A novel approach to blood supply in the era of large-scale combat operations

Abstract:

Future large-scale combat operations (LSCOs) against a near-peer adversary are projected to generate casualty volumes far exceeding those experienced during the Global War on Terror. Estimates range from 800 to 3,600 US casualties per day, potentially overwhelming a military medical system optimized for counterinsurgency warfare with rapid evacuation and limited daily losses. Hemorrhage remains the leading cause of preventable battlefield death, and blood is the cornerstone of combat casualty care. Although the military blood system advanced significantly during the Iraq and Afghanistan conflicts, it was not designed for sustained, high-volume attrition warfare. The Global War on Terror data provides critical insight. Of ∼53,000 wounded service members over two decades, roughly 20% received blood transfusions, leaving nearly 42,500 wounded who did not require transfusions. Extrapolated to a projected 72,000-casualty LSCO scenario, ∼57,500 individuals would constitute a “walking wounded” population—hemodynamically stable casualties who could represent a substantial, immediately available donor pool. We propose institutionalizing a structured “Walking Wounded Blood Bank,” in which eligible, stable casualties donate blood before evacuation. In addition, integrating blood donation into routine redeployment processing could further augment supply during protracted conflict. In contrast, harvesting blood from the deceased is biologically unsound, ethically problematic, and mathematically negligible as a scalable solution. Preparation for LSCO requires confronting the arithmetic of mass casualties. Leveraging the walking wounded and redeploying forces as structured donor populations offers a pragmatic, ethical, and operationally feasible strategy to expand transfusion capacity before demand exceeds supply. (J Trauma Acute Care Surg. 2026;101: S143–S145. Copyright © 2026 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.)

During the Global War on Terror (GWOT), the United States military grew accustomed to fighting limited counterinsurgency campaigns with low casualties and high survival rates, facilitated by theater air superiority that allowed short transport times to a higher level of care. This assumption collapses in the face of a projected large-scale combat operation (LSCO) against a near-peer adversary, like China or Russia. US military planning experts predict ∼800 American casualties per day for 3 months (72,000 total) in a sustained war.^1,2 Even more sobering, the US Army War College journal Parameters projects that American soldiers could suffer as many as 3,600 casualties per day in a war against another superpower.³ At that rate, the United States would exceed the total number of wounded soldiers sustained over two decades of GWOT, but in a matter of weeks.

Such numbers would not just stress the system—they would overwhelm the military medical infrastructure. Successful combat trauma care is centered around blood administration and hemorrhage control. Hemorrhage remains the leading cause of preventable death on the battlefield. The current military blood system, though vastly improved during Iraq and Afghanistan, was designed around expeditionary counterinsurgency warfare, not sustained near-peer conflict with thousands of casualties daily. Whole blood programs, walking blood banks at forward units, and the continental US resupply would face unprecedented demand, not seen since WWII. A conflict generating even 800 casualties per day would rapidly deplete stored blood products in theater; one producing 3,600 daily casualties would create a logistical crisis measured in hours, not weeks.

To understand the magnitude of the challenge, it is necessary to look back in time. During the 20 years of GWOT, ∼53,000 US service members were wounded in action, and about 7,000 were killed.⁴ Trauma registry research suggests that roughly 20% of battlefield casualties received an average of one unit of blood.⁵ In one study of 10,172 casualties, 2,608 received transfusions, a proportion consistent with that 20% estimate.⁶

If we apply that 20% estimate to the ∼53,000 wounded, we can infer that around 10,600 service members received at least one unit of blood. That leaves roughly 42,400 wounded soldiers who were evaluated at a hospital, yet never received a unit of blood. While wounded, these individuals likely did not present with severe injury patterns and hemodynamic instability requiring blood transfusion. Many sustained orthopedic injuries, concussions, or other trauma that did not necessitate transfusion before evacuation. In the anticipated mass-casualty LSCO scenario of 72,000 casualties, 80% or 57,600 would be this population—the so-called “walking wounded”—representing a potentially lifesaving reservoir of blood.

