Brothers in Arms featured in San Antonio Medicine

July 3, 2018

By Dr. Samantha Gomez Ngavmmtikul

The South Texas Blood & Tissue Cen­ter, working in conjunction with regional medical helicopter providers and the Southwest Texas Regional Advisory Council, has launched a new program for emergency transfusions called "Brothers in Arms."

The program, which has the potential to dramatically change trauma care in this country, began earlier this year. It provides specially tested whole blood for transfu­sion use in 18 medical helicopters, as research has shown whole-blood transfusions are better than pRBC or com­ponent therapy at countering blood loss, dramatically improving survival rates.

San Antonio is one of the first cities to implement the system, which is based on a battlefield program developed by the U.S. military and later adapted at the Mayo Clinic trauma center. The 75th Ranger Regiment "O Low-Titer Whole Blood Pro­gram" was the recipient of the Army's Greatest Innovation Award in 2017.

The program was established in San An­tonio with support from a grant provided by the San Antonio Medical Foundation.

"Implementing this program for civilian use will truly transform how emergency care can be administered on medical heli­copters and significantly improve survival rates for trauma victims." said Elizabeth Waltman, COO of the South Texas Blood & Tissue Center, which is a subsidiary of San Antonio nonprofit BioBridge Global

"This is also the first step toward a longer-term solution for saving more lives in mass-casualty situations, especially if we are able to expand the program in the fu­ture to include emergency care provided by ambulance services."

Blood donations for Brothers in Arms come from a group of male O-positive blood donors who have low titer levels of anti-A and anti-B antibodies (IgM). The cutoff level is a ration of less than 1:256; approximately 15 percent of male O-posi­tive donors are considered low-titer under those criteria. Donors in the program are tested annually.

As of April 17, STBTC has 179 donors enrolled in the program, with more added every week. A total of 136 units have been collected from that group. Using blood from O-positive donors, the most common type in the United States, can help reduce ongoing strains on the O-negative inventory. 

Kept in proper conditions, the whole blood also preserves platelets and their functionality beyond the current 5-day shelf life - up to 35 days under proper conditions. 

South Texas Blood & Tissue Center's sister blood-testing organization, QualTex Laboratories, worked with the military to develop the testing protocol to identify O­positive donors with low antibody levels, making it possible to use O-positive blood for these trauma victims. The program is targeting male O-posi­tive donors because men tend to have lower levels of certain types of antibodies in their blood than women, reducing the possibility of transfusion-related acute lung injury (TR.ALI) among patients.

STBTC is developing a committed pool of male O-positive donors for the Brothers in Arms program to ensure a regular supply. The goal is to expand the program to provide whole blood to area emergency vehicles and trauma centers throughout the region.

Blood for the program does not un­dergo any modification at STBTC.

Brothers in Arms represents a collab­oration among the South Texas Blood & Tissue Center, the Southwest Texas Re­gional Advisory Council, University Health System, the San Antonio Military Medical Center, The U.S. Army Institute of Surgical Research; the UT Health Sci­ence Center and medical helicopter serv­ices Air Evac Lifeteam, PHI Inc. and San Antonio AirLIFE.

Research led by Dr. Donald Jenkins, a former U.S. Air Force officer and the prin­cipal architect of the Joint Trauma Theater Trauma System in Iraq and Afghanistan, showed that combining the practice of pre-hospital transfusions with specially tested units of whole blood rather than transfusing individual blood components of red cells, plasma or platelets -is most effective in treating trauma victims suffer­ing from significant blood loss. 

"The general mortality rate for critically injured patients requiring massive transfu­sions at hospital trauma centers is 75 per­cent," said Jenkins. "Our battlefield experience showed that providing earlier, pre-hospital transfusions of whole blood, rather than blood components or primarily red blood cells, brought mortality rates down as low as 20 percent." 

Jenkins later began to transfer the pro­gram to civilian use as trauma medical di­rector at the Mayo Clinic. He is now a surgical critical care specialist affiliated with University Hospital in San Antonio, and the Betty and Bob Kelso Distinguished Chair in Burn and Trauma Surgery at UT Health San Antonio. 

The idea of using type O whole blood in emergencies dates to battlefield use in World War I, and during the latter stages of World War II, the concept of using only low-titer type O blood for emer­gency use was introduced. The system re­mained in place through the Korean and Vietnam wars.

It was discontinued when the process of separating red cells from platelets and plasma became common during the 1970s.

Blood for emergency use is stored at the helicopters' base station in a moni­tored refrigerator. The units are moved to a transport container when the helicop­ters receive a call.

The South Texas Blood & Tissue Ceri­ter is a nonprofit community blood center that provides blood, plasma, platelets and other blood components to more than 70 hospitals in more than 40 counties in South Texas. It is the largest blood sup­plier in our region. 

STBTC has seven donor rooms in South Texas and conducts thousands of mobile blood drives each year. More information about the center and the Brothers in Arms program is available at SouthTexasBlood.org

Dr. Samantha Gomez Ngavmmtikul is Associate Medical Director for BioBridge Global.