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Wild Blue Yonder on the Air - Ep. 5 - Lt. Col. Karen Buikema on "Strategic Direction for Blood Banks" with Sara Belligoni and Brian Hastings

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0:00:13.1 Sara Belligoni: Alright, good morning everyone and thanks for joining us today at the Humanitarian and Disaster Relief Panel. My name is Sara Belligoni, and it's my pleasure to moderate this session in which Lt. Col. Buikema will present her research title Blood is the Price of Victory: Preparing the Military Blood Banking Community for Tomorrow's Fight. And I also thank Mr. Brian Hastings, the Director of the Alabama Emergency Management for joining us as the other discussant of this panel.

So I'm going to introduce myself real quick. I'm a PhD candidate in Security Studies at the University of Central Florida. I earned both my bachelor's degree and master's degree from Università degli Studi Roma Tre in Italy, which is also my home country, and probably you can hear that from my accent. And I also earned Certificate in Global Affairs from New York University. I'm a researcher, and I served as a geopolitical analyst for think tanks, research, and academic institutions. And I mainly research on civil military humanitarian coordination and disaster policy. I publish policy commentaries addressing these topics in the Middle East, East Africa, and Latin America, and I'm also currently a member of a working group investigating the impact of public policies of the COVID-19 pandemic here in the United States.

Now, I want to introduce you all to our panel by mentioning a real world event. So we probably all know what catastrophe the earthquake in Haiti caused in 2010. But we probably don't know that years after the disaster, Haiti was still struggling with the recovery, and in 2015, the Haiti's national blood transfusion center stopped working. There was no chance to fix it right away, and certified blood products were becoming scarce. So the Haitian Red Cross called upon the international community for help. The American Red Cross sent 1000 units of blood within five days, and then as there was also no blood testing kits available, Italy and South Africa prepared to ship some supplies, while the Dominican Red Cross work hard to try to send them those kits immediately. The lives that were saved thanks to this multilateral operation are countless and the reason why I wanted to mention this real world event, it's because I want to invite you all to think about the importance of blood bank management, while also how such management is important within both the military and civilian sphere. Now, we will talk about that a little bit more later, and we will address also how civil military coordination is important in crisis response.

 Now, I want to thank Lt. Col. Buikema's research because this panel can focus and discuss the important of setting procedures for blood bank management, especially within the military field while also stressing the importance of addressing urgent issues given the changing global environment and the high rates of in-theatre blood waste. So it's my pleasure to leave the floor to Mr. Hastings for introducing himself, and then Lt. Col. Buikema for introducing herself and then presenting her research.

Brian Hastings: Hey, thank you, Sara. And on behalf of Governor Ivey and the Cabinet of Alabama, it's an honor and a privilege to be here, a part of this prestigious and really important panel, and thank you to all the folks who have signed up to listen to this discussion today. So as Sara said, I'm Director Brian Hastings. And so I was appointed by Governor Ivey in September 2017 to be the Director of Alabama Emergency Management Agency. And who would have known that I would have come into this job during three historic seasons of disasters and hurricanes living in coastal Alabama.

It's interesting, I didn't retire from the Air Force thinking that I would continue in public service, but it's something that I've always been drawn to. Entering into Alabama Emergency Management Agency the last three and a half years and including COVID-19 have been historic for many reasons. One being that we've gotten 10% of all our major disaster declarations in the year 2020 alone, and 13% of all our major disaster declarations since 1961 since I have joined Alabama Emergency Management. So you could get a sense that maybe my staff in Alabama are waiting my resignation to end the disaster child that I've brought to Alabama. So it's been very, very, very challenging. And 2020 brought with it our third largest individual assistance disaster with Hurricane Sally, we actually felt the impacts of three of the 22 billion-dollar disasters in 2020, which also smashed a record of the costs and devastation of the number of billion-dollar disasters per year. And here we are still recovering from COVID-19.

So a little bit about me and my background. I'm an academy grad from 1990, I've spent 27 years in the Air Force, I think and speak a little bit differently than most people in this field, I'm not an emergency manager by trade, I'm an A-10 pilot and a teacher and an educator, and a trainer. So my degree was in astrophysics, applied physics, my two masters, I've a master's in Aeronautical Sciences from Embry-Riddle, and then a Master of Arts in military sciences for national resourcing national security strategy, with a concentration in strategy.

