The Evolution of Transfusion Medicine in the Military Setting: From Experimental Methods to Contemporary Operational Blood Logistics

Jan Ammann^a, Diana Sauer^b

^a Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Bundeswehr Hospital Ulm

^b Department of Transfusion Medicine, Bundeswehr Central Hospital Koblenz

Summary

Few medical procedures are as closely linked to the realities of armed conflict as blood transfusion. In environments dominated by explosions, penetrating trauma, and mass casualty incidents (MCI), outcomes are determined not by refined diagnostics but by how rapidly adequate oxygenation and stable coagulation can be restored. Military settings have repeatedly acted as catalysts for medical innovation. Under these conditions, new transfusion medicine concepts were standardized and introduced into broad clinical practice or abandoned when safety concerns emerged.

This article traces these developments from the perspectives of technical feasibility, organizational implementation, and operational medical practice. Particular attention is given to compatibility, which became reliably manageable only after the discovery of the ABO blood group system, as well as to the introduction of anticoagulation and blood storage. The establishment of blood banks and military blood programs is also addressed. In addition, operational treatment concepts are described, including forward medical care, the use of whole blood and freeze-dried plasma, and so-called walking blood banks (WBB), defined as rapid whole-blood donation by pre-screened personnel when conventional supply chains are unavailable.

Keywords: transfusion medicine; military medicine; blood supply; whole blood; damage control resuscitation; freeze-dried plasma; combat casualty care

Introduction

Few medical procedures are as closely linked to the realities of armed conflict as blood transfusion. Where explosions, penetrating traumas, and mass casualty incidents (MCI) prevail, the decisive factor is not refined diagnostics, but how quickly adequate oxygenation and stable coagulation can be restored. Historically, military settings have repeatedly accelerated medical development, significantly shaping today’s transfusion medicine. Under these conditions, new transfusion medicine concepts were standardized and adopted for broad application or discarded due to safety concerns.

This article traces the historical development of transfusion medicine in the military context, following key lines of development from early technical prerequisites to modern operational concepts. Initially, the focus was on questions of immunological compatibility, which only became reliably manageable with the discovery of the ABO system, the introduction of anticoagulation, and the possibility of blood storage. Building on this, organizational developments are described, particularly the establishment of blood banks and military blood programs. Finally, the focus shifts to operational medical implementation, ranging from forward medical care to the use of whole blood and modern concepts like freeze-dried plasma and so-called walking blood banks (WBB: rapid whole-blood donation by pre-screened personnel).

The Beginnings of Transfusion: Empiricism, Risk, and Serendipity (17^th–19^th Century)

The earliest attempts at transfusion were marked by a lack of understanding of immunohematological relationships and the absence of effective anticoagulation methods. Direct “arm-to-arm” transfusions from donor to recipient, as well as animal-to-human experiments, led to unpredictable and sometimes fatal reactions [2][9]. Application under field conditions was practically excluded, as the biological foundations of blood compatibility were still unknown. In the 19th century, there was cautious clinical establishment for individual indications, particularly through the work of James Blundell; nevertheless, transfusion remained a technically demanding and risky procedure that could not be safely integrated into everyday clinical practice [2][14].

The Discovery of Blood Groups: Landsteiner and the Overcoming of Transfusion Incompatibility (1900–1930)

Understanding immunological incompatibility enabled transfusions to be controlled for the first time. For military casualty care, this was the decisive prerequisite for all later developments in blood supply. Without reliable compatibility, a broad and structured application of transfusion was doomed to failure. Standardized tests and clearly defined processes reduced acute transfusion reactions and enabled, for the first time, planned care for larger patient collectives [1].

The Introduction of Blood Storage: Citrate Addition and Blood Depots in World War I

The inability to reliably anticoagulate collected blood was a major obstacle to practical transfusion for a long time. Only with the introduction of anticoagulants and preservative solutions did blood storage become clinically applicable, making transfusion independent of the immediately present donor. During World War I, this possibility was systematically utilized out of military necessity. Oswald Hope Robertson established forward depots of preserved, tested whole blood, while Lawrence Bruce Robertson significantly contributed to the clinical acceptance and dissemination of blood-product shock therapy in war surgery [23]. The pattern of this era is characteristic. Medical innovation only became operationally effective through organization, testing, and consistent process discipline (Figure 1).

