KANDAHAR AIR FIELD, Afghanistan — Blood spurted out of the arm of an Afghan soldier as he lay unconscious in a U.S. military field hospital in Zabul province on Sept. 17.
The soldier, wounded in a rocket-propelled grenade attack, had a hole in his arm the size of a quarter and an obvious fracture that caused a sickening lump in his bicep.
Surgeons slit the length of his upper arm with a scalpel and drilled holes into the broken bones so that they could clamp them together.
All the while, the victim was losing blood, and it soon became clear that he could use some more. Thankfully, the medical team had the necessary units close at hand to infuse their patient.
But it had taken the hard work of many to get the blood to Zabul as well as dozens of other remote hospitals that the U.S. and its allies operate in Afghanistan.
The story of how the military gets blood to wounded personnel in a combat zone starts at base clinics all over the U.S., where servicemembers, civilians and families donate. Once donated blood is screened for infectious diseases, it’s flown from the East Coast to a trans-shipment center on a U.S. Air Force Base in Southwest Asia.
A shipment arrived at the base in mid-September on a contracted 747 cargo jet.
Made up of hundreds of 450-milliliter units of packed red blood cells carried in cardboard boxes and surrounded by ice, the shipment was then taken to the trans-shipment center and placed in high-tech coolers that are rigged to sound an alarm if their temperature changes.
The center — which opened in 2004 — sends 1,000 to 1,200 units of blood to Bagram and Kandahar air fields in Afghanistan each week, but it’s not as busy as it was a few years ago, when it was also supplying clinics in Iraq. In 2006, the center sent out 11,000 units of blood in a single week.
Packed red blood cells, which expire 45 days after they’re drawn, are a week old when they arrive at the center, which also receives other blood products such as frozen red blood cells, good for 10 years after they’re drawn, and frozen plasma and cryo-precipitate (a plasma extract), good for a year after they’re drawn.
The shipment didn’t sit for long. The day after the blood arrived at the center, it was loaded onto an Air Force C-130 transport plane, flown to Kandahar and delivered to the 932nd Blood Support Detachment — the Blood Knights. The unit’s executive officer, 1st Lt. Johnny Arterson, 34, of Albany, Ga., said Blood Knights at Kandahar and Bagram distribute blood to 33 medical treatment facilities in Afghanistan.
Not all the hospitals that get blood are American. U.S. blood products for the treatment of U.S. troops are sent to British hospitals at Camp Bastion and Forward Operating Base Shukvani and a Spanish hospital in Herat, Arterson said.
“We look at what units are using and the type of blood they are using and we try to project out what medical professionals in an area will need so they always have the freshest, safest blood,” he said.
Some blood products that can’t be flown into theater are platelets — components of the blood that assist with clotting and hemostasis (the process that stops bleeding). The military started giving platelets to troops in Iraq and they are widely used in Afghanistan today.
Platelets have a much shorter shelf life than other blood products — seven days — and they need to be agitated constantly. So instead of flying them to Afghanistan, the military collects platelets from donors at Kandahar and Bagram to distribute to treatment centers every few days.
The Blood Knights’ commander, Capt. Ronnie Hill, 36, of San Angelo, Texas, said there have been many advances made in the use of blood products during the Iraq and Afghan wars.
For example, “Golden Hour” containers — small coolers that are used to transport blood — were fielded during Operation Iraqi Freedom allowing first responders to infuse it closer to the time of injury, he said.
“Vampire” missions, where medics carry a mobile blood infuser on a helicopter and pump blood into a patient in flight, began in Afghanistan last summer and are credited with saving numerous lives.
One of the biggest users of blood products in Afghanistan is the NATO Role 3 hospital at Kandahar. In August, for example, doctors there infused 237 units of blood products. Some patients with very serious injuries get dozens of units. Children or adults with minor wounds, only get a few.
One morning last month, Petty Officer 2nd Class Robert Lund, 32, of Marysville, Mich., cradled a year-old Afghan child in his arms at the Role 3 facility. The boy, who hospital staff did not name because of patient privacy laws, had a bandaged stump where his left leg used to be. Both his parents and a sibling had been killed a few weeks earlier when the family’s motorcycle hit a roadside bomb.
Doctors gave him a blood transfusion during the operation that saved his life, said Lund, a hospital corpsman for the Navy.
“He’s doing great compared to where he was,” said the father of two.
While Lund was comforting the Afghan child, surgeons in the hospital’s trauma bay tended to a wounded Afghan soldier whose head was injured so badly in a rocket attack that part of his brain was visible.
In the hospital’s laboratory, Petty Officer 2nd Class Ryan Serrano, 30, of the Philippines, analyzed a blood sample from the wounded man to find out his type. Patients who need a transfusion initially receive type O blood, which anyone can tolerate. Once their blood type is known, they usually get that kind.