And so my last 10 jobs, and why I'm really excited to be a part of this panel and here with Karen and Sara, is that I've been a commander since 2007, both in armistice and of combat organizations. I've been in Germany, I've been in Korea, I was deployed to Afghanistan as the Vice Commander of 10,000 Airmen during the height of Afghanistan Operation. So I understand the risk that commanders are taking and the importance of the Platinum Minutes and Golden Hour in combat operations that allow us to get our injured veterans and contractors and just casualties of war back to some place to stabilize them and keep them alive. The system is just completely amazing. So I'm really excited about being here, having a conversation with Karen to highlight her incredible research and the things that I've learned and hopefully can share with the folks who are tuning in today. So without further ado, it is my absolute pleasure to introduce Lt. Col. Karen Buikema.

Karen Buikema: Hey, thanks Brian and Sara. I appreciate the opportunity to be here today and to talk about the research that I've done over the last year. Like mentioned, my name is Lt. Col. Karen Buikema. I am a biomedical lab officer in the Air Force, I've been a part of the Air Force Medical Service for the past 18 years. And recently, like two weeks ago, just graduated from Air War College and will be heading off to Lackland Air Force Base to take another squadron command as the commander of the diagnostics and therapeutics squadron, which of note is also the home of the largest blood donor center in the Department of Defense. So this research really was timely considering the job that I'm going to next.

My background, I am also from the Chicago area. So my Alabama accent is missing as well but the Midwest one comes out every once in a while. And I am a graduate of Marquette University in Milwaukee, Wisconsin. I have a degree in clinical laboratory science, and I'm also... My master's degree is in immuno-hematology from the George Washington University, and I'm a graduate of the Armed Service Blood Bank Fellowship, which was at Walter Reed and the National Institutes of Health.

And so I have been a career Air Force lab officer with specifically a specialty in blood banking and transfusion medicine. Like Brian, I was in Afghanistan in the height of a lot of the fighting that was happening there in 2010, 2011. I managed the apheresis blood collection and emergency blood collection processes in Kandahar, which was a very, very busy time to be doing that at the NATO Role 3 Hospital there with some of our partner countries. This past year in Air War College has been front and center and foremost in my career professionally for the past 18 years, and it's kind of something that while a lot of folks maybe don't think often about blood and how it gets there, and how important it might be, has been the focus of my professional life, my entire time in the service.

So I'd like to start with a quote by Thomas Jefferson that kind of puts a perfect cap, I think, on my profession, and that is, he once said, "The tree of liberty must be refreshed from time to time with the blood of patriots and tyrants alike." Now, I'm sure when he said that he was not talking about blood banking, because it wasn't a thing back then. However, it does really perfectly capture how important blood is in the military setting and in military medicine.

So recently, the past 20 years of fighting in Afghanistan and in Iraq, one of the biggest things that has come out of that from a military medicine standpoint, is that we currently have a 98% casualty survival rate, which means that if you are fortunate enough or unfortunate enough to be injured but fortunate enough to then be transported back to any type of theater care, the survival rates for those individuals are 98%, which is very astronomically high and pretty awesome, and I think a lot of military medics will pat themselves on the back, deservedly so, because of how awesome that number is. There are three main reasons for that, and one of the key reasons for that success rate is the robust and rapid availability of blood products very close to the point of injury. Brian mentioned the Golden Hour. And what that is, is from the time of injury, the one hour after the time that an injury, whether it's a blast injury, a gunshot wound occurs, to be able to get blood products into a patient within that first hour has proven itself to be very key to positive outcomes for that patient and for survivability.

So the military blood banking community... The organization that runs all of that, just for background is called the Armed Service Blood Program. The Armed Service Blood Program has developed a very, especially over these past 20 years, a very robust and complex but very efficient process for getting blood where it needs to be in theater. So we've done a great job. So the question, I guess, would be, what's the point of your research, what are you looking at? If everything's perfect, why did you research it? Well, I think the take-home message if you don't really get anything else out of this 45-minute discussion is that blood is very, very difficult to produce safely and effectively. It's not just like what you see on TV. "Oh, just give them O-neg and everything will be fine." There is a lot of complexity associated with creating a safe blood product. We do that. However, we also waste, as a military medicine community, we waste a lot of blood, a lot. The numbers are staggering, and I'll go into that in a little while.

