"We have a lot of wounded, and we have to get blood for them through acquaintances". What prevents timely transfusions

Roman Shtybel, 26, an anesthesiologist at the Ivano-Frankivsk Oblast Children's Hospital, volunteered for the Hospitallers medical battalion. Now he works in a medevac stabilization center in a hot spot.

Roman focuses on the problem of blood. Wounded soldiers usually receive blood transfusions at the hospital. The medic is convinced that in order not to waste time that could cost lives, it should be done on the way to the hospital — at the stabilization center.

hromadske talked to Roman Shtybel and the command of the Medical Forces to find out what gets in the way of this, where to get blood, why not all medics want to do transfusions and why the Medical Forces of the AFU are against it.

The sooner the blood is transfused, the more stable the patient will be 

Let's start with the main thing: why do we need to transfuse blood on the way to the hospital?

Let me tell you how evacuation works. First, the wounded are taken from their position and given first aid. Then paramedics or medics take the wounded to a stabilization center where surgeons and anesthesiologists treat the soldier.

Such a point should be located in a safe place. But near Bakhmut, the doctors, with whom I was with, decided to stay closer to one of the most combat-ready brigades — the 93rd Kholodnyi Yar Brigade. They were two or three kilometers from the front, and the journey took five minutes. The road to other centers can take up to half an hour. During this time, the wounded can lose a lot of blood.

At the center, the doctors' task is to stabilize the fighter's condition, including stopping the bleeding: replace the tourniquet with a pressure bandage, tamponade the wound, apply vascular clamps, and restore blood volume. This allows the wounded person to get to the hospital, which takes an hour or two.

If the blood is not stopped, the person will either not get there alive or will be in critical condition. It will take doctors a long time to get the wounded out of it. That is, the sooner the blood is infused, the more stable the patient will be.

Why did blood transfusions at stabilization centers only start now, since the war has been going on for nine years?

The army has long lived by the Soviet model, and military medicine was in a deplorable state until 2014. Now it is being rectified. But not as fast as we would like.

Each medical facility, including the stabilization center, has its own functionality and appropriate medicines. Not all formularies include blood. But last summer, the Ministry of Health allowed transfusions in stabilization centers.

That is, the first question was resolved: it is allowed. However, others arise. For example, who will transfuse blood? This is not a routine procedure. In civilian medicine, transfusiologists or anesthesiologists are responsible for transfusions. In the professional armies of the world, military doctors are able to do this. In Ukraine, they are not. There is a lack of anesthesiologists both in the stabilization centers and in military medicine in general.

So there is a need to train a large number of people. And this is one of the obstacles. Because who will teach them and when? Specialists do not have time for training for beginners now.

It helps that there are doctors from several teams at the stabilization centers, including the Hospitallers. That's why, in my experience, one or two anesthesiologists are always on hand.

The uniqueness of our war: the scale

Doctors at the front largely work according to international protocols. Can we borrow the experience of other countries in the matter of blood?

We can adopt many elements, but our war is unique. International protocols are designed for special operations forces. Let's say 20-30 people are going on a mission. The medics have information about their blood, they have bags with this group in case of injury.

Where I worked, there can be up to 200 wounded people a day. It is impossible to predict which of them will need blood and how much. It is very expensive to give everyone group O, and there are not that many donors.

We had a patient who received three donor packs and two from his pleural sinuses in the stabilization center, and another 10 packs during surgery. This is a lot. It is clear that not all of these 150-200 wounded need this amount of blood. However, it must be taken from somewhere, stored and constantly replenished.

Blood has an expiration date. If it is not used, it will be lost. This would not be a big deal — some part of it always becomes unusable, but in our war it is a matter of scale. There is not enough blood.

During my work with a dozen brigades, I saw only one where there was blood. They had achieved this on their own. And we at the stabilization center, with 150 wounded per day, have to write some letters of request, look for personal connections.

Where to get blood and what can it be replaced with?

Donors are often medical workers or fellow soldiers. For example, wounded with contusion come to us, they have no blood loss. If they don't mind, we take theirs.

We determine the group, rhesus factor, and do a rapid test for the most common infections: hepatitis, syphilis, tuberculosis, HIV, etc. No one can guarantee that the wounded will not get some other infection after the transfusion. But it is better than dying. Of course, it is optimal to have tested blood brought in.

