Massive transfusion needs during war or other casualties

INTRODUCTION In today's world, it is imperative to be prepared for the worst possible situations like disasters. A disaster is a sudden, calamitous event that seriously disrupts the functioning of a community or society and causes human, material, and economic or environmental losses that exceed the community's or society's ability to cope using its own resources. Disasters can be natural or anthropogenic or human-made and technological in nature that can impact a community.[1] Natural disasters are naturally occurring physical phenomena caused either by rapid- or slow-onset events which can be geophysical (earthquakes, landslides, tsunamis, and volcanic eruptions), hydrological (floods and avalanches), climatological (drought, wildfires, and extreme temperatures), meteorological (cyclones and storms), or biological (disease epidemics and insect or animal plagues). Human-made disasters can be both intentional and unintentional, resulting from human intent, negligence, and/or errors.[2] Wars and terrorist attacks are the classic examples of human-made disasters. India has faced about five wars against its neighbors and several terrorist attacks since independence [Table 1].[34]Table 1: Chronological list of wars and all major terror attacks in India that led to death and injuriesMASS CASUALTY EVENT Massive disasters such as natural calamities, epidemics, fire accidents, terrorist attacks, and war outrages may lead to mass casualty event (MCE), affecting a large number of people and usually require an emergency medical support. MCE is an incident in which emergency medical service resources such as personnel, life-saving drugs, and equipment are overwhelmed by the number and severity of casualties. MCE can be defined as any event resulting in a number of victims large enough to disrupt the normal course of emergency and health-care services.[5] MCE is marked by a relatively sudden and dramatic event that causes a surge in a number of patients.[6] BLOOD TRANSFUSION AT TIMES OF DISASTER Blood transfusion services play a critical role in the provision of medical care by providing life-saving safe blood and blood components to the needy patients affected by disasters due to human-made or natural hazards. It is a key enabler to the response to MCE. The safe and timely provision of blood products is of crucial importance in the prevention and mitigation of morbidity and mortality due to traumatic injuries.[7] Blood bank operations and blood transfusion services must be coordinated with other clinical teams dealing with MCE. Transfusion demand and capability planning should be an integral part of the medical planning process for emergency system preparedness.[8] Timely flow of information to the blood bank, namely, relevant data and the number of blood units required, might help in the initial estimates of the need of blood and blood components in the effective management of MCE. BLOOD TRANSFUSIONS IN RELATION TO WORLD WAR Blood transfusion was the most important medical advance of World War I. Prior to World War I, blood transfusion was a rarely performed and risky procedure. On the eve of the war, scientific development in relation to transfusion technology progressed, making it a more viable procedure. Canadian and American surgeons pioneered blood transfusion techniques during the War. Blood transfusion has been proved to be an important factor in reducing the number of deaths in every subsequent war in countries able to support organized systems of transfusion. Maj. L. B. Robertson of the Canadian Army Medical Corps performed a number of transfusions, without crossmatching, in 1916 and 1917, and wrote articles discussing his successes. He initiated new techniques, such as the syringe–cannula technique, that simplified transfusion procedures.[9] Peyton Rous et al. at the Rockefeller Institute developed the tools of modern blood banking, namely, hemagglutination blood typing and red blood cell (RBC) storage solutions. These tools were utilized in the battlefield by Rous's postdoctoral student Lieutenant Oswald Robertson of the Medical Officer Reserve Corps, US Army, in 1917. Robertson demonstrated the effectiveness of using typed, stored blood for transfusions in 1917 and was an instrumental force behind popularizing this procedure during the war. Blood transfusion became the accepted resuscitation therapy in the British Expeditionary Force where many American hospitals and physicians were attacked in March 1918. Based on the World War I experience, the British entered World War II with a functioning blood transfusion system based on the Robertson model.[10] In an outbreak of MCE, about 50%–80% of the acute casualties were usually transferred to the closest medical facilities within a short period of time. The casualties need to be treated within the first golden 3–6 h of reaching the health-care facilities. Hemorrhage is the leading cause of preventable mortality in these patients, which accounts for 50% of fatalities in the first 24 h. One of the greatest hazards of hemorrhage by the wounded is shock. Many British doctors initially preferred to treat shock with infusions of saline or of “Bayliss' gummy solution” – a colloid preparation of gum Arabic (from the sap of the Acacia tree), suggested by physiologist William Bayliss. When Canadian physicians joined the war in support of the British Empire, they introduced the syringe and paraffin tube methods of blood transfusion. Notable among the Canadians was L. Bruce Robertson from Toronto who had recently trained with Lindemann in New York and who published his wartime transfusion experiences in the British Medical Journal in 1916–1917, highlighting the benefits of infusing blood.