And while that's been sustainable for our current conflict, looking forward into the future and the kind of changing character of war and what your peer and peer competition looks like, that rate, the difficulty that it takes to make blood and the rate at which we waste it, is potentially not going to be sustainable. What are the trends that are emerging that are gonna make it even harder and how do we move forward strategically as an Armed Service Blood Program to transition now so it's not too late 10 years from now when we find ourselves in a peer competition that we're trying to scramble and fix it so that we can maintain that 98% survivability rate that now, while it's a great accomplishment, is also kind of become the standard and become the expectation? So how do we do that?

Five key emerging challenges that you see and trends that are happening, I'm gonna combine the first two. But one, they are the decrease in blood donations. People just don't donate blood at the same level and at the same consistency that they used to, and all the trends indicate that. And the second thing that combines with that is as global diseases are on the rise and the safety expectations of blood products are on the rise, fewer and fewer people are even eligible to donate blood. And the complexity of making a product and the testing required, especially in the United States, to have what's considered a safe blood product is so complex. Only estimated and maybe 38% of people in the country can donate blood anyway, and of that 38%, only 10% actually do. So you have a really hard time just getting people to donate blood.

And the third thing is a decline and a decrease of professional laboratory staff. The clinical lab science career field is one that has been slowly diminishing over the years for multiple reasons. And of that and what I really want to highlight through my research is in the military itself, we have lab officers. The Army, the Navy, the Air Force, we all do that, my AFSC. The ability to do blood bank operations, even amongst the lab officers in the military, in the comfort level and the training is very minimal.

So a survey was done in 2020 of Air Force lab officers, just at the end of last year, of Air Force lab officers and less than 7% of them had any experience at all doing blood bank operations, and over 85% said they felt completely dissatisfied and uncomfortable with the training that they have received if they were put in a position where they would need to run, manage, and lead emergency blood bank operations. And these are the people responsible for doing it. So that highlights a huge problem that needs to start getting addressed now.

Fourth, and I mentioned this all ready, but near-peer power competition is gonna create a limited and restrictive access to the battle space. We can have a very robust logistical resupply capability in Afghanistan, in Iraq, where we've enjoyed pretty much open access to areas where we need to go. If we were to get in a war with a peer, that access wouldn't be there to the same level as we've had, and we wouldn't always be able to have the comfort level that, "Oh the helicopters are coming with fresh blood because they have access to the... To us." It won't be the case necessarily in a war with, let's say China or Russia.

And finally, and this is kind of the capstone of all of this, our current in-theater blood product wastage rate is complex and as hard as it is to create all that blood, once we get it in theater right now, depending on the blood product, the type of blood product we're talking about, 2020 we wasted or pretty much destroyed 90% of the products that we put in theater or 97%, like I said, depending on the blood product we're talking about. Those rates are astronomically high, and I think, to a lay person, it almost seems like mind-blowingly horrible. I will tell you, as a subject-matter expert, it's not quite that bad, but they are too high, they're too high. They're not sustainable moving forward. You are gonna have really, really high wastage rates, you need to have those just in order to provide the safety net that we need, but those rates are just too high.

So considering all those challenges and all the things, how hard it is to get blood where it needs... Good safe blood, where it needs to be, those wastage rates, even ethically, are not really sustainable. So how do we move forward and how do we start to prepare? My four recommendations for this, the first one, I'm not gonna lie, I stole this from our nuclear deterrence theory, is we need to develop a triad of blood products, if you will, that we keep in theater. And I'm not gonna get into too many of the specifics because I don't want to get too clinical, but those three things would be frozen blood products, low titer O whole blood, and then a robust in-theater walking blood bank program.