It only took the corpsman a few minutes to get the soldier’s type by whirling a test-tube full of blood in a centrifuge and mixing it with other types. He took great care and had another medic check his results, because infusing the wrong blood type can provoke an allergic and even fatal reaction.
The same process goes on when patients arrive at the field hospital on Forward Operating Base Apache in southern Afghanistan’s Zabul province — a place as close to the battlefield as any treatment center in theater.
“We are a modern day M*A*S*H (Mobile Army Surgical Hospital) facility,” said Navy Capt. James Bates, 48, of Coronado, Calif., commander of a 24-person Forward Surgical Team working at the hospital last month.
Medical personnel in Zabul focus on preserving life, limb and eyesight before patients are flown to the Role 3 at Kandahar, he said.
The plywood building where they work includes a trauma bay with three beds, an operating room where two patients can be operated on at once, and a recovery room where staff prepare patients for medevac.
A routine helicopter flight from Kandahar brought a batch of blood products to FOB Apache where Petty Officer 2nd Class Roberto Sanchez, 28, of Houston, stored them in refrigerators next to the operating room.
As of last month, most of the patients who the team at FOB Apache had treated were Afghan soldiers. Only a few American and Romanian troops had required surgery there over summer, according to team members.
When the Afghan soldier with the hole in his arm and broken bones from the rocket attack arrived, Sanchez checked his blood type, prepared four units of packed red blood cells and defrosted four units of fresh frozen plasma in case it was needed.
Since the Navy team arrived in April they’d infused about 200 units of blood into 50 patients. A bad casualty can go through 16 units of blood, Sanchez said.
On April 6, after suicide bombers killed several U.S. personnel and injured more than 20 other people in Zabul, FOB Apache activated its “walk-in blood bank,” a group of donors who give blood if there isn’t enough at the hospital to cope in an emergency.
Navy Cmdr. James Feeney, 44, of Simsbury, Conn., the chief surgeon at Apache, said the fresh whole blood used in that case was actually better than preserved blood products because it had more clotting factors and could carry oxygen to the body immediately, unlike stored blood products, which are degraded by chemicals added to preserve them.
Unfortunately, whole blood is not approved for use by the Food and Drug Administration. The Army is the only U.S. organization that has researched its efficacy, but the results appear “spectacular,” Feeney said.
Not all the effects of blood transfusions are positive.
Recipients are more prone to infections, not just of wounds but also lung and urinary tract infections that might be a result of an immune-suppression effect. So giving a patient hetastarch — a product that boosts the volume of fluid in their veins — is sometimes a good alternative to blood products, especially with young healthy patients like soldiers, Feeney said.
However, red blood cell transfusions are great at expanding the volume of fluid in a patient, since they don’t leach through veins and arteries like intravenous fluids, he said.
As surgeons worked on the soldier with the broken arm, the anesthesiologist, Navy Lt. Commander Robert Brett Goy, ran tests to gauge his patient’s condition. He looked at a range of factors to include the man’s heart rate and blood pressure before deciding that he’d benefit from a transfusion of two units of packed red blood cells and two units of plasma.
The patient’s condition determines the quantity and types of blood products that might be infused, he said.
“He was having problems with his blood pressure and his heart rate was high,” Goy said. “I gave him a couple of liters of fluid and he responded a little, but his blood sugar was low. I felt he’d benefit from a little bit of blood especially since he’s going to an Afghan hospital. They are not quite as likely to monitor those things post-operatively.”
Doctors expected the Afghan soldier with the broken arm to make a full recovery.
Back at Kandahar, the Regional Command-South and 4th Infantry Division surgeon Lt. Col. Chris Jarvis, 43, of St. Louis, said advances in the use of blood products Iraq and Afghanistan will change the way transfusions are done in U.S. civilian hospitals.
Death rates from combat wounds are now 5 percent to 7 percent in Afghanistan. That compares to 25 percent death rate from combat wounds in Vietnam and a 20 percent death rate during Desert Shield/Desert Storm, he said.
“The use of tourniquets and other methods of hemorrhage control have been what have led to this dramatic improvement,” he said. “As a product of that we need blood because they are going to lose a lot during primary surgery at the Role 2 and Role 3 locations.”
In Regional Command-South in the last six months, doctors have pumped more than 1,200 units of blood into about 250 soldiers. In one case a soldier wounded in Afghanistan received 78 units of blood products, Jarvis said.
“The No. 1 killer on the battlefield has always been hemorrhage and it is almost always been from an extremity wound — an amputation” he said. “Now that we have learned how to control the bleeding people are living with an injury that, historically, almost always led to death.”