This leads to a provocative but practical proposal: institutionalizing a structured “Walking Wounded Blood Bank.” In forward areas, mildly injured service members could be screened and donate blood before evacuation from the theater. To be eligible for donation, service members must meet donation criteria required by the Armed Services Blood Program (ASBP) and American Red Cross (ARC); more specifically, donors must be in good health, hemodynamically normal, of appropriate age and weight, and have their medication and immunization records reviewed. Individuals who are tachycardic, hypotensive, have equivocal FAST exams, are of concern for moderate to severe traumatic brain injury, or do not meet the ASBP or ARC criteria will be excluded. The GWOT data suggests that for every one transfused casualty, there were three wounded who did not require blood. Furthermore, collecting blood from individuals who are already at a medical facility equipped to transfuse blood would make collection and storage logistically simple. In mass casualty-producing conflicts, utilizing this untapped donor pool would significantly augment supply during critical surges.

Beyond the walking wounded, another opportunity for donation lies at the end of every deployment cycle. Over the two decades of war during the GWOT, about 2.7 million Americans deployed at least once, according to the US Department of Veterans Affairs and the Department of Defense.⁷ Even if only a fraction were eligible donors at scheduled redeployment from the combat zone, the aggregate supply would be substantial. A policy strongly recommending blood donation immediately before redeployment to the United States could create a robust and continuous supply of fresh blood. Integrating blood donation as a standard element of the redeployment process would be administratively feasible and ethically defensible if conducted with proper safeguards, screening, and medical oversight. In a protracted LSCO, such measures could mean the difference between sufficiency and shortage.

What should not be considered a viable solution, however, is harvesting blood from the recently deceased, as was done by Russian forces in WWII. This idea has been theoretically discussed at military meetings. Clinical evidence does not support this practice as safe or reliable for transfusion. After death, circulation ceases, clotting cascades activate, red blood cells undergo hemolysis, and gut bacterial translocation begins. Electrolyte shifts and biochemical degradation rapidly compromise blood quality.^8,9 Our experience on the battlefield is that the casualties who die where blood could be harvested have devastating injuries and are profoundly coagulopathic. Postmortem blood harvesting is untested, biologically unstable, ethically fraught, and operationally ill-advised. Furthermore, because most deaths (>90%) on the battlefield die of catastrophic injuries before reaching a hospital, this potential donor pool pales in comparison to the walking wounded or redeployed soldier groups as highlighted earlier.¹⁰ During the 20 years of GWOT, 7,000 soldiers died in Iraq or Afghanistan. Assuming blood was harvested from all individuals who died after reaching a battlefield hospital (~700), when compared with the walking wounded or redeployed soldier groups, deceased donors would have only produced 1.7% and 0.03% as much blood, respectively. In the desperation of mass casualty warfare, it may be tempting to look to every possible source—but science, safety, ethics, and mathematics are non-negotiable.

The reality is alarming. A near-peer war will likely generate thousands of American casualties per day. The military blood supply system would face an extraordinary strain and almost certainly break. The experience of GWOT shows both the scale of injury—53,000 wounded, 7,000 dead, and ~10,600 transfused. It also reveals a largely untapped reservoir for the future LSCO: tens of thousands of wounded who did not require blood and millions of deployed service members who could contribute to supply before leaving the theater. A “Walking Wounded Blood Bank,” combined with structured redeployment donations, offers a pragmatic and ethical approach to vastly expand the military blood system’s capabilities. In contrast, harvesting blood from the deceased remains scientifically unsupported, mathematically inadequate, and is morally and operationally dangerous. Preparing for LSCO means confronting uncomfortable arithmetic now—before the first day when 3,600 casualties arrive, and the blood to save them runs out.

Supplementary Material

ta-101-s143-s001.pdf ^{(1.1MB, pdf)}