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

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.).