for the airlifted blood be instituted at once and that the chart originate with the center collecting the blood.

2. That the responsibility for handling blood be fixed at all stages en route and that those responsible be instructed to keep the temperatures of the blood as far as possible between 39 and 50 F (4 and 10 C.).

These recommendations were put into effect on 17 February 1945.

EXPENDABLE REFRIGERATION CONTAINERS FOR THE
OVERSEA AIRLIFTS

One highly favorable circumstance in the program of blood for Europe was that shipments began in late August and most of the bloods flown across the Atlantic without refrigeration were moved during the coldest part of the year, when overheating of the blood was unlikely. During this interim, active work continued on an expendable iced container, which was ready in the spring, when warmer weather began. Also during this period, the Navy accumulated sufficient experience flying blood to the Pacific in ACD solution to produce statistical evidence of its safety. The use of this solution permitted a reduction of 400 cc. in the size of the bottle, which largely compensated for the additional space occupied by the iced containers.

Containers

Navy container.-The Navy expendable refrigerated box was put into use as soon as the Navy airlift of blood to the Pacific began in November 1944. Trial runs began in September. When the insulated chests were demonstrated by Capt. Lloyd R. Newhouser, MC, USN, at the Conference on Blood Preservation on 19 January 1945 (11), about 19,000 bloods had been shipped in them by plane from San Francisco to Pearl Harbor, re-iced there, and then flown on to Guam, and thence to more forward points. The overall rate of discard had been 1.7 percent, and the reaction rate in about 6,000 transfusions had been 2.7 percent.

The Navy chest (fig. 140, p. 612) was made of plywood insulated with 3 inches of Fiberglass. It weighed 87 pounds packed and occupied 5.9 cubic feet. Inside, a galvanized iron receptacle contained a central canister filled


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with 15 pounds of ice and had space for sixteen 600-cc. flasks of blood in ACD solution.

Testing had been rigorous and had included parachute drops, without damage. The observations of Lt. (later Lt. Cdr.) Henry S. Blake, MC, USN, on a test shipment had shown that temperatures within the chest were maintained at 45.5 to 48 F. (7.5 to 9 C.).

Army container-The Army container (fig. l82, p. 762), as finally developed, was made of reinforced (double) cardboard, insulated with aluminum foil and cotton batting. It was both flameproof and moistureproof. Like the Navy box, it occupied 5.9 cubic feet. It was fitted with wire racks which held 24 recipient sets and twenty-four 600-cc. bottles of blood in ACD solution. The compartment for ice held 19 pounds, and both icing and re-icing were simple. The empty box weighed 35 pounds and, with its contents, about 105 pounds. The shipping weight per bottle was thus only 4 pounds, against 5 pounds per bottle for the Navy container.

The date and hour of packing were recorded on the instruction sheet on the lid of the box. Also recorded were the date and hour (about 48 hours later) when re-icing would be necessary if the box had not arrived at its destination.

Ice was supplied to the bleeding centers at Boston, New York, and Washington in the amount of about 1,000 pounds each per day. The blood was refrigerated as soon as it was collected, and the containers were re-iced as necessary before they were placed on the oversea planes and again after they were removed. Re-icing en route was cared for, by arrangement, by the Air Transport Command and the Naval Air Transport Service.

Specific instructions were given to all bleeding centers for the correct handling of the insulated boxes and the new solution bottles.

These containers proved entirely satisfactory throughout the remainder of the airlift. They also proved useful to oversea organizations, such as clearing stations, which had no refrigeration, as well as to installations in which refrigerating space was limited. The only real objection to them concerned their original color, a light, glossy tan. On occasion, stacks of empties in the field attracted enemy planes on strafing missions, particularly on moonlight nights. Advanced blood banks in the European theater quickly learned that these boxes must be camouflaged or destroyed. The same complaint was made about Navy boxes in the Pacific. Later, all containers were painted olive-drab.

Changeover to Refrigerated Containers and ACD Solution

The Reynolds Metal Co., without waiting for a formal order, provided six insulated sample containers, and they were shipped to Paris, two a day, on 26, 27, and 28 February. Each contained 24 bottles of blood. Observations en route and at the Paris Blood Bank indicated an entirely satisfactory per-


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formance (15). The temperature was at all times within the required range (39 to 50 F., 4 to 10 C.), and refrigeration lasted longer than the period set forth in the specifications for the containers. At the end of the longest run, 64 hours, the box still contained 10-12 pounds of ice, and all the bloods in it were in excellent condition.

Meantime, arrangements were made in the Zone of Interior for requisitioning the necessary containers and also for the changeover from Alsever's to ACD solution. All changes had to be carefully integrated with each other: The blood had to be flown to Europe daily; it could not be held over. Most centers did not have storage facilities for more than a 3-day supply of containers. Orders for the larger bottles of blood, containing Alsever's solution, had to be canceled, but only just in time for the bottles containing ACD solution to be ready in correlation with the delivery of the containers.