Fig. 1: Blood transfusion in the military context (Image credit/Copyright: Wellcome Collection/Mytcett Collection, London: “Blood transfusion” (L0024143). CC BY 4.0.)

The Establishment of Blood Banks: Organization of Blood Supply and the Spanish Civil War as a Testing Ground (1930s)

In the 1930s, transfusion medicine transformed from an individual therapeutic approach to an established medical procedure with its own infrastructure. Bernard Fantus coined the organizational concept of the “Blood Bank” in 1937 at Cook County Hospital, establishing blood preservation and stockpiling as a clinical standard process [8]. This created a close interaction between civilian and military development. Civilian institutionalization enabled large-scale application, while military demand further accelerated standardization.

The Spanish Civil War (1936–1939) played a special role in this phase, as it was the first to practically test how blood could be made mobile and available near the front. The Canadian surgeon Norman Bethune developed and operated a mobile transfusion service in 1936/37, which brought citrate-anticoagulated, stored blood close to the front, rather than moving wounded individuals backward for treatment [11][20]. Bethune’s achievement layed less in technical innovations than in organizational performance. He connected donor recruitment, preservation, transport, indication, and distribution for the first time into a consistently functioning supply chain. It became clear that transfusion medicine in war is inextricably linked with logistics and leadership [11][20].

Organized Blood Supply in World War II: Blood Programs, Plasma, and Albumin

World War II accelerated the transition from the blood bank as a single institution to a systematically organized blood supply. The goals were no longer just the availability of blood, but also standardization, testing, transportability, and clearly defined processes along a military supply chain. On the British side, the Army Blood Transfusion Service (ABTS) was systematically built up before the war. Lionel Whitby explicitly described this step as a connection between peacetime and wartime requirements [28]. In the USA, the blood supply was programmatically organized and implemented on a large scale. Historical analyses emphasize the close interconnection of medical requirements with donor recruitment, production, and distribution [13][16] (Figure 2).

Fig. 2: Plasma transfusion of a wounded soldier in World War II ­(Sicily, August 9, 1943) (Image credit/Copyright: U.S. National ­Archives and Records Administration (NARA), Public Domain)

After 1945, the blood supply was no longer understood as an isolated measure but as a cohesive supply chain. The subsequent conflicts in Korea and Vietnam further shifted the focus toward speed, as faster evacuation and mobile surgical care posed new requirements for blood logistics.

Advancement of Blood Supply Along the Supply Chain: Korea and Vietnam (1950–1970)

During the Korean War, mobile surgical care concepts such as Mobile Army Surgical Hospitals (MASH) were established, closely linked to increasingly air-supported casualty evacuation. Shortened transport times led to more severely injured patients reaching definitive care alive, shifting the need for blood products further forward along the treatment chain. Military transfusion medicine thus increasingly became a discipline driven by logistics and processes. Ensuring a continuous cold chain, reliable inventory management, standardized issuance processes, and clear identity controls and documentation had to be reconciled with the tactical possibilities of transport (Figure 3).

Fig. 3: Airborne casualty evacuation to a MASH (Korea, July 29, 1951). (Image credit/Copyright: Sgt. Paul E. Norman/U.S. Department of Defense (VIRIN 111–376734). Public Domain (PD-US Military)).

Technically, this development was facilitated by the transition from glass bottles to plastic blood bags [4][21]. These enabled more robust sterile handling, facilitated transport, and made closed systems for collection and storage clinically applicable [27].

The transfused blood volumes increased significantly as medical and logistical supply chains improved. In the Vietnam War, whole blood consumption from 1968 onwards reached a magnitude of over 30,000 units per month (peak 38,000/month in February 1969), encompassing over 1.08 million units in the supply chain to South Vietnam (1966–1970) [25].