And just a quick summary of all those things, what that provides is the ability to create the product that you need when you need it, as opposed to... Think of blood like milk. And if you have 50 gallons of milk on the shelf, but you only drink two. It expires and it goes away. That's the same type of idea. But if you have frozen blood, low titer whole blood and the ability to collect blood in theater, you're not gonna be expiring nearly as much as if you just have fresh blood waiting there and then it doesn't get used. So that's the first point.

The second one, in order to do that and to have that triad successfully in place, we need lab professionals, laboratory officers who are trained and competent. And so in that, the Defense Health Agency through the clinical lab office there needs to develop a very robust tri-service laboratory officer training, so that that 85% of folks who say, "I am completely uncomfortable doing this even though it's one of my primary jobs." We can start to change that trend. And obviously that needs to happen sooner rather than later, start that training because that's not gonna be fixed overnight with that huge group of individuals. The third, and I think potentially the most exciting is the Defense Health Agency needs to invest in more research and development associated with blood products, or transfusion medicine. One of the things that is really exciting, but really no research has been done is the potential of utilizing the space force to... We talk about the inability to have freedom of movement in the battlefield in potential war with China or something like that, or a more peer adversary.

Utilizing the space force to store blood products in space, to transport blood products through space, would be unbelievably awesome as far as creating the logistical capabilities that it would allow. However, there has been no research done on what the storage emulsion of blood products would be if they've been stored in outer space, and that has to be done in order to, again, ensure the safety and efficacy of those blood products. And another perfect example would be viable blood substitute. That is something that does not exist and to continue research into that process and procedure or potential... And then the third research type thing that I've mentioned in my paper, would be talking about pathogen inactivation technology. So there are transfusion transmitted diseases, diseases that can be transmitted to folks through blood products. The ability to create some type of technology that would inactivate pathogens in blood, so that I could transfuse you a unit of blood that potentially had malaria in it, but we killed all of those parasites through, whether it's some type of UV-like technology or whatever the case may be to make it so that you wouldn't have to worry about that potential pathogen. Transfusion transmitted disease would be astronomical in helping with the safety of the blood products that we have.

And then finally, the last recommendation that I have would be to look at... The Air Force Medical Service has a program of global health engagements where we, through humanitarian efforts, kind of some of the things that Sara mentioned, we partner with nations to build bridges and build relationships, looking specifically at those global health engagements from a transfusion medicine standpoint to countries... and I specifically mentioned the Philippines and Thailand, countries around the South China Sea area, places where potential conflict would happen, that we currently have defense, mutual defense treaties and alliances with. If, for example, we were in some type of conflict in the South China Sea area and we had an inability to get blood products, American blood products into that region, currently, the blood products produced in the Philippines and Thailand, there's some safety concerns there.

But if we invested in the Philippine blood program, the Thai blood program, and were able to develop and create more safe and effective practices there, then we could rely on them as partners to potentially be a source of blood for our service members as well. So that was kind of a very, very quick summary of my year-long research project. I will say the bottom line, our current processes work great. We have created a wonderful program that has saved countless... Thousands and thousands of lives of injured service members. However, there's a quote by General Douhet that General Brown always likes to say about victory smiling upon those who anticipate the change in the character of war, not upon those who wait until the change happens. So we can't wait. We need to start anticipating what the change of war is gonna look like and start putting those actions in place now so that 10 years from now, we're ready to go and we can keep saving lives.

Bellgoni: Thank you so much for this presentation. I think it's just great that you are not only dedicating time to these specific studies but your career, and I really appreciate that as someone that is more on the theoretical research side, because as I always say, I try to, I would say, understand the point of view who is in the field.

I really want, again, just catch on what you said when you were mentioning the importance of working with civilians, with I would say also local authorities of countries where potentially the military can be deployed. I think that what I want also the audience to do here is to think about what we learn from this research and also how we can somehow translate those policy recommendation to a more overall blood bank management, so for the medical community overall. For instance, when civilians or militaries or even civilians and militaries together intervene in post-disaster or post-conflict settings, medical teams face several challenges. They can range from clinical challenges, ensuring that the blood products are meeting the standards and also logistics challenges. So those related to supply chain issues. And when involved in international operations, civilians and militaries are often required to work together and doing so also with a third actor that are the local authorities. There are therefore context-specific issues, I would say, that need to be considered when it comes to the blood bank management.

