title: Risk management analysis of air ambulance blood product administration in combat operations.
abstract: BACKGROUND
  Between June-October 2012, 61 flight-medic-directed transfusions took place aboard U.S. Army Medical Evacuation (medevac) helicopters in Afghanistan. This represents the initial experience for pre-hospital blood product transfusion by U.S. Army flight medics.
  
  
  METHODS
  We performed a retrospective review of clinical records, operating guidelines, after-action reviews, decision and information briefs, bimonthly medical conferences, and medevac-related medical records.
  
  
  RESULTS
  A successful program was administered at 10 locations across Afghanistan. Adherence to protocol transfusion indications was 97%. There were 61 casualties who were transfused without any known instance of adverse reaction or local blood product wastage. Shock index (heart rate/systolic blood pressure) improved significantly en route, with a median shock index of 1.6 (IQR 1.2-2.0) pre-transfusion and 1.1 (IQR 1.0-1.5) post-transfusion (P < 0.0001). Blood resupply, training, and clinical procedures were standardized across each of the 10 areas of medevac operations.
  
  
  CONCLUSIONS
  Potential risks of medical complications, reverse propaganda, adherence to protocol, and diversion and/or wastage of limited resources were important considerations in the development of the pilot program. Aviation-specific risk mitigation strategies were important to ensure mission success in terms of wastage prevention, standardized operations at multiple locations, and prevention of adverse clinical outcomes. Consideration of aviation risk mitigation strategies may help enable other helicopter emergency medical systems to develop remote pre-hospital transfusion capability. This pilot program provides preliminary evidence that blood product administration by medevac is safe.
authors.affiliation: U.S. Army Health Clinic, Schofi eld Barracks, Wahiawa, HI, USA.
authors.forename: Nicole
authors.initials: N
authors.lastname: Powell-Dunford
authors.forename: Jose F
authors.initials: JF
authors.lastname: Quesada
authors.forename: Robert F
authors.initials: RF
authors.lastname: Malsby
authors.forename: Victoria
authors.initials: V
authors.lastname: Chou
authors.forename: Robert T
authors.initials: RT
authors.lastname: Gerhardt
authors.forename: Kirby R
authors.initials: KR
authors.lastname: Gross
authors.forename: Stacy A
authors.initials: SA
authors.lastname: Shackelford
mesh_terms: D000328:Adult; D055826:Afghan Campaign 2001-; D017732:Air Ambulances; D016913:Blood Component Transfusion / Q000592:standards* / Q000706:statistics & numerical data; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008887:Military Medicine; D008889:Military Personnel; D012151:Resuscitation / Q000379:methods / Q000592:standards; D012189:Retrospective Studies; D012308:Risk Management; D012769:Shock / Q000628:therapy; D014481:United States; D055815:Young Adult