Already in the Korean War, whole blood of blood group 0 was used as a universal product, classified as low-titer (as “Safe Universal Donor Blood”) versus high-titer based on Anti-A/Anti-B titers; in later supply stages, an ABO-compatible transfusion was increasingly sought whenever possible [26]. At the same time, a component-oriented approach gained greater traction in military operations, enabling more flexible stockpiling and targeted substitution [18]. In trauma care, however, this also led to new missteps, particularly a temporary neglect of early coagulation therapy [15][18].

During this phase, training became increasingly important. Conducting blood transfusions in the field required well-drilled teams, consistent temperature management, early recognition of acute transfusion reactions, reliable documentation, and clear indication setting. Transfusion competence thus became a matter of system capability rather than individual skills alone [18][25][26].

With the increasing complexity of supply systems, the need for overarching safety and quality mechanisms became evident [25][26]. The rising number of transfusions made clear that availability alone was not sufficient; structured control and quality assurance were necessary [7][25]. This initiated the subsequent phase of increased regulation and systematic monitoring of transfusion safety and side effects [7].

Establishment of Transfusion Safety: Regulation and Quality Control (1970–2000)

With the growing awareness of transfusion-associated transmission of viral diseases, the focus of transfusion medicine shifted significantly. The emphasis now moved to developing systematic testing procedures, stricter donor selection, seamless traceability, and standardized quality processes [7]. For military systems, this posed a particular challenge, as high safety requirements had to be compatible with operational conditions, including time pressure, limited infrastructure, and constrained cold chains [7][25]. Transfusion medicine thus finally evolved into a discipline where product quality, organizational procedures, and training must work together inseparably. If these aspects are not jointly considered, errors within the supply system can rapidly spread [7].

Hemostasis-Oriented Shock Therapy in Modern Conflicts: Iraq, Afghanistan, and the Present

From experiences with modern conflicts, which were partially characterized by long preclinical care times, today’s hemostasis-oriented shock therapy has developed. The concept of so-called damage control resuscitation (DCR, structured early blood and coagulation therapy to prevent trauma-induced coagulopathy) addresses the early onset of coagulation disorder after severe trauma and aims for early, coagulation-oriented administration of blood products instead of a predominantly crystalloid-dominated volume therapy [15]. The military background is clear, as preventable bleeding remains one of the most common causes of death in the early period after injury. Analyses of battlefield mortality repeatedly show severe bleeding as the leading cause of preventable fatalities [6].

From this emerged the principle of making blood products available as early as possible along the supply chain. This concept, often referred to as “Blood Far Forward,” describes the provision of blood as far forward as tactically feasible in the early treatment sections to avoid time-critical delays in hemotherapy [3] (Figure 4).

Fig. 4: Preparing a blood transfusion during airborne evacuation (Bagram, Afghanistan, 2013) (Image credit/Copyright: DoD photo by Senior Airman Chris Willis, U.S. Air Force (130323-F-LR266–126) Public Domain)

In parallel, there was a renewed turn towards the use of whole blood [29]. In situations where individual blood components are not fully available or logistical constraints complicate balanced component therapy, blood group O with a low antibody titer (low-titer O) is a pragmatic option under certain operational conditions [24]. Observational studies suggest that warm, fresh whole blood may be associated with improved survival rates under certain operational conditions, although the evidence is limited by its retrospective nature [22].

Walking Blood Bank (WBB): Donor-Supported ­Whole Blood Supply in Operations

The so-called Walking Blood Bank (WBB) refers to a prepared system for the rapid collection of whole blood by previously tested and registered operational personnel when regular blood product supply chains are interrupted. The goal is to enable rapid, on-demand whole-blood transfusions under operational conditions without relying on stored blood products. Multinational experiences from Afghanistan demonstrate the practical feasibility of this approach and the importance of clearly defined procedures for donor selection, testing strategy, and documentation [12]. Systematic reviews emphasize that a WBB is not an improvised procedure but a structured, prepared concept with defined activation criteria and risk-minimizing measures [5].

Freeze-Dried Plasma (FDP): Coagulation Therapy under Operational Conditions

Freeze-dried plasma (FDP) is plasma that has been freeze-dried and can be quickly reconstituted before use, eliminating the need for complex cooling and thawing procedures. This addresses a significant logistical problem with plasma therapy under military operational conditions: deeply frozen plasma must be thawed in a time-consuming manner before administration. FDP thus enables early coagulation therapy even in forward treatment sections.