For instance, the blood products are present in the field, and they are made available for only the militaries or also the civilians depending on the context, and then also based on the state capacity of the country where we are working within, then what the kind of healthcare system we are working within. Is in a healthcare system that can support us or is in a healthcare system that we have to support. And what happens also with the requirements of the blood products, especially when, for instance, military forces can somehow have to intervene in disaster settings and so these blood products might be okay for the, let's say in the case of the United States, the FDA standards, but what about standards that might come into play in the field. So I think that crisis response plans specifically for the blood bank management needs to consider blood product requirements, blood product types, plans for clinical and medical personal mobilization, options for the transportation and storage. And this makes the whole picture very complex, but I think we are in a good. I would say that the military is doing a great job in setting what we have now, but what we need to do better, or what are the directions for doing that better. And I think that the overall medical community can learn from that.

So I would say that what I would like to discuss a little bit more is what can the military and civilian actors can learn each other, what eventually the civilian sphere can learn from what the militaries are doing, and especially how the two can better coordinate the blood bank management when operating in a third country, and especially when the third country's authority somehow are involved in this management. I think it's important to address these questions based on the global environment in which we are right now, in which the number of these officers are seeing militaries more and more involved, and also are seeing more and more coordination between civilians and militaries. So I would like to leave the floor and open a little bit the discussion on these topics.

Buikema: Sara, you bring up some outstanding points, and I think one of the key ways that the civilian sector, especially in the United States, and the military sector, can work together is through training. Like I mentioned, looking at military lab officers and their comfort level with managing blood banking and managing emergency blood bank operations is very minimal. Why? It's because as officers we're kind of expected to be a jack of all trades and in the laboratory career field, you're not focusing all of your... Very few people, myself excluded, I suppose, and there's a few folks like me, but very few of us focus our entire careers specifically on blood banking and on transfusion medicine. They're focusing on many, many other things.

And so because of that, there are potentials with the civilian sector, whether it's the Red Cross, American blood systems, other... That are civilian, FDA itself, The American Association of Blood Banks, like various regulatory agencies where starting something like an education with industry fellowship for our lab officers to go and do things there, and to get the training with the people who do it, 24/7, 365 days a year, would be just invaluable to helping them be ready and comfortable with having to lead in the situation, whether it's in a deployment environment or an emergency situation that would happen here in the United States. So I think that's a clear one, and I also think usually the civilian sectors, whether again, it's the Red Cross or whoever, is always very willing to have that partnership. There's usually not a lot of hesitancy because you're talking about trained competent folks. We do it with trauma surgeons all the time at air-force medicine, partner with civilian hospitals and institutions. They get free labor, they get free trauma surgery labor, and our surgeons are able to hone, sharpen and keep their skills good to go. It would be the exact same thing.

And I think that's a key way that we could partner together. I also think inviting some of the regulatory agencies to see some of the complexities associated with doing transfusion medicine in the middle of a battlefield, so they can start to understand the challenges that we're juggling as we're trying to maintain safe products and then have those experts help us come up with ideas of how to do this safer, how to do it more efficiently. There are tons of room for collaboration, I think in that environment. And then finally, to your point about other countries and partnering with them, that is a whole another panel discussion, I think, to a certain level. When I was in Afghanistan, I had the opportunity to work with the Afghan Minister of Health, and we actually had a blood drive for a women and children's hospital in Kabul and it was outstanding.

And one of the things he told me was, the entire budget for the entire Afghan Ministry of Health, probably about the same as the budget for a really big high school in New York City. You know what I mean? And this is for a whole country. And so you look at the challenges associated with them trying to do medicine, and just transfusion medicine in and of itself is very complex, and how can we partner with them better. One of the questions I've been asked multiple times is, "Hey, why don't we give our blood before it expires to other countries? Why are we letting all this blood expire on the shelf? Why aren't we giving it to other countries?" And I think that's something that needs to be explored, but I will just caution that that's not as easy to do as it is to say, for many reasons, whether it's standards in those other countries, religious aspects in those other countries, also just kind of, "Well, when do we give it? When it has five days left? When it has two days left? And what standard do we want to set as well?" But I think there's potential there, and it's something that needs to be explored more and more.

