Specific Topic(s):

• Adaptation of clinical care to operational/military situations.

• Blood as a particularly ‘sensitive’ medical supply commodity.

Key references:

‘Ethical principles of health care in times of armed conflict and other emergencies’ –

1. Ethical principles of health care do not change in times of armed conflict and other emergencies and are the same as the ethical principles of health care in times of peace.

2. Health-care personnel shall at all times act in accordance with relevant international and national law, ethical principles of health care and their conscience. In providing the best available care, they shall take into consideration the equitable use of resources.

Geneva Conventions:

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.

1. All the wounded, sick and shipwrecked, to whichever Party they belong, shall be respected and protected.

2. In all circumstances they shall be treated humanely and shall receive, to the fullest extent practicable and with the least possible delay, the medical care and attention required by their condition. There shall be no distinction among them founded on any grounds other than medical ones. https://ihl-databases.icrc.org/applic/ihl/ihl.nsf/Article.xsp?action=openDocument&documentId=6EAD04662456DA32C12563CD0051D78D

Customary IHL:

Rule 110. The wounded, sick and shipwrecked must receive, to the fullest extent practicable and with the least possible delay, the medical care and attention required by their condition. No distinction may be made among them founded on any grounds other than medical ones. https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_rul_rule110

Ethical principles:

World Medical Association CODE OF CONDUCT: DUTIES OF PHYSICIANS WORKING IN ARMED CONFLICT AND OTHER SITUATIONS OF VIOLENCE – The medical duty to treat people with humanity and respect applies to all patients. The physician must always give the necessary care impartially and without discrimination on the basis of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, or social standing or any other similar criterion. https://www.wma.net/policies-post/wma-regulations-in-times-of-armed-conflict-and-other-situations-of-violence/

Discussion:

Review of the question: this question is a proxy for the issue of the allocation of scarce resources to treat patients and the adaptation of ‘standards of care’ to crisis situations. There are predictable high demand medical commodities (blood, oxygen, ICU beds, etc.) that may need to be controlled in their use or compromises made in the standard/quality of care.

Interpretation of the principles/policy from the references: medical care should be provided solely on the basis of clinical need; this also applies to the allocation of scarce medical supplies. However, it is appropriate to mitigate anticipated shortfalls of medical materiel with emergency procedures.

Framework for answering the scenario/question:

• 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 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 oversight of the allocation of blood by a senior clinician in the event of significant demand?

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

Further discussion points

• 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. Review the evidence and procedures for setting up EDPs.

• Can ‘low volume/high demand’ treatments be earmarked for particular patients? – e.g. national blood supplies only for use on national patients?

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

• What are the implications of asking relatives of local nationals to donate blood for local national casualties?

Author: Professor Martin Bricknell

Further reading:

WHO Website Blood Transfusion Safety: https://www.who.int/health-topics/blood-transfusion-safety/#tab=tab_1

Doughty, H., Thompson, P., Cap, A.P., Spinella, P.C., Glassberg, E., Skogrand Eliassen, H., De Pasquale, M. and Strandenes, G. (2016), A proposed field emergency donor panel questionnaire and triage tool. Transfusion, 56: S119-S127. doi: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. https://doi.org/10.1007/978-3-030-20820-2_1

DeGOWIN EL. The Possible Role Of Whole Blood Transfusions In Military Medicine. JAMA. 1945;127(16):1037–1039. doi:10.1001/jama.1945.02860160013004 https://jamanetwork.com/journals/jama/article-abstract/273752 (note the date of publication)