Time is crucial in the collection, delivery, and distribution of whole blood for large numbers of traumatic casualties. From 1965 forward, the stimulus behind the plans for a whole blood distribution program to support U.S. forces in the war in Vietnam was the need for speed. Blood is perishable, and its useful life is short. From donor to patient, liquefied whole blood has a life expectancy of 21 days. Still, the most desirable blood for transfusion is the freshest blood available of the group and type specific for the recipient, completely and accurately processed and cross matched- a combination of perfections difficult to achieve in war.

The dominant conviction of the early blood program planners in USARPAC and USARV was that whole blood requires professional surveillance in handling from the moment it is drawn from the donor until the moment it is administered to the patient. Contaminated blood can be lethal.

By 1965 and the buildup of forces in Vietnam, the time had come to move with haste. Fortunately for the planners, requirements for whole blood increased slowly in 1965 and not with the same explosive force experienced at the beginning of the Korean War. Another asset was the substantial number of directives and guides already written and the existence of the Military Blood Program Agency.

Colonel Neel, Surgeon, USMACV, Major (later Colonel) Frank W. Kiel, MC, Commanding Officer, 406th Mobile Medical Laboratory, Vietnam, and Colonel Joseph F, Metzger, MC, Commanding Officer, 406th Medical Laboratory, Japan, in late 1965, were guided by three major principles based on experience gained thus far in the collection, processing, handling, and distribution of blood for troops in Vietnam. These medical officers, however, could not envision that requirements for whole blood would climb slowly but steadily from less than 100 units per month in 1965 to 8,000 units by February 1966, skyrocket to more than 30,000 units per month by 1968, peak at 38,000 units in February 1969, and fall rapidly to less than 15,000 units by mid-1970.(Chart 12)

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CHART 12- UNITS OF BLOOD AVAILABLE IN SOUTH VIETNAM, BY MONTH,
JANUARY 1965-DECEMBER 1970 ¹

¹Includes shipments from the continental United States, the Pacific Command, and blood collected in South Vietnam.
Source: Report, US Military Whole Blood Program in support of Combat Operations South Vietnam, 1965-1970, prepared for the Deputy Surgeon General, February 1971.

The first guiding principle was that a source of whole blood outside Vietnam and the Pacific Command was essential. Donor resources in the Pacific could not meet the demands for whole blood during the buildup. Second was the establishment of a central depot in Saigon where all whole blood shipped from Japan could be received, transshipped, and distributed for use in the field. Third was the need for a system of forward mobile blood storage subdepots operated by the Army and colocated with hospitals and medical units in the Army, Navy, and Air Force along the South Vietnam coast.

A single American hospital in Vietnam, the 8th Field Hospital, administered all whole blood transfusions until the spring of 1965. Every 10 days, 10 units of universal donor low titer group O blood were shipped to the hospital from Japan to meet the small demand for transfusions. Seldom did the demand for blood exceed the supply, and even during the surprise attacks by the Vietcong at Qui Nhon and Pleiku, in February 1965, the 406th Mobile Medical Laboratory bled local donors to supply the needed 123 units of whole blood. After the 3d Field Hospital arrived in Saigon in May 1965, it became the central blood depot in Vietnam, and the 406th Mobile Medical Laboratory, a satellite of the 406th Medical Laboratory in Japan, was charged with distributing whole blood to all US forces in Vietnam.

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In the meantime, with the expanding need for blood, reorganization of the whole blood program for PACOM (Pacific Command) was underway. Colonel Metzger was also designated Blood Program Officer, PACOM, with direct responsibility to CINCUSARPAC (Commander in Chief, US. Army, Pacific) for the co-ordination and integration of plans, policies, and procedures to insure blood for all areas in USARPAC, including USARV.

