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the results are based on an assumption that the mani- with traumatic injuries after a bomb explosion at the Boston
kin acted like a bleeding patient, but the manikin has Marathon. N Engl J Med. 2014;370:1441–1451.
no pain response. If the inexperienced user’s excessive 2. King DR, Larentzakis A, Ramly EP; Boston Trauma Col-
laborative. Tourniquet use at the Boston Marathon bombing
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then when patients feel pain, real-world results may be 594–599.
more like that of the experienced user. A controlled ex- 3. Caterson EJ, Carty MJ, Weaver MJ, Holt EF. Boston bomb-
periment is not as chaotic as mass casualty situations ings: a surgical view of lessons learned from combat casualty
that entail other considerations such as human factors, care and the applicability to Boston’s terrorist attack. J Cranio-
fac Surg. 2013;24:1061–1067.
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mance under stressful situations with associated distrac- lives in Boston marathon bombing.” The Huffington Post.
tions. Given these limitations, the current understanding 18 April 2013. http://www.huffingtonpost.com/2013/04/18/
of improvised tourniquets does not permit a definitive tourniquet-boston-marathon-explosions_n_3109055.html.
Accessed 21 July 2014.
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technique of use. gency tourniquet program’s lessons learned with devices and
designs. Mil Med. 2011;176:1144–1152.
Future directions for research include study of other 6. Clumpner BR, Polston RW, Kragh JF Jr, et al. Single versus
purposes, such as looking at more users to better under- double routing of the band in the combat application tourni-
quet. J Spec Oper Med. 2013;13:34–41.
stand user variability in skill level, looking at bystander 7. Polston RW, Clumpner BR, Kragh JF Jr, et al. No slackers in
capacity to use tourniquets, looking at learning curves tourniquet use to stop bleeding. J Spec Oper Med. 2013;13:
of users with increasing experience by numbers of uses, 12–19.
and progressing to fill the many other empiric gaps in 8. Kragh JF Jr, Walters TJ, Westmoreland T, et al. Tragedy into
knowledge regarding improvised tourniquet use, such drama: an American history of tourniquet use in the current
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as which techniques are better, which device designs are 9. Littell RC, Milliken GA, Stroup WW, et al. SAS for Mixed
better, and which training programs are better. A search Models. 2nd ed. Cary, NC: SAS Institute Inc.; 2006.
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by research, the user’s understanding of tourniquets and niquets.” USA Today. 17 April 2014. http://www.usatoday.com
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and-windlass tourniquet was only 68% effective and gency tourniquets to stop bleeding in major limb trauma. J
this rate did not achieve the minimum threshold of reli- Trauma. 2008;64:S38–49.
ability of 80%.

Disclaimer
Cadet Altamirano is with the US Corps of Cadets, US Mili-
The opinions or assertions contained herein are the pri- tary Academy, West Point, New York.
vate views of the authors and are not to be construed
as official or reflecting the views of the Department of COL (Ret) Kragh is with the US Army Institute of Surgical
Defense or US Government. The authors are employees Research, Joint Base San Antonio Fort Sam Houston, Texas.
E-mail: john.f.kragh.civ@mail.mil.
of the US Government. This work was prepared as part
of their official duties and, as such, there is no copyright Dr Aden is with the US Army Institute of Surgical Research,
to be transferred.
Joint Base San Antonio Fort Sam Houston, Texas.
Disclosure Dr Dubick is with the US Army Institute of Surgical Research,

The authors declare no conflicts of interest. Joint Base San Antonio Fort Sam Houston, Texas.

References
1. Eikermann M, Velmahos G, Abbara S, et al. Case records of
the Massachusetts General Hospital. Case 11-2014. A man

46 Journal of Special Operations Medicine Volume 15, Edition 2/Summer 2015