A French study on military application in Afghanistan demonstrated practical feasibility and clinically relevant effectiveness under operational conditions [17]. Meta-­analyses evaluate FDP positively, especially regarding logistical advantages, but continue to note a heterogeneous evidence base for clinical endpoints [19]. In the context of early hemotherapy, it is less the individual product that is decisive than its reliable availability at the right time [19].

Conclusion

The development of transfusion medicine in the military context shows that medical progress under operational conditions becomes sustainably effective only when technical innovation, organizational implementation, and clinical application interact. Only the knowledge of blood groups made transfusions manageable; the introduction of anticoagulation and preservation enabled blood storage, thus supporting its use independent of the donor; and organizational structures finally created the conditions for reliable care of larger patient collectives. With the increasing speed of evacuation, the need for blood products shifted earlier into treatment phases, while rising usage numbers simultaneously imposed higher demands on safety and quality.

As early as the establishment of blood banks and the first mobile transfusion services in the Spanish Civil War, it became clear that transfusion medicine in the military environment is primarily a logistical and organizational system performance [11][20]. World War II accelerated the widespread implementation of blood and plasma programs, promoted the development of fractionation procedures, and, at the same time, highlighted tensions among availability, safety, and quality [10][13][16][28]. Modern concepts like damage control resuscitation, the renewed use of whole blood, walking blood banks, and freeze-dried plasma are direct responses to time-critical supply situations, trauma-induced coagulation disorders, and vulnerable supply chains under operational conditions [3][5][12][15][17][18][29].

For the medical service, this results in a clear consequence. Transfusion medicine in operations is not an isolated medical measure but a collaborative effort involving logistics, leadership, training, and clinical expertise. A safe blood supply requires that these areas are jointly planned, trained, and implemented. Only the interplay of standardized procedures, consistent quality assurance, and realistic supply concepts enables the reliable provision of the high-value resource blood under operational conditions.

Key Points

• Military operational conditions have accelerated innovations in transfusion medicine while simultaneously highlighting structural weaknesses.
• Preservation and blood bank structures made transfusion reliably available and applicable on a larger scale in operations.
• With increasing evacuation speed, the need for blood products shifts to early treatment phases, giving logistical supply a decisive role.
• Damage control resuscitation concepts prioritize early hemostasis and the early use of blood products instead of a predominantly crystalloid-dominated volume therapy.
• Walking blood banks and freeze-dried plasma are important operational options but require clear protocols, training, and consistent risk management.