[11] BLOOD REQUIREMENT IN MASS CASUALTY EVENT As per the mass casualty management data, the infusion of fresh whole blood to the trauma victim is considered to be the best transfusion therapy. Between 62% and 74% of the total requirements of either whole blood or packed RBC (PRBC) in the first 24 h of MCE occurs within the first 4 h. In an emergency where type-specific blood is not available or where blood grouping cannot be done due to shortage of time or resources, the following guidelines will be followed: For whole blood or PRBC: O-ve group of blood shall be issued primarily to the women of childbearing age. O+ve group of blood may be issued to men and women of age group above 50 For fresh frozen plasma: AB Plasma shall be issued For platelet: ABO Compatible platelets shall be issued.[12] However, the normal protocol shall be to transfuse crossmatched blood if the patient's clinical status permits about 30 to 45-min wait for the complete crossmatching process. Even if the situation is emergent, it is ideal to use group-specific blood where possible, to avoid depleting type O blood component stock. Transfusing type-specific blood has been shown to be safe in trauma situations and avoids the transfusion of significant anti-A and anti-B antibodies from the residual plasma in packed O red cell units. Studies have shown that blood typing and screening for unexpected antibodies can be completed within 30 min of trauma patient's arrival even during MCE. Hence, group-specific blood components can be transfused wherever possible. MEETING BLOOD NEEDS DURING MASS CASUALTY EVENT Historically, blood supply needs during disaster response have been met with the quantity of products available locally. During MCE, communications may be disrupted, and transportation of supplies may not be possible due to bridge collapse or impassable roads. Promotion of local blood donation may be helpful to maintain product supplies in an emergency requirement. The awareness and publicity given for blood donation and transfusion during World War II helped to create a strong link in the public mind between the individual act of donating blood and the care of victims of war and disaster. Recently, worldwide efforts have been undertaken to utilize social media and smartphone applications to make the blood donation process more convenient, offer additional services, and create communities around blood donation centers. India has a fragmented blood transfusion system which is demand driven and is predominantly relies on replacement donors and to some extent voluntary blood donors. Moreover, most blood banks work in isolation and are not integrated with other blood donation centers and health organizations, which may impact the blood donation and blood transfusion services' quality in the event of MCE. PLANNING FOR DISASTER MANAGEMENT Prediction and planning is essential for both blood demand and supply management in the time of MCE [Table 2]. With the advent of information technology, simulation models are available to improve our understanding of blood demand and supply as well as test potential strategies for managing instances of overwhelming demand following MCE. All the blood banks shall have a standard operating protocol to handle the emergency whenever a notification of an MCE is received. The standard operation protocol shall be related to positioning of trained personnel for the specific activities; recording and reporting on the existing inventories of blood and blood components, raw materials, namely, blood collection bags, and reagents for processing of blood components; ordering of required inventories and follow-up for immediate supply; shifting of work priorities during the event; handling both victim and donor samples; and issuing safe blood and blood components in time for transfusion.[7] An emergency operations plan (EOP) shall be created, and the staff members shall be trained through education, assigning rolls, and practicing and reviewing the EOP. By discussing the risks, explaining the staff responsibilities, identifying the communication methods, and outlining the authority structure, the staff members can understand their roles and responsibilities and get prepared to handle the emergency at the time of MCE.[13] Attention must also be paid to cold chain management, especially during the transport of blood between organizations and departments.Table 2: Blood transfusion management during mass casualty eventFurther, in the mass casualty conditions, blood bank personnel should be made alert to a potential blood collection error and mistransfusion errors. Unidentified patients are subjected to errors due to the limitation in their temporary identification number. Modern technologies, including error reduction design wristbands, barcode-based system, or radiofrequency identification tags, may help enhance the reliability of patient identification and providing the right component in the mass casualty setup. It is imperative to maintain the quality of the process and products even during the emergency requirements. The National Accreditation Board for Hospitals and Healthcare Providers provides all the requirements related to hospital safety, risk management, disaster planning, monitoring, and evaluation. These standards provide a framework for quality assurance and quality improvement and focus on patient safety, employee safety, community and environment safety, and quality of patient care. The Chapters Facility Management and Safety and Continuous Quality Improvement directly focus on emergency response and management including disaster management and relevant indicators and their monitoring to check the compliance to these standards on a continuous basis.