In the event of a prolonged war in the Pacific, injured U.S. troops might be saved by blood provided by U.S. allies, thanks to a series of formal international blood pacts the military says will soon be in place.

“If something kicks off in Taiwan, we’ve said we will come to the defense of Taiwan,” said Navy Capt. Leslie Riggs, division chief for the Armed Services Blood Program. “Our military personnel are gonna need care and there’s only so much that we can provide.” 

To create a blood pipeline to those future battlefields, U.S. officials are mid-way through formalizing blood sharing agreements with the U.K. and Canada, with a spring exercise planned to put them into practice. Studies to determine commensurable blood collection and manufacturing methods in Taiwan and Australia are pending legal review, according to Riggs.

The agreements would be first-of-their-kind formalized agreements between the U.S. and allies, establishing assurances that the methods those countries use to collect, store and transport blood for military use meet U.S. standards.

Once in place, medics could one day use blood products from those partner countries instead of waiting for shipments from the U.S. 

How military medics and doctors get blood to injured troops has evolved over the years based on hard lessons learned during the wars in Afghanistan and Iraq. 

“Hemorrhage is the number one cause of preventable death on the battlefield,” Maj. Gen. Paula Lodi, Commander of the 18th Medical Command told Task & Purpose. 

A study on battlefield fatalities in Iraq and Afghanistan between October 2001 and June 2011 found that 87% of all combat deaths occurred before troops reached a medical treatment facility.

U.S. medical officials have seen the same pattern in Ukraine, where up to two-thirds of wounded troops “expire between the point of injury and the first role of a real medical care like a battalion aid station or clinic or something like that,” Riggs said.

“Getting that patient to that first role of care doesn’t happen quickly and when it doesn’t happen quickly and you don’t have these blood products there to sustain life, that injured casualty is going to expire,” he said.

In the early 2000’s, medical teams followed standards at the time which called for two liters of IV solution  before blood but treatment often led to other issues, like continued bleeding due to ineffective clotting. Instead, teams began using plasma and red blood cells or whole blood donated by other troops, a practice that’s now incorporated into current standards, according to the book, “Out of the Crucible: How the Us Military Transformed Combat Care in Iraq and Afghanistan.” 

In 2004, the Defense Department adopted new transfusion guidelines: “Patients should either receive fresh whole blood, or a balanced mix of blood products that resembles as much as possible the blood they have shed,” the authors wrote.

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Today, and especially in the Indo Pacific, medical combat troops are focused on far forward care which takes into account delayed evacuations and prolonged field care, Lodi said.

Every year, the Army holds a logistics exercise called Operation Pathways, a rehearsal of how the U.S. would respond to a large war in the region. The annual training has illuminated the challenges of operating in a region that’s “twenty times” the size of Europe and a “non-contiguous region with 50% of the Earth’s ocean,” Lodi said at a conference in October.

If the military isn’t able to set up safe evacuations, injured troops are going to have to “hunker down” and receive care on the ground which would likely include Taiwanese military or civilian medical systems and in some cases, Taiwan’s blood supply, Riggs said. 

Another goal of the Army is to make sure that troops have blood products on hand in order to receive them within 30 minutes of an injury, according to Maj. Nekkeya McGee, 18th MEDCOM’s Pacific Region Blood Manager.

“We want to get blood as close to the point of injury as we possibly can,” McGee said. This also includes pre-screening troops at their home station and training them on “how to do emergency whole blood collections at that point of injury to help out their battle buddy.”

With blood sharing agreements in place ahead of time, “we can manage our expectations of what’s in the realm of possible and the more things that we can have in place ahead of crisis or contingency operation, the better we can plan where our gaps are,” Lodi said.

Informal agreements already exist with France for U.S. forces in Africa and in South Korea for bi-annual exercises with U.S. troops since 2017.

When setting up the agreements, one of the considerations is whether the country has a military blood program in place. If not, they look at their civilian blood system to make sure there’s the right management structure, checks and balances between operations and quality assurance, dedicated transportation facilities to move the blood in a timely fashion, and a reliable electric grid, Riggs said. 

Maj. Chih Huang, ASBP program division chief of operations said that during his time stationed in South Korea, they practiced blood sharing exercises twice a year which helped them figure out who to contact and the chain of command. By having a mechanism in place, it’ll make everything run smoother, he said. 

“If we do need to borrow each other’s blood,” Huang said, “we know what to do.”

CORRECTION: An earlier version of this inaccurately stated that agreements between the US, Australia and Taiwan are pending. That is incorrect. The studies to determine whether Australia and Taiwan blood standards are commensurable are pending.

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