The embryonic whole blood distribution system in Vietnam, continued to expand and by 1967 was serving all Free World forces in Vietnam, excluding the RVN Arm which met its own blood needs. The responsibility for supervising and operating the central blood bank in Vietnam came under the, technical direction of Colonel Hinton J. Baker, MC, Commanding Officer, 9th Medical Laboratory, 3d Field Hospital, Saigon. The USARV Central Blood Bank operated under the parent laboratory's 9th Medical Laboratory Detachment and was supported by personnel from the 3d and 51st Field Hospitals, and five subdepots in the blood distribution system: the 406th, 528th, and 946th Mobile Medical Laboratories at Nha Trang, Qui Nhon, and Long Binh, respectively; the Naval Support Activity Hospital, Da Nang; and the 96th Evacuation Hospital, Vung Tau.

As troop strength grew and combat casualties increased, the task of distributing whole blood, plasma, and related products in South Vietnam developed into the largest blood distribution system ever undertaken by a single organization.

Colonel James E. McCarty, MC, became Blood Program Officer, PACOM, in June 1968 and commander of the 406th in Japan at the same time. He and his predecessor, Colonel Metzger, visited South Vietnam regularly, conferred with the surgeon, and inspected blood facilities throughout the country.

The primary source for whole blood used in South Vietnam until July 1966 was the 406th Medical Laboratory in Japan. Mobile bleeding teams were dispatched from the laboratory to donor resources in Japan, Korea, Okinawa, and Taiwan. A very valuable donor resource was found in the Yokosuka Naval Base when the Pacific fleet came in, and reserve donor resources also existed in Hawaii, Guam, and the Philippines. With vigorous command support and the dedicated work of blood-drawing teams, supply kept, pace with demand until June 1966. Blood collections in, PACOM rose from 201 units in January 1965 to 7,426 in January 1966 and 12,984 in June 1966.

Blood collected in PACOM was processed and shipped from the 406th in Japan to large troop concentrations along the coast of South

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Vietnam at Saigon, Nha Trang, Qui Nhon, and DA Nang. By 1965, it was apparent that this plan would not work because aircraft could not be scheduled economically from Japan to each of the four areas regularly enough to keep the supply levels of blood at the proper level. Communications between Japan and the coastal cities were poor, and shipments of blood often arrived in Vietnam without the knowledge of those persons handling it. Planners had also become sharply aware that blood could not be, handled as a routine supply item even in a dedicated medical supply system.

In short, by 1965 it was clear in PACOM that the whole blood distribution system should consist of a central depot in Saigon with several small mobile subdepots located in areas of high troop intensity.

The Military Blood Program Agency

In June 1966, the need for whole blood in Vietnam became urgent. Blood donor resources in PACOM had been exceeded, and the blood program officer estimated that 1,000 units of low titer group O blood per week would be needed. CINCUSARPAC sent a request, to the MBPA (Military Blood Program Agency) to ship the needed blood to the 406th.

Four years earlier, in May 1962, responsibility for implementing and coordinating the whole blood, program in CONUS was delegated to the Secretary of the Army by the Secretary of Defense. Hence, The Surgeon General of the Army established the MBPA on 17 July 1962 to support emergency requirements for whole blood in war. The agency, staffed by medical officers of the three services, maintained close working relationships with the US Public Health Service, the Office of Emergency Planning, Executive Office of the President, and the American Red Cross.

Armed Services Whole Blood Processing Laboratory

The MBPA incorporated the donor collection and processing capabilities of the three military departments. Blood was collected by 42 donor centers designated by The Surgeons General of the Army, Navy, and Air Force and shipped by air to the triservice ASWBPL (Armed Services Whole Blood Processing Laboratory), McGuire Air Force Base. (Chart 13) All group O blood was titered, and after a thorough inspection and verification of groups, Rh types, and other essentials, blood was flown via Elmendorf Air Force Base, Alaska, to Yokota Air Force Base in Japan. At each point, shipments were, re-iced, if necessary, and flown to the 406th Medical Laboratory in Japan. From Japan, whole blood was

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flown to the 9th Medical Laboratory, Saigon, and distributed from there to subdepots in South Vietnam.