Hastings: The more we talk, the more I learn about this. As a public servant, I like to say where I am, I build community, and our number one priority in operations is to save lives and then mitigate suffering. And so emergency management and resilience at large is a collection, it's a collective, is the power of people, individuals, communities, families responding to, caring for and recovering from disasters. And so social cohesion is a leading indicator in all disasters of not only surviving but thriving. So one thing that I hear over and over again in your themes or really the US blood system is the logistics of life. It is the logistics of life. Without it, there is no life. In your paper, you state, "In order to ensure the blood is always available regardless of logistical resupply capabilities," which you're talking about right now, "The third pillar of the theater blood supply, a robust walking blood bank must be implemented DOD-wide." However, you also mentioned, and this is something we're seeing right now in COVID and in emergency operations, that the younger generations don't donate blood at the same rate as older generations.

While only 38% of the population is eligible, only 10% donate. So recently, I was inspired by my son to give. So I've been giving every couple of months and I'm on my sixth and I got one more power red and I'll be at a gallon donation. But that's what I've chosen to do as a leader in Alabama for the national emergency for COVID-19. And actually, I think I contracted COVID during my fifth donation and brought it to my family. But then I went and donated again in May. So how would you encourage and develop the required spirit of volunteerism, the personal courage, the risk acceptance or as you had mentioned, the altruistic human beings to create normal blood donations or normalize just giving blood and emergency donations in the younger generation, especially specifically the military, to keep our US blood system, but really what we're talking about here the military blood system healthy because it is the logistics of life? And would you think about normalizing it in some of our exercises or completion of training and education programs just to make it a habit of what we do for each other and increase that social cohesion inside the military?

Buikema: Absolutely. And Brian, you bring up a great point as far as within the military itself making it almost a habit or that sense of... Almost like a sense of obligation that we feel to do that. I will say the Department of Defense in total has about 20 blood donor centers at various military installations, the Air Force only has three. But the three that the Air Force has, one of them, the one at Lackland Air Force base is the biggest donor center in the Department of Defense by far. And the reason why it's so huge is because donating blood is a big part of going through basic training. When you're in basic training, again, it's completely voluntary, but you're offered the opportunity to donate blood. And for the folks listening if you've ever been through any type of... Or seen a movie, when you're in basic training and someone offers you, "Hey, you can go sit on this comfy chair for 20 minutes and nobody's gonna yell you and you can eat cookies and drink juice," most people in basic training are like, "Absolutely, I'm gonna go do that," even if they're afraid of needles. It's worth it just for the Oreos and the juice that you get to have and a break from your drill instructors. So we do that now. We start it early.

The other larger donor center that we have is at Keesler, which is again another training base with a huge training population. And so we're starting that thought process early in folks. And I will say also in theater, when the need for emergency whole blood collections come up there is never a problem finding donors to donate blood. So I think within the military community itself, when the urgency is there and the need is there, every... I had guys, I had to say, "Listen, you cannot donate blood because you're not the right blood type," and they were mad at me and I'm like, "There's nothing I can do, I'm sorry. You're the wrong blood type." But they want to so bad to take care of their injured colleagues. So there's an understanding there. I would say, as a community as a whole, I think in America. Let's just say Millennials, because that's who we like to talk about, sometimes they get this bad rap of, "Hey, they're not as into altruistic type things."

There was a report that came out in the New York Times a little while ago that said, actually, millennials are very into volunteerism, and that younger generation really wants to. It's very important to them, giving back and volunteering and helping in the community. I think the problem with the blood banking industry and with that... It hasn't marketed itself well. And the importance and the significance of it, everyone just kind of assumes the blood's gonna be there. And if you really sit down and talk to someone, it's like, "Well, where do you think it came from?" It's not like drugs, we didn't make it, and the pharmaceutical companies don't make it. Somebody had to go donate blood. The Bloodmobile in the parking lot at the grocery store is actually doing something very important. And I don't know, I'd have to research this more, how many Americans really understand that and really see that, "Hey, without you doing this, we don't have any blood." People think... You don't get paid to do any blood. It's free.