As for substitutes. If the bleeding is very heavy, you need to pour enough fluid to prevent the heart from stopping. The engine does not work without gasoline. Previously, we used to infuse crystalloids, an aqueous solution of various salts. But a certain concentration of clotting factors must remain in the blood. Crystalloids dilute them. It turns out to be a vicious circle: on the one hand, we cannot let the heart stop, on the other hand, the fluid dilutes the blood, and it just pours out of the wound because it cannot clot.

We use artificial substitutes to help blood clot, but they are mega-expensive. One of the clotting components is dry plasma. It is only now beginning to be purchased centrally.

It is best to infuse unaltered donor blood — whole blood. It is a natural substance that has everything to help a person recover faster. It cannot be replaced by anything else to the full extent.

Doctors should be able and willing to transfuse

In your opinion, how much did the condition of the wounded improve when blood transfusions started in stabilization centers?

It is effective, the patients have become more stable. We don't have cardiac arrests in the vehicle and severe conditions when we have to use special drugs to start the heart. For every 100 wounded, we infuse blood into five or six. The more blood we give, the better condition the patient will be in when they get to the hospital and the shorter their rehabilitation will be. It's about the quality of medical care.

What other problems are there with transfusions?

As long as the war is ongoing, blood must be donated constantly. A healthy person with a normal weight can do it once every three months.

Logistics is a huge problem. The Ministry of Health has to establish contacts with transfusion centers so that they provide blood to the Ministry of Defense. And the Ministry of Defense has to ensure the delivery to the position. It is important to work all the way from the donor to the wounded soldier.

The blood needs to be stored. The problem can be solved by refrigerators in vehicles and at stabilization centers. This is not something too expensive. But the Ministry of Health and the Ministry of Defense should come to a common opinion on this issue.

There is a request for personnel. Few people know how to transfuse blood. And among them there are those who do not want to. Some are afraid of complications. They say, if I'm not sure it won't harm the person, I'd rather not do it.

Medical personnel at the stabilization centers want blood to be brought. But in my experience, it is not military medics who save lives there, but mobilized civilian doctors or volunteers. They worked in different conditions, and often they need to be convinced that transfusion is what saves lives. The process should become mandatory. That's why the army is an army with its own vertical: a deputy or chief medical officer comes and orders: "That's it, we are infusing blood."

"Hospitals give blood to stabilization centers, but write it off for themselves"

Another doctor from a stabilization center anonymously shared his experience: "Since July last year, there has been an order of the Ministry of Health on blood transfusions in pre-hospital settings. But the medical command of the Armed Forces is against it, because blood products are not in their formulary. Therefore, we have no right to either receive it officially or write it off. However, when lives are at stake, many doctors from the stabilization centers make arrangements with hospitals. They give us blood, and in the documents they write that "Joe Bloggs received two doses from us". The reason is that hospitals are interested in ensuring that the patient does not arrive in a state of hemorrhagic shock.

There are other problems: doctors who are ready to do this need to be trained. Because there are indeed risks: a person can die if he or she is given the wrong group, the wrong rhesus factor. But there is universal blood for this purpose.

"We manage without transfusions"

Yevheniya Slivko, advisor to the commander of the Medical Forces, commented on the situation for hromadske:

"Over the past year, it has been crucial to form a blood bank that would provide frontline surgical groups. Now, in all combat areas, at any time of the day, even on the most difficult days of defense, blood was delivered to where it was needed. 

We set up the logistics within a month and a half after the full-scale invasion. As a result, we reduced the number of fatalities due to combat injuries by 2.8 times. 

Blood from blood banks is delivered to mobile and near-front hospitals as soon as possible. There are conditions for storage and specialists who know how to transfuse it. Surgeons on the front line say that a timely transfusion (within 40-60 minutes after an injury) helps reduce the risk of postoperative complications by up to 50%. And we are succeeding in this."

Commenting on stabilization centers, Yevheniya said:

"Units of the Armed Forces set up stabilization centers on the basis of civilian medical facilities, so the Ministry of Health allowed transfusions. However, according to the Armed Forces formulary, stabilization centers do not provide blood transfusions. Their task is to provide first aid. To stabilize the wounded and send them further.

Stabilization centers are often staffed by medics who have only completed tactical medicine training. Therefore, there are few specialists who could do this. All specialists are on rotation, even those from the military medical academy. There are issues with blood transportation and storage. So we need to work on all this."

Yevheniya says that even without transfusions at stabilization centers, "we manage to get by. The efficiency of logistics shows that we do. Not always. But we manage."

hromadske asked the Ministry of Health for a comment. The agency said that the ministry had developed a draft resolution of the Cabinet of Ministers on meeting the needs of law enforcement agencies. And they will be able to make their position on blood public after the document is approved.