The first shipment of whole blood, 2,036 units, arrived in Japan from the United States in July 1966.

From July 1966 to 1967, two shipments of 1,500 to 2,500 units of whole blood were received from CONUS each week. To boost blood needs, Colonel Metzger recommended in 1967 that daily shipments to total 5,000 units each week be made from CONUS to arrive in Japan early in the morning, from Mondays through Fridays. Daily shipments began in mid-August 1967. The total number of units of blood collected and shipped to Vietnam are shown in Table 9.

¹ The total figures for each year include blood shipped to the 406th Medical Laboratory in Japan by CONUS and that collected in PACOM by the 406th.
² Excludes blood collected and shipped in December 1970. December statistics were not available.
Source: Report, Administrative Division, 406th Medical Laboratory, USAMC, Japan,1970.

From 1969, whole blood was flown by MATS C-141 Starlifter to Japan. This blood, plus fresh frozen plasma and whole blood obtained by the 406th, was flown by commercial airline to the USARV Central Blood Bank in Saigon and after June 1969 to Cam Ranh Bay, the new location of the blood bank. (Map 5) Blood was approximately 7 days old by this time. Most of it went forward by C-130 fixed wing aircraft to one of the six subdepots at Long Binh, Nha Trang, Qui Nhon, Pleiku, Chu Lai, and DA Nang. From these subdepots, blood of all types and fresh frozen plasma were sent by fixed wing aircraft, helicopter, or ambulance to the various field, evacuation, and surgical hospitals. Low titer group

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Map 5

O positive blood was shipped from the subdepots to division clearing stations by helicopter.

The Department of Defense, and thus MBPA, felt that blood quotas should be assigned according to available donor resources. The military departments originally felt that quotas should be assigned according to

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their blood requirements. Fortunately, this problem was resolved early and essentially the following distribution prevailed:

After the Tet Offensive in 1968, military officials feared that another such offensive would interrupt the supply of blood from the USARV Central Blood Bank in Saigon, or that the airfield at Tan Son Nhut might be seized. Plans were initiated to construct a new central blood bank at Cam Ranh Bay on the grounds of the 6th Convalescent Center. The new laboratory was completed in June 1969 and the USARV Central Blood Bank moved there in July 1969.

The building, with 1,000 square feet of laboratory floor space and 600 square feet of' cement under cover, accommodated a 1,800 cubic foot walk-in refrigerator. The neat new structure was considered to be in a more secure area at Cam Ranh Bay than in Saigon, and air transportation from Japan was readily available. (See Map 5.) Maximum flexibility was achieved by the relocation of the central blood bank. The

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3d Field Hospital, redesignated a subdepot, could quickly revert to a central blood bank if an emergency arose, and the subdepot at DA Nang, after expansion, was fully capable of serving as a central blood bank.

In early 1965, it was decided that only universal donor low titer group O blood would be shipped to Vietnam, and that the use of group and type-specific blood would be confined to the offshore hospitals in Japan and in the Philippines. The great advantage of universal donor blood is that it is impossible to give a patient the wrong group of blood. As the requirements for blood increased, and as hospitals in Vietnam became more sophisticated, blood program officials decided to utilize fully the available donor population. Less than 45 percent of the donor population had group O low titer blood, and 55 percent of the donor population was not being bled.

The first shipments of group A blood arrived in Vietnam in December 1965, and shipments with random blood group distribution, groups A, AB, B, and O, without selection, arrived in January 1966. The clearing companies and forward surgical hospitals continued to use only group O low titer blood because they could not cross, match, but evacuation hospitals began to give other type-specific transfusions almost exclusively.

