Page 13 - Journal of Special Operations Medicine - Summer 2014

gushed into the air above the entry wound, suggestive Figure 6 SJT secured and maximally inflated over the left
of active arterial bleeding. There was no evidence of an femoral area to control hemorrhage.
exit wound where the C-A-T had been covering the pos-
terior aspect of the upper leg, implying that the bullet
remained in the casualty’s leg and could possibly have
caused a proximal femur fracture or entered the casu-
alty’s pelvis. There was no clinical evidence of pelvic in-
stability on physical examination. A medic immediately
applied direct manual pressure to the wound (Figure 5)
while another medic applied pressure to the left inguinal
area with a pressure board, an improvised device con-
sisting of a piece of plywood wrapped in SAM splint
secured with duct tape; pressure board use augments ap-
plication of direct pressure to vascular pressure points.
A third medic was dispatched to the American side of
the aid station to retrieve the SJT. After approximately 3
minutes of direct manual pressure, the entry wound was
packed with Combat Gauze while continued pressure
was applied to the femoral area with the pressure board. the SJT was placed slightly proximal to the position to
A pressure dressing using roll gauze and a compression compress the femoral area. Therefore, the SJT had to
wrap was applied to the packed wound. The casualty be slid down distal to the casualty’s pelvis. Also, the
was then briefly lifted from the litter to slide the SJT casualty himself, while not truly combative, was not
under his pelvis, where it was connected, tightened, and particularly cooperative in the process despite the intra-
inflated to a sufficient pressure to eliminate peripheral venous narcotic analgesics and reassurances from the
pulses in the left leg (Figure 6). interpreter and the Afghan medics. Finally, because the
hemorrhage had diminished after the Combat Gauze
The time required to apply the SJT was approximately packing and pressure dressing use, there was slightly
3 minutes. This reflects the total time from the moment less urgency to the rapidity of placing the SJT. The ac-
the SJT was brought into the ANA trauma room un- tual time to secure the SJT, once properly positioned,
til it was secured. The small space between the trauma was about 60 seconds.
beds required the American medics to take some time
to manage the ANA medics who were hovering at their Shortly after the placement of the SJT, the enroute criti-
elbows (Figure 5). There was also a brief delay in com- cal care nurse (ECCN) and flight medic arrived at the
munication, which went through the interpreter to the aid station to prepare the casualty for the MEDEVAC
ANA medics when the U.S. medics were about to lift flight. Peripheral intravenous catheter access was estab-
the patient to place the SJT, a device with which they lished but lost in both the left and right arms during
were unfamiliar. When the casualty was initially lifted, the course of the resuscitation. Right tibial intraosse-
ous access was established using an EZ-IO Intraosse-
®
Figure 5 Medic applying immediate manual pressure to ous Infusion System (Vidacare, San Antonio, TX, USA;
wound to control heavy arterial bleeding after removal http://www.vidacare.com/) just before departure of the
of C-A-T.
MEDEVAC flight to an Afghan hospital. During the
majority of the 15-minute MEDEVAC flight, the casu-
alty remained hemodynamically stable with a subopti-
mal oxygen saturation (85–88%) despite supplemental
oxygen at 15L/min. Within 5 minutes of landing at the
Afghan hospital, the casualty developed increased work
of breathing as evidenced by abdominal retractions with
a decreased level of consciousness. Radial pulses weak-
ened but the carotid pulse remained strong. The left leg’s
distal pulses, however, were detected by manual palpa-
tion by the ECCN. Reassessment of the wound site and
bandage revealed no evidence of hemorrhage, no swell-
ing of the proximal leg, and the SJT remained in place.
At that point, blood transfusion was considered prior
to landing but the estimated time of arrival to the Af-
ghan hospital was less than 2 minutes. The casualty was

SAM Junctional Tourniquet Battlefield Use in Afghanistan 3
®