References

1. Aymard JP. Karl Landsteiner (1868–1943) and the discovery of blood groups. Transfus Clin Biol. 2012;19(4–5):244–248. mehr lesen
2. Boulton FE. Blood transfusion: additional historical aspects. Part 1: The birth of transfusion immunology. Transfus Med. 2013;23(6):375–381. mehr lesen
3. Cap AP, Pidcoke HF, DePasquale M, et al. Blood far forward: time to get moving! J Trauma Acute Care Surg. 2015;78(6 Suppl 1):S2–S6. mehr lesen
4. Carmen R. The selection of plastic materials for blood bags. Transfus Med Rev. 1993;7(1):1–10. mehr lesen
5. Degueldre J, Dessy E, T’Sas F, et al. A systematic review of indications when and how a military walking blood bank could bridge blood product unavailability. Blood Transfus. 2024;22(5):395–404. mehr lesen
6. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001–2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S431–S437. mehr lesen
7. Engle RE, Bukh J, Alter HJ, et al. Transfusion-associated hepatitis before the screening of blood for hepatitis viruses. Transfus Med Rev. 2014;28(4):199–210. mehr lesen
8. Fantus B (ed). Blood preservation. JAMA. 1937;109(2):128–131.
9. Fastag E, Varon J, Sternbach G. Richard Lower: the origins of blood transfusion. J Emerg Med. 2013;44(2):e241–e244. mehr lesen
10. Featherstone PJ, Ball CM. The development of albumin solutions in the Second World War. Anaesth Intensive Care. 2023;51(4):236–238. mehr lesen
11. Franco A, Cortes J, Alvarez J, Diz JC. The development of blood transfusion: the contributions of Norman Bethune in the Spanish Civil War (1936–1939). Can J Anaesth. 1996;43(10):1076–1078. mehr lesen
12. Hejl CG, Martinaud C, Macarez R, et al. The implementation of a multinational “walking blood bank” in a combat zone. J Trauma Acute Care Surg. 2015;78(5):949–954. mehr lesen
13. Hedley-Whyte J, Milamed DR. Our blood your money. Ulster Med J. 2013;82(2):114–120. mehr lesen
14. History of blood transfusion. Nature. 1940;146:228–230. mehr lesen
15. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma. 2007;62(2):307–310. mehr lesen
16. Kendrick DB. Blood Program in World War II. Washington, DC: Office of The Surgeon General, Department of the Army; 1964. mehr lesen
17. Martinaud C, Ausset S, Deshayes AV, et al. Use of freeze-dried plasma in a French intensive care unit in Afghanistan. J Trauma. 2011;71(6):1761–1764. mehr lesen
18. McCoy CC, Brenner M, Duchesne JC, et al. Back to the future: whole blood resuscitation of the severely injured trauma patient. Shock. 2021;56(1S):9–15. mehr lesen
19. Mok G, Hoang R, Khan MW, et al. Freeze-dried plasma for major trauma—systematic review and meta-analysis. J Trauma Acute Care Surg. 2021;90(3):589–602. mehr lesen
20. Pinkerton PH. Norman Bethune, eccentric, man of principle, man of action, surgeon, and his contribution to blood transfusion in war. Transfus Med Rev. 2007;21(3):255–264. mehr lesen
21. Prowse CV. Commercially available blood storage containers. Vox Sang. 2014;107(1):1–3. mehr lesen
22. Spinella PC, Perkins JG, Grathwohl KW, et al. Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries. J Trauma. 2009;66(4 Suppl):S69–S76. mehr lesen
23. Stansbury LG, Hess JR. Blood transfusion in World War I: the roles of Lawrence Bruce Robertson and Oswald Hope Robertson. Transfus Med Rev. 2009;23(3):232–236. mehr lesen
24. Strandenes G, Berséus O, Cap AP, et al. Low titer group O whole blood in emergency situations. Shock. 2014;41(Suppl 1):70–75. mehr lesen
25. U.S. Army Center of Military History. Medical support of the U.S. Army in Vietnam, 1965–1970. Chapter IX: The military blood program. [Internet]. 2002 [last access March 5, 2026]; available from: https://webdoc.sub.gwdg.de/ebook/p/2005/CMH_2/www.army.mil/cmh-pg/books/vietnam/medspt/chpt9.htm mehr lesen
26. U.S. Army Medical Department Center of History & Heritage. The blood, plasma, and related programs in the Korean War (Recad Vol. 1, Chapter 3–5). [Internet]. o. J. [last access March 5, 2026]; available from: https://achh.army.mil/history/book-korea-recad1-ch3-5/  mehr lesen
27. Walter CW, Murphy WP Jr. A closed gravity technique for the preservation of whole blood in ACD solution utilizing plastic equipment. Surg Gynecol Obstet. 1952;94(6):687–692. mehr lesen
28. Whitby L. Transfusion in peace and war. Lancet. 1945;245(6332):1–4.
29. Zielinski MD, Jenkins DH, Hughes JD, et al. Back to the future: the renaissance of whole-blood transfusions for massively hemorrhaging patients. Surgery. 2014;155(5):883–886. mehr lesen

Manuscript Data

Citation

Ammann J, Sauer D. The evolution of transfusion medicine in the military setting: From experimental methods to contemporary operational blood logistics. WMM 2026;70(5E):3.

DOI: https://doi.org/10.48701/opus4-868

For the Authors

Commander (Navy MC) Dr. Jan Ammann

Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy

Bundeswehr Hospital Ulm

Oberer Eselsberg 40, D-89081 Ulm

E-Mail: janammann@bundeswehr.org