Unfortunately, random shipments resulted in excessive amounts of group A blood in the depots in Vietnam. With the institution of shipments from CONUS by MBPA in July 1966, the numbers of units of universal donor group O low titer blood shipped to Vietnam increased, and by 1967, shipments exceeded requirements by 65 percent. As more and more Vietnamese were cared for in US military hospitals, with the Vietnamization of the combat role, a new problem with blood group distribution arose. The requirements for group B increased in proportion to the number of Vietnamese admitted to American military hospitals. The approximate percentage blood group distribution for American and Vietnamese populations in the following tabulation readily show that Vietnamese required more group B blood:

Hemolytic and Nonhemolytic Transfusion Reactions

Between March 1967 and June 1969, approximately 364,900 transfusions were recorded. During that period, 38 hemolytic and 979 nonhemolytic transfusion reactions were reported, or about 1 hemolytic,

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transfusion reaction per 9,600 transfusions and one nonhemolytic reaction per 370 transfusions. Causes of the nonhemolytic reactions are unknown and while they never threatened life, these reactions were considered detrimental to the well-being of the severely wounded patient. The cause of these reactions is exceedingly complex, and much research is needed in this neglected field.

The Coagulopathies

Bleeding problems, called variously the oozing syndrome, tomato juice syndrome, or red ink syndrome, were frightening to the most experienced battle surgeon. To see a patient suddenly begin to bleed profusely from every orifice and wound just as heroic surgery appeared to be successful was a dramatic experience.

Coagulopathies may be divided into two groups, if it is remembered that the division is an oversimplification. Since coagulopathies usually occur in combinations and rarely in the pure form, study under field conditions is almost impossible. Coagulopathies that, respond well to fresh blood are attributed to deficiencies of platelets or deficiencies of coagulation principles other than platelets. The latter principles respond well to fresh frozen plasma or fresh blood. Coagulopathies that do not respond well to fresh blood may be attributed to circulating anticoagulants, disseminated intravascular coagulation, or circulating intravascular fibrinolysins.

While physicians generally recognized the classification of coagulopathies, there was little agreement about the proper treatment. One group of physicians treated all coagulation problems with fresh blood while others differentiated the various syndromes and used more specific treatments, such as fresh blood, fresh frozen plasma, cortisone, heparin, epsilon, aminocaproic acid- or prayer. Fortunately the number of patients suffering from coagulation problems was small, but the threat after massive, transfusions and surgery was ever present.

In April, 1968, fresh frozen plasma was introduced in Vietnam as a means for controlling coagulopathies following surgery and massive transfusions. The availability of fresh frozen plasma resulted in a decrease in the, quantity of fresh whole blood drawn in Vietnam. Fresh plasma is obtained at the 406th Medical Laboratory in Japan by the process of plasmapheresis from a limited group of donors of the AB group- the ideal donors for fresh plasma. These donors may be bled every week or every other week. Blood from them is spun down, plasma rises to the top, and red cells settle at the bottom. While plasma is drawn off in satellite bags and frozen immediately, red cells are returned to the donor.

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Since plasma proteins are replenished rapidly, each donor may contribute 2 units weekly for as long as 2 years, without effects . Donors in the AB group have no isoantibodies in their plasma and it may be given to patients of any blood type- a real breakthrough.

The amount of whole blood outdated because, it was not used in 21 days was frequently significant and occasionally, during lulls in the fighting, reached 50 percent of the blood in Vietnam per month. The average amount of outdating was approximately 29 percent with extremes of 9 percent and 50 percent.

Use, of whole blood was best during periods of greatest military activity. While much speculation and discussion transpired about this significant problem, the simple facts are that blood was usually from 4 to 7 days old before it arrived in Vietnam. Outdating was difficult to eliminate because filling requisitions instantly for subdepots throughout Vietnam was impossible. Some waste of blood was the price that bad to be paid to assure that not one fighting man would die for the want of blood.

Most blood 21 to 31 days old was shipped to ARVN hospitals for local use and for Free World forces if they desired it. During the early days of the buildup, 31-day-old blood was destroyed, but as the war progressed, blood was converted to plasma lyophilized by the vacuum system.