On 24 March 1945, Maj. Gen. Paul R. Hawley made the urgent request of The Surgeon General that, beginning at once, all blood shipped to the European theater be refrigerated and be put up in ACD solution (16). Alsever's solution, he said, had been satisfactory in respect to cell survival in the recipient within the age limits used, but the pressing need for refrigeration made it advisable to change to ACD solution, to reduce the volume of shipments but permit shipment of the same amount of blood. The theater experience with ACD solution had been too small for valid comparison with Alsever's solution, but he was willing to accept the NRC (National Research Council) pronouncement that it was at least as satisfactory.

When General Hawley made this request, practically everything in the Zone of Interior was ready for the changeover to ACD solution and the use of expendable insulated containers. In fact, a radiogram had already been sent to him on 19 February 1945, from the Office of The Surgeon General, informing him that the 1,200 bloods delivered daily to Paris unrefrigerated and in 1,000-cc. bottles in Alsever's solution would shortly be replaced by the same number in 600-cc. bottles in ACD solution and in insulated, expendable containers. The total weight requirement of each shipment would be 5,000 pounds and the total space requirement 320 cu. ft.

The new plans were put into effect on 1 April 1945, and the first blood was flown from the east coast to Europe under these arrangements on 9 April 1945.

Flying chilled blood to Europe on planes without refrigeration was a highly successful expedient. That it succeeded does not make the plan either wise or desirable. All future programs for the use of whole blood should include provisions for constant, reliable refrigeration.

On the other hand, this unrefrigerated blood saved an untold number of lives that would have been lost if, because refrigeration was lacking, no blood at all had been flown to Europe.


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References

1. Minutes, meeting of Subcommittee on Blood Procurement, Division of Medical Sciences, NRC, 18 Aug. 1941.

2. Rous, P., and Turner, J. R.: The Preservation of Living Red Blood Cells in Vitro. I. Methods of Preservation. J. Exper. Med. 23: 219-237, February 1916.

3. Kendrick, D. B.: Refrigeration Applications for Blood Plasma and Biologicals. Refrigerating Engineering 47: 33-39, January 1944.

4. Memorandums and correspondence on transportation of blood in Church containers, 5 Mar. 1943-15 Dec. 1943. [On file, Historical Unit, U.S. Army Medical Service, Walter Reed Army Medical Center, Washington, D.C.]

5. Memorandums and correspondence on shipment of blood by trucks, 9 June 1944-8 Aug. 1944. [On file, Historical Unit, U.S. Army Medical Service, Walter Reed Army Medical Center, Washington, D.C.]

6. Memorandum, Lt. Col. Douglas B. Kendrick, MC, to Chairman, Medical Department, Technical Committee, Office of The Surgeon General, 15 Nov. 1943, subject: Military Characteristics of Refrigerator for Frozen Biologicals.

7. Letter of Intent, Lt. Col. Douglas B. Kendrick, MC, to Mills Industries, 23 Nov. 1943, subject: Purchase of "Whole Blood Cabinet."

8. Memorandum, Lt. Col. Douglas B. Kendrick, MC, for Director, Technical Division, Surgeon General's Office, 24 May 1944, subject: Blood Transfusion Equipment, Field.

9. Memorandum, Lt. Col. D. B. Kendrick, MC, for Brig. Gen. Fred W. Rankin, 23 Aug. 1944, subject: Conference on Supply of Whole Blood for the ETO.

10. Bushby, S. R. M., Kekwick, A., Marriott, H. L., and Whitby, L. E. H.: Survival of Stored Red Cells After Transfusion. Lancet 2: 414-417, 5 Oct. 1940.

11. Minutes, Conference on Blood Preservation, Division of Medical Sciences, NRC, 19 Jan. 1945.

12. Kendrick, D. B., Elliott, J., Reichel, J., Jr., and Vaubel, E. K.: Supply of Preserved Blood to European Theater of Operations. Bull. U.S. Army M. Dept. No. 84, pp. 66-73, January 1945.

13. Memorandum, Capt. John Elliott, SnC, to Chief, Surgical Consultants Division, Office of The Surgeon General, through Director, Army Medical School, 1 Feb. 1945, subject: Transportation of Blood from the U.S. to the ETO Blood Bank in Paris.

14. Memorandum, Maj. John J. McGraw, Jr., MC, for Chief, Overseas Branch of Issue Division, Supply Section, Office of The Surgeon General, 1 Feb. 1945, subject: Report of Trip to ETO Blood Bank.

15. Memorandum, Capt. Leslie H. Tisdall, MC, for Chief, Development Branch, Office of The Surgeon General, 8 Mar. 1945, subject: Test Shipment of Refrigerated Blood.

16. Memorandum, Maj. Gen. Paul R. Hawley to The Surgeon General, 24 Mar. 1945, subject: Refrigeration of Blood for Trans-Atlantic Shipment.

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