Page 14 - Journal of Special Operations Medicine - Summer 2014

transferred to the care of the Afghan physicians, who when tensioning the belt, then the TCD stays in place
performed urgent surgical intervention. He ultimately and this pitfall is avoided).
required 10U of transfused blood and recovered suf-
ficiently to be transferred to another Afghan hospital Regarding the return of distal pulses during the MEDEVAC
for further treatment and rehabilitation 5 days after the flight, collateral arterial flow around the common femo-
injury. ral pressure point may occur by way of other arteries
to the lower extremity, and such collateral flow may al-
low the pulse to become palpable distally. Swan et al.
12

Discussion
described this phenomenon in normal human subjects
This case is the first reported use to our knowledge of with pressure point compression, but in the present case
the SJT being used for life-threatening junctional hem- hemorrhage control was maintained by such compres-
orrhage in the prehospital setting. As use of the various sion while collateral flow was observed.The casualty ex-

available junctional tourniquets increases, it is essen- perienced no complication from either the hemorrhage
tial that the initial experiences with these devices be control or the collateral flow.
reported to increase awareness of their availability and
capacity to treat these complex casualties. This practi- Another advantage particularly relevant to this casualty
cal, “real world” experience regarding the advantages is the SJT’s ability to act as a pelvic splint. Although
and disadvantages of these devices in turn may lead to this casualty did not have obvious pelvic instability by
improved training beyond what can be accomplished in manual assessment to suggest a pelvic fracture, there
a simulated setting for emergency healthcare personnel was no exit wound present. It is possible that the bullet
who may be required to use a junctional tourniquet on struck the femur and entered the pelvis causing further
a casualty in either the military or civilian setting 13–15 vascular damage and hemorrhage. If intrapelvic hemor-
(Table 2). rhage occurred, the SJT’s pelvic splint effect may have
diminished further blood loss. In addition to the blood
One of the primary advantages of the SJT in the pres- loss from the initial injury, the possibility of intrapelvic
ent case was the relative ease in learning how to use the hemorrhage may have accounted for the casualty’s per-
device. The medics who successfully used the SJT had sistent mild hypoxia and mild clinical decompensation
only received the device approximately 1 month prior near the end of the MEDEVAC flight.
to using it on this casualty. After simply reading the “In-
structions For Use” included with the tourniquet, they The present case reported is similar to that of Corpo-
were able to master its application and subsequently ral “Jamie” Smith except that with the passage of 20
performed periodic drills to reduce the time required to years, dedicated junctional hemorrhage control research
secure the device. During these drills, they refined their has moved the trauma field beyond past ineffective mea-
ability to keep the inflatable Target Compression Device sures toward the current device-based interventions that
(TCD) properly positioned over the common femoral may lead to saved lives on the battlefield. Future direc-
artery where the femoral pulse is palpated. They noted tions for further work include increasing awareness of
that sometimes the TCD shifted in position as the tourni- the capacity to control prehospital junctional bleeding;
quet belt handles were pulled asymmetrically to tighten awareness may be improved by better logistics, refined
the belt (if the pulls are symmetrically counterbalanced training, and more research and development.

Table 2 Advantages and disadvantages of interventions learned in initial laboratory use*
Intervention Advantages Disadvantages
Digital compression Fast, easiest to target, one-handed Smallest muscles tire fastest
Manual compression Heels of hands work quickly If two hands are used, no hand is free
Knee compression Powerful, sustained, no hands Clumsy, can obscure wound
Kettlebell Fast, rounded edges, frees one hand Heavy, tilts, one hand to steady
CRoC First available, best known device Disc can fall, has the most steps
SJT Fast, may use binder on pelvis Newest, least known device
JETT Harness may splint a pelvis fracture Disc can fall, two straps, two discs
AAT Targets pressure point broadly May block vena cava
Note: *Adapted from Kragh et al. with permission.
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4 Journal of Special Operations Medicine Volume 14, Edition 2/Summer 2014