Under what circumstances would it be appropriate to use local donors t · Medical

5 Under what circumstances would it be appropriate to use local donors to provide blood for patients in a military medical facility in place of the usual standard of care to pre-screen blood donors and use fully screened blood?

Step 1 – IDENTIFY THE PROBLEM(S)

Briefly state the Scenario: Under what circumstances would it be appropriate to use local donors to provide blood for patients in a military medical facility in place of the usual standard of care to pre-screen blood donors and use fully screened blood?

• List the Issues that arise from the scenario

• Allocating scarce resources to treat patients and adapting ‘standards of care’ to crisis situations.

• Predictable high-demand medical commodities (blood, oxygen, ICU beds, etc.) may need to be controlled in their use or compromises made in the standard/quality of care.

Identify Critical Information required and Assumptions to be made

• What is the formal policy for the standard of care for administering blood in your facility?

• Is there a predictable possibility that the supply may be inadequate (e.g. in a mass casualty situation)?

• Is it possible to set up an emergency donor panel (EDP)? Can this EDP be pre-screened?

• In a crisis, can you ask for volunteers to be an EDP? Who authorises this decision?

• Are there arrangements for senior clinicians to oversee the allocation of blood in the event of significant demand?

• Are all of these contingencies covered by policies and procedures?

Step 2 – ANALYSE

Patient: A blood transfusion could be a life-saving intervention which constitutes the principle of beneficence and non-maleficence as potentially failing to save a patient’s life would be maleficent.

It could be argued that in a crisis or mass casualty situation, where a large number of patients need a transfusion but the supply is inadequate, deviating from the standard of care might be beneficial for those patients whose lives are at risk. Following this scenario, if resources need to be allocated, there could be a framework to determine which patients should be offered transfusions first in a just manner.

WMA. ‘Ethical principles of healthcare in times of armed conflict and other emergencies’. At: https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/

Clinical: Medical personnel should follow the ethical principles of healthcare as they do not change in times of armed conflict or other emergencies.

The most important duty of a medical professional is to promote health and to save lives, and their primary obligation is always to their patients. - WMA Code of Conduct. ‘Duties of physicians working in armed conflict and other situations of violence’. At: https://www.wma.net/policies-post/wma-regulations-in-times-of-armed-conflict-and-other-situations-of-violence/

Medical care should be provided solely based on clinical need; this also applies to the allocation of scarce medical supplies. However, it is appropriate to mitigate anticipated shortfalls of medical material with emergency procedures.

Legal: ‘Customary IHL, Rule 110’ and the ‘Additional Protocols of the Geneva Conventions’ both state that patients in military hospitals must be treated and should receive the appropriate medical treatment for their condition with the least possible delay relative to the practicality of said treatment. They should be treated humanely, respected, and protected regardless of which party they belong to as there should be no distinction made among them based on non-medical grounds. - Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I), 8 June 1977. ‘Article 10 Protection and care’. At: https://ihl-databases.icrc.org/applic/ihl/ihl.nsf/Article.xsp?action=openDocument&documentId=6EAD04662456DA32C12563CD0051D78D

IHL: Rule 110. ‘Treatment and Care of the Wounded, Sick and Shipwrecked’. At: https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_rul_rule110

Societal/Military: Public Health states that all donor blood has to be checked before use to prevent transmission of infectious diseases such as HIV and hepatitis, and promotes a reliable supply of blood as the safest way to ensure an adequate supply of safe blood. - WHO. Blood Safety and Availability. 2023. At: https://www.who.int/news-room/fact-sheets/detail/blood-safety-and-availability

Military and civilian guidelines advocate for transfusion strategies that replicate the effectiveness of whole blood (“balanced transfusion”) in treating both traumatic and non-traumatic haemorrhage including post-partum bleeding and gastrointestinal bleeding. -

Doughty, H., Thompson, P., Cap, A.P., Spinella, P.C., Glassberg, E., Skogrand Eliassen, H., De Pasquale, M. and Strandenes, G. A proposed field emergency donor panel questionnaire and triage tool. Transfusion (2016), 56 Suppl2: S119-S127. At: https://doi.org/10.1111/trf.13487

Step 3 – FUSE

● Summarise conclusions

● Insert citations to key reference sources for your analysis

● Determine the exact Decision(s) to be made

Emergency procedures to mitigate shortfalls of medical supplies (in this case, blood) could be critical to improving patient care. The resuscitation of patients who require a blood transfusion is a medical emergency and a life-saving procedure and as discussed above, military medical personnel have a duty to save lives and provide treatment to those wounded with minimal possible delay. Not providing a transfusion from a local donor that may not have been able to undergo extensive screening could result in preventable casualties but also accompanies an increased risk of ABO mismatch, infection, and other complications. In this case, a risk-benefit assessment should be made and discussed with superiors. - Gurney, Jennifer M.; Spinella, Philip C., ‘Blood transfusion management in the severely bleeding military patient’. Current Opinion in Anaesthesiology. 2018. At: https://journals.lww.com/co-anesthesiology/fulltext/2018/04000/blood_transfusion_management_in_the_severely.15.aspx

Step 4 – DECIDE

• What is your Decision?

• Why (can you justify it)?

• Residual uncertainly, need for review?

An emergency donor panel (EDP) could provide rapid transfusion support for military environments that fall outside the normal regulated supply of cold-stored whole blood so that warm fresh whole blood can be safely collected ‘on scene’. Careful pre-screening is essential to reduce risks and provide safety for both donors and patients. - Doughty, H., Thompson, P., Cap, A.P., Spinella, P.C., Glassberg, E., Skogrand Eliassen, H., De Pasquale, M. and Strandenes, G. A proposed field emergency donor panel questionnaire and triage tool. Transfusion (2016), 56 Suppl2: S119-S127. At: https://doi.org/10.1111/trf.13487

Thompson, P., & Strandenes, G. (2019). The History of Fluid Resuscitation for Bleeding. Damage Control Resuscitation: Identification and Treatment of Life-Threatening Hemorrhage, 3–29. At: https://doi.org/10.1007/978-3-030-20820-2_1

Consider the history of blood transfusion in the military and emergency situations. There is widespread acknowledgement that safe fresh, whole blood is the best resuscitation fluid in trauma. You should review the evidence and procedures for setting up EDPs and assess whether it is a feasible option in your facility, consider that this is a balance of risk, lives could be lost otherwise as haemorrhage is the leading cause of preventable death on the battlefield and in civilian trauma.

Further discussion points:

● Can ‘low volume/high demand’ treatments be earmarked for particular patients? – e.g. national blood supplies only for use on national patients? What are the implications of asking relatives of local nationals to donate blood for local national casualties?

● Think of other examples of such a commodity: analgesics (especially opioids), anaesthetic drugs, orthopaedic fixators, and antidotes to toxins (e.g. snake antivenom).

Reviewed and formatted by:

Adriana Salas Yeguez, MBBS Year 3 King’s College London

December 2024