Page 11 - Journal of Special Operations Medicine - Summer 2014

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First Case Report of SAM Junctional Tourniquet Use in
Afghanistan to Control Inguinal Hemorrhage on the Battlefield

Jeffrey K. Klotz, MD; Maura Leo, BSN, RN, CEN; Brent L. Andersen, Jr.; Adrien A. Nkodo;
Gaston Garcia; Amanda M. Wichern; Michael J. Chambers; Ohmar N. Gonzalez;
Mason U. Pahle; Joshua A. Wagner; John Robinson, PA; John F. Kragh, Jr., MD

ABSTRACT
Junctional hemorrhage, bleeding that occurs at the junc- to the development of junctional tourniquets to control
tion of the trunk and its appendages, is the most common hemorrhage in this anatomically complex and clinically
preventable cause of death from compressible hemor- challenging body region.
rhage on the battlefield. As of January 2014, four types of
junctional tourniquets have been developed and cleared As of January 2014, four devices have been cleared by
by the U.S. Food and Drug Administration (FDA). Suc- the FDA for junctional hemorrhage control: (1) AAT ,
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cessful use of the Abdominal Aortic Tourniquet (AAT ) which was recently renamed the Abdominal Aortic and
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and Combat Ready Clamp (CRoC ) has already been Junctional Tourniquet [AAJT ] (Compression Works,
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reported. We report here the first known prehospital use Birmingham, AL, USA; http://www.compressionworks.
of the SAM Junctional Tourniquet (SJT) for a battlefield net/); (2) CRoC (Combat Medical Systems, Fayetteville,
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casualty with inguinal junctional hemorrhage. NC, USA; http://www.combatmedicalsystems.com/); (3)
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Junctional Emergency Treatment Tool (JETT , North
Keywords: SAM Junctional Tourniquet, junctional hemor- American Rescue Products, Greer, SC, USA; http://www.
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rhage, prehospital care, hemorrhage control, wounds and narescue.com/); and (4) SJT (SAM Medical Products,
injuries Wilsonville, OR; http://www.sammedical.com/) (Table
1). The SJT also is cleared by the FDA for the treatment
of suspected pelvic fractures. Successful use of both the
AAT and the CRoC on casualties with junctional hem-
Introduction
orrhage in both military and civilian settings has been
In Black Hawk Down: A Story of Modern War, Mark reported. Current U.S. Army Tactical Combat Casu-
6–9
Bowden recounts the frantic attempts by Sergeant First alty Care Guidelines recommend the immediate applica-
Class Kurt Schmid, a highly trained Special Operations tion of a Committee on Tactical Combat Casualty Care
Forces (SOF) medic, to save the life of Corporal “Ja- (CoTCCC)-recommended junctional tourniquet if the
mie” Smith after he began hemorrhaging on the streets bleeding site is appropriate for its use. We report here
10
of Mogadishu, Somalia, from a gunshot wound to his the first prehospital use of the SJT with the intent of
proximal thigh in 1993. Despite Schmid’s heroic efforts increasing awareness of this innovative method of junc-
and aggressive countermeasures to stop the bleeding, tional hemorrhage control.
Smith eventually exsanguinated from his wound over
a few hours. Smith’s death and other tragic, “excruci-
atingly painful and obviously ineffective” experiences Technique of Use:
with controlling junctional hemorrhage, specifically To Control Difficult Bleeds in the Inguinal Area 11
bleeding that occurs at the junction of the trunk and its
appendages, have been the impetus for the U.S. military • Slide the belt underneath the patient, positioning the
to develop interventions to treat these life-threatening target compression device (TCD) over the area to be
injuries. 1–3 In the current war in Afghanistan, most casu- compressed (Figure 1).
alties with potentially survivable injuries die from hem- • Use sterile gauze or hemostatic dressing if targeting
orrhage. As the use of extremity tourniquets became directly over a wound.
4
widespread, junctional hemorrhage became the most • For bilateral application, use a second TCD.
common preventable cause of death on the battlefield. • Hold the TCD in place and connect the belt using the
5
This urgent operational and clinical capability gap led buckle (Figure 2).

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