So those people who go... College students who donate plasma and they get paid, that's not used for human transfusion. That's used to make reagents and things like that. Blood that's transfused to human beings in our country is all voluntarily donated. And so explaining that and making people aware of that. I don't think people know. And that would just be my guess. I'd have to do a little bit more research into that. But that's kind of where I'm at with... Hope that answers your question a little bit.

Hastings: It does. And one last thing I would say, and then I'm gonna hand it back over to the ladies, and Sara and Karen, you can bring us home. But this app. This is an American Red Cross app. So every time you donate blood, it tells you that it was kept some place, it was tested, they'll keep it local because when you donate local, they incentivize local cohesion, and then all my blood so far has gone over to Georgia, which is fine also. But it also tells you the high school it goes to and that it's being used. So you're actually connected with it, the lives that you're saving, and maybe the military can go down that path too. So you get this sense of, "Oh my God, this really is working." Now, our waste rate, sometimes in combat is a little higher, but still the connection with another human is just really, really powerful. So thank you, Karen, I appreciate that. 

Buikema: Absolutely, thanks Brian. Sure, so I think the civilian community when it comes to natural disaster response and things like that, there's a lot to be learned from the military program in the military sector, in that the military is inherently flexible in what we do. We have to be flexible, and flexibility is the key to air power. And thinking, outside the box thinking that comes with just the military in general, but definitely comes with military medicine. There were times in Afghanistan I didn't have any of the supplies that I needed, or they were all expired, and I needed to figure out how to still create this safe product, right? In the civilian sector in the United States, even if there's a big earthquake or a mass shooting or things like that that happen that require a lot of blood products.

We tend to be very altruistic in those times. Everyone rushes to donate blood because they do something, want to help. I think a good way to look at it is, "How do we take that immediate response or that immediate desire to help and do altruistic things to help in this one particular situation and try to create a more longer lasting altruistic mindset within folks? Because... If you look at it, a 100 people can go donate blood after a mass shooting and they might only need 20 units of blood. The rest of that blood's potentially gonna be wasted because again, it's only good for 42 days. And so if you have this huge amount of blood that comes in for one event and it's not needed, that's unfortunate. You want... Instead, "Hey, come back in three weeks and donate because we're going to need it for cancer patients or moms having babies, whatever the case may be." I think that's one way. Another thing though, is just back to that flexibility mindset that the military has and looking at, "Hey, I don't have what I need, there's been an earthquake or there's been a tornado."

"I don't have what I need, how do I function? How do I continue moving forward?" The military blood banking community is a wonderful resource as far as ideas and training for how to deal with those actions because it's what we live and breathe all the time when we're deployed and in those type of environments. So again, I just think there's a lot of mutual training that can happen back and forth that would be very helpful for both entities.

Bellgoni: Thank you. And I see Brian, just follow up, like, "Can the US military blood bank be used for civilians in disaster relief?"

Buikema: So it definitely could, the blood that's collected in the United States. So sometimes for emergent needs we'll have to collect blood in Afghanistan or blood in Iraq. That stuff is not FDA approved, so no, that would not be used in the United States. But every military blood donor center is an FDA-approved licensed donor center. The blood products that are collected at those donors centers are the equivalent and just as safe and good and tested the same as anything collected from the Red Cross or American blood centers, any of those. So it could if need be. I know there are times, we have huge blood drives at the Air Force Academy, for example, a couple of times a year, and there will be times when we collect just a massive amounts of blood and we don't need it all to meet our quotas for overseas, we will give those to the civilian community because again, ethically, and morally to just let that blood go to waste would be just horrific. So we will then donate that or give it once our quotas, that what we need for theater usage has been filled, we'll donate that to the civilian sectors.

Bellgoni: Thank you so much. We are at the end of our panel. So I want to thank Karen and Brian again for this awesome discussion, and the Air University and MGMWerx for the support and logistics. And thank you so much for attending, everyone. We hope that you all enjoy it, and you have learned something about the blood bank management, and we definitely look forward to staying in touch if anyone wants. And again, thank you so much, everyone, for attending today.

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