Lengthening the Life of Blood

Efforts were constantly made to extend the shelf life, of blood. One of the most promising was the addition of small amounts of the amino acid adenine which increased the shelf life of whole blood to 40 days. Blood with such an additive was tried on a limited basis in Vietnam during 1969. The blood was transfused to patients admitted to the hospitals at Long Binh, and no adverse effects were found in numbers of clinical tests. As soon as the oxygen-carrying capacity of adenine-treated red cells can be improved, adenine may well be added to all units of

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liquid preserved blood used in combat military blood banking. Experiments indicate that the oxygen-carrying capacity of treated red cells may be increased by adding small amounts of inosine.

Freezers for Fresh Frozen Plasma

The freezing compartment of an ordinary refrigerator is not cold enough to keep fresh frozen plasma for more, than a week or two. Factor V, the most critical of all clotting f actors, is present in the plasma, and it deteriorates slowly at temperatures above -20°C. A small freezer, used by construction engineers to cool steel rivets, was ideal for storing fresh frozen plasma. Steel rivets contract when cooled and expand to give a snug fit as they warm up. After diligent searching, enough of these freezers were found for all hospitals in Vietnam. By July 1969, a newly designed 4-cubic foot freezer, similar to the construction engineer's freezer, was issued in Vietnam.

The Styrofoam Blood Box

While the war in South Vietnam will be remembered by most military men as the war in which air mobility came of age, it will be remembered by many people, both Vietnamese and American, as the war of the white styrofoam blood box. The Styrofoam blood box was introduced in late 1965 and was without question one of the most important technical advancements to come out of the blood distribution program. Major William S. Collins II, director of the blood bank at the 406th Medical Laboratory, suggested modifying the standard disposable blood box by replacing the cardboard divide insert with a Styrofoam insert which he had devised. The new insert, when placed in a cardboard shipping container, permitted shipment of blood at the required temperature regardless of outside temperatures. The shipping container is easier to handle and was less susceptible to damage or destruction. Major Collins received $935 for his suggestion, and his innovation resulted in a first-year savings of $56,000 and a new flexibility in military blood banking.

The Collins box, which occupies only 3 cubic feet and weighs only 40 pounds when filled with 18 units of whole blood and wet ice, replaced the Hollinger box, which occupies 8 cubic feet and weighs 115 pounds when filled with 24 units of blood and wet ice. In addition to weighing less, the Collins box offers other equally important advantages: it costs only $1.40, or $98.60 loss than the $100 Hollinger box; it is expendable and does not have to be returned through the system to Japan. The Collins box maintains an adequate ice level for 48 hours, twice as long as the Hollinger box. The castoff Collins Styrofoam blood boxes were

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grabbed by American servicemen and Vietnamese civilians to be used as private iceboxes in hot and dusty Vietnam.

Wet icemaking machines used to manufacture ice for blood shipments plagued their users at all blood depots with maintenance problems. Research to resolve the problem was started by the USARV blood program officer.

Another significant question concerned how much universal donor group O low titer whole blood could be given to a casualty before be would have a reaction to his hereditary specific type and group. At least one important experiment was done at Walter Reed Army Medical Center on a small group of men who had received from 21 to 44 units of universal donor group O blood, but results were inconclusive.

For the first time in US military history, every unit of whole blood used to support the war was donated free of charge by military personnel, their dependents, and civilians employed at military installations.

Donors were not motivated by profit. No high-pressure advertising programs were permitted, yet nearly a million and a half volunteers gave blood. Not once was it necessary to initiate contracts for blood to be supplied by the American Red Cross or the American Association of Blood Banks. Even in the most difficult times, when blood requirements reached 38,000 units a month, the civilian blood collection system was not upset by the additional military requirements to support an ongoing war.

Most of the credit for donor recruitment must go to the young officers and the sergeants. These dedicated individuals instilled such confidence in their men that the fear of giving blood and the social pressures against the war were overcome.