Combat and Cruise Ships: Reviving the Practice of Fresh Whole Blood Transfusion in Remote Environments

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Author: Scott Bland, MSIV
Campbell University School of Osteopathic Medicine

Whole blood was the only available transfusion product prior to the development of Cohn’s plasma fractionation process in 1947.[1] However, with advances in laboratory technology and more targeted therapies in hospital settings, the medical community has greatly increased the use of individual blood components, including red blood cells, platelets, and plasma. These components allow for more specific treatment effects, fewer unintended effects, potentially longer shelf life, and more uses per donation than whole blood.[2] In optimal situations, the contemporary choice of processed and screened donations is clearly the safest, but there are uses for fresh whole blood that merit consideration.

In some austere environments, such as Antarctica, rural Australia, combat zones, and the open ocean, both military and civilian medical teams have found utility for fresh whole blood transfusions as a lifesaving treatment for hemorrhage. Providers encountering a crisis in these environments can find themselves unable to stabilize their patient long enough to transport them to a higher level of care. Fresh whole blood transfusions may aid in preserving a patient’s life until definitive care can be established.

In the military environment, a preventable death is defined as a death that could have been prevented by access to proper medical care. Improvements in medical training and evacuation have reduced these drastically, but the majority of deaths deemed preventable are still related to hemorrhage.[3] A number of nations are currently employing fresh whole blood transfusions to provide more time for evacuation of bleeding soldiers. The Norwegian Naval Special Operations Command (NORNAVSOC) refers to this process as a “buddy transfusion.”[4] All soldiers in NORNAVSOC are carefully blood typed and screened repeatedly. Each soldier has multiple methods of documenting his or her type and carries his or her own transfusion kit. The unit medic maintains a list of the soldiers’ blood types, as does the central medical command, for verification via radio. If transfusion is needed and there are no prepackaged blood products available, the medic will use the patient’s transfusion kit to draw one unit of blood from an appropriate donor and then immediately transfuse the donated blood into the injured soldier. NORNAVSOC sets the correct typing of donor and recipient as the critical step. In order to proceed with transfusion, the soldier must clearly identify his or her type and the medic must read each type out loud to the team. The American military has even given credence to using blood compatibility as a component of team selection.[5]

Outside of the military, an urgent need for blood in other remote environments may require the use of whole blood transfusion. Cruise ships, for example, are often many hours away from a hospital. While passengers have access to onboard clinical and medical staff, blood products are not typically stocked on cruise ships. Royal Caribbean Cruise Lines (RCCL) approaches a hemorrhagic crisis by asking other passengers for blood donations and blood-typing is performed.[6] Due to time and laboratory restraints, hemorrhaging patients are asked to sign a consent acknowledging that donations will not have been screened for disease, although RCCL states that calls for volunteers generally produce 4-8 passengers who are regular blood donors at home. Of the fifty-eight patients who received transfusions between 2009 and 2017, per RCCL, forty would have died had they not received blood from a fellow passenger.[6]

Extensive blood testing and processing has become the standard in the American medical community. Deviating from that standard certainly has risks that must be weighed carefully. Kauvar et al. report that among massively-transfused patients, there was no significant mortality difference between recipients of fresh whole blood and blood products.[7] An emergency medical service (EMS) organization with an average service time of fifteen minutes would be unlikely to see this as a viable choice. However, for hemorrhaging patients in combat, aboard cruise ships, or even in expedition medicine or extremely rural environments, conventional medical care could be hours or days away. For these patients the transfusion of fresh whole blood offers an alternative with increased odds of surviving to receive definitive treatment.[7]


1. Kendrick DB, Heaton LD, Coates JB, McFetridge EM. Byproduct of Plasma Fractionization. In: Blood Program in World War II. Washington DC.: Office of the Surgeon General, Dept of the Army; 1989.

2. Basu D, Kulkarni R. Overview of blood components and their preparation. Indian J. Anaesth. 2014;58(5):529-537.

3. Daniel Y, Habas S, Malan L, Escarment J, David J-S, Peyrefitte S. Tactical damage control resuscitation in austere military environments. J R Army Medl Corps. 2016;162(6):419-427.

4. Strandenes G, Pasquale MD, Cap AP, et al. Emergency Whole-Blood Use in the Field: A simplified protocol for collection and transfusion. Shock. 2014;41:76-83.

5. Rush, Stephen. “54. Ranger Blood Program”. PJ Medcast. 2017. Accessed January 31, 2017.

6. Strandenes G, Hervig TA, Bjerkvig CK, et al. The Lost Art of Whole Blood Transfusion in Austere Environments. Curr Sports Med Rep. 2015;14(2):129-134.

7. Kauvar DS, Holcomb JB, Norris GC, Hess JR. Fresh Whole Blood Transfusion: A Controversial Military Practice. J Trauma: 2006;61(1):181-184.