[14] TRANSFUSION OF BLOOD COMPONENTS Blood transfusion services are crucial for saving lives in massive disaster situations. Providing safe blood and blood components at the times of war-like scenarios and MCE is not only a challenge to the blood transfusion service but also a time to showcase the efficiency and commitment of the transfusion services in the service of the nation. Transfusion of PRBC serves as a life-saving or resuscitation treatment in MCE, especially in the first 2 h after admission when the patients are getting transferred to the operating room for emergency treatment. The mean demand for blood units is more than 50% at this time. During the deadliest mass shooting in Las Vegas, USA, on October 1, 2017, about 58 people were killed and more than 600 people were injured. About 185 mass shooting victims were admitted in three health-care units. During the first 24 h, these patients received 499 blood components or 2.7 units per admission.[15] The release of blood components for transfusion in an emergency situation of MCE from blood bank may occur in one of the following three pathways: (1) in an emergency when there is no time available to verify the blood grouping of the patient, an emergency type O negative blood or O positive is released on arrival based on the sex and age of the patient; (2) when some time is available to do the blood grouping of the patient, group-specific blood units can be released for transfusion based on immediate-spin crossmatch only to verify the major blood group compatibility between the patient's and the donor's blood units which may take approximately 10 min from the first blood specimen tube's arrival to the blood bank; (3) after full blood grouping and Anti-Human Globulin (AHG) crossmatch or a complete type and screen for unexpected antibody and immediate-spin crossmatch has been performed which may take about 30–45 min of receiving blood specimen tubes. If a patient is transfused with the blood units released based on the 1st or 2nd pathway, a complete type and screening and/or AHG crossmatch will be performed and the treating physician will be notified of the result as soon as it is available.[7] HANDLING BLOOD DONATION DURING MASS CASUALTY EVENT Careful planning and execution is essential to ensure the uninterrupted transfusion services during emergency conditions. It is also very important to have control over the number of blood units collected versus requirement. During the time of disaster, the response for blood donation may be disproportionate to the medical need. The surge of blood donors with patriotism may hamper the blood collection and processing system. It may also put pressure and increased workload on the blood bank personnel as well as depletion of raw materials used for blood collection and processing. United Blood Services, the Las Vegas blood bank, now called Vitalant, reported receiving 791 donations immediately after the Las Vegas mass shooting and reported that 137 of these donations (17%) were “wasted,” meaning that the donated blood went unused and was subsequently discarded.[15] Drash[16] reported that hundreds of volunteers lined up to donate blood in the aftermath of the mass shooting at a Pittsburgh synagogue and said that calls for blood donations after such MCEs are not always necessary and may not be the best immediate response to such tragedies. The public call for blood donors was not necessary to meet immediate demand and led to resource waste. The American Red Cross, which supplies about 40% of the nation's blood and blood components, said “it is grateful that blood donation is one way people consider helping when tragedy strikes. However, it is important to emphasize that the need for blood is constant and the Red Cross depends on the generosity of volunteer blood donors to provide lifesaving blood for those in need each and every day and not only during times of emergency.” Blood is a precious commodity, and it should never be wasted. Hence, it is important to encourage the people to donate regularly rather than in the immediate aftermaths of MCE. It is advisable to drive the awareness that blood required for today's disaster was donated yesterday. Working with the media to communicate consistently to the public on the actual requirement of blood donation will help to minimize the influx of donors. Further, such donors may be redirected to donate blood units later when there is an immediate requirement.[17] Blood banks should prepare emergency plans to handle the MCE and incorporate them into the health sector's general disaster plans in coordination with the national disaster program. Maintaining regular donation and sufficiency of the blood inventory is more important than handling emergency donation in times of crisis. A task force may be assigned, and all the team members of the task force shall be trained on the EOP for managing the MCE. Post training, the task force team should practice on a regular basis, identify the flaws in the system, and they should be corrected. This helps in providing possible care for the needy patients.

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