Page 162 - Journal of Special Operations Medicine - Winter 2015

limbs to tourniquet ischemia. The first four-star en-
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The U.S. Central Command . . . dorsement of the TCCC and tourniquets occurred when
mandated in 2005 that all individuals General Doug Brown, Commander of the USSOCOM
deploying to that combat theater in 2005, mandated TCCC training and equipment for
be equipped with tourniquets and all deploying special-operations units. The U.S. Central
Command, largely through the efforts of former Colo-
hemostatic dressings. nel Doug Robb, also mandated in 2005 that all indi-
viduals deploying to that combat theater be equipped
Iraq and Afghanistan did not have high-quality, com- with tourniquets and hemostatic dressings.
mercially manufactured tourniquets and had to rely on
improvised tourniquets of varying quality. As awareness of the success of the TCCC Transition Ini-
tiative and the U.S. Central Command directive spread
The expanded use of tourniquets in the military did not throughout the military, conventional units began to
occur as a gradual evolutionary process but rather as the adopt the TCCC, including tourniquets. In 2005 and
result of a series of discrete events in 2004 and 2005. 2006, tourniquet use expanded rapidly throughout the
First, in 2004, the USSOCOM funded a U.S. Army In- U.S. military. The beneficial impact of the battlefield use
stitute of Surgical Research (USAISR) study of prevent- of commercially manufactured tourniquets was very
able deaths in special operations units in Afghanistan well documented by an army orthopaedic surgeon, Col-
and Iraq. This study, first authored by the USAISR com- onel John Kragh, during his time at a combat support
mander at the time, Colonel John B. Holcomb, MD, hospital in Baghdad in 2006. 8
FACS, found a 15 percent incidence of preventable
deaths among the special operations fatalities that had By the end of 2011, Colonel Brian Eastridge’s landmark
occurred through November 2004, including a number study “Death on the Battlefield” found that potentially
of deaths from extremity hemorrhage that could have preventable deaths from extremity hemorrhage had
easily been prevented with nothing more than an effec- dropped from the 7.8 percent noted in the previously
tive tourniquet. 5 mentioned Kelly study to 2.6 percent, a decrease of 67
percent. The studies by Kragh and Eastridge and other
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Second, Dr. Holcomb directed that USAISR researchers U.S. military authors established the benefit of battle-
conduct a comparative study of commercially available field tourniquets in combat casualties. Eastridge’s paper
tourniquets. This study, conducted by Tom Walters, documented that as of June 2011, there were 4,596 total
MD, and colleagues, recommended three tourniquets U.S. combat fatalities. Of these deaths, 119 servicemen
for use by the military: the Combat Application Tour- and servicewomen died from isolated extremity hemor-
niquet (C-A-T), the Special Operations Forces Tactical rhage. If the incidence of death from extremity hemor-
Tourniquet (SOFTT), and the Emergency and Military rhage had continued at the 7.8 percent rate observed in
Tourniquet (EMT). All these tourniquets had been the Kelly study, the number of deaths from extremity
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proven in the laboratory to be 100 percent effective in hemorrhage would have been 358. In considering this
stopping arterial blood flow to extremities. The EMT, number, it should be noted that Kelly’s 7.8 percent in-
a pneumatic device, was less well-suited for battlefield cidence of death from extremity hemorrhage included
use. The Committee on Tactical Combat Casualty Care fatalities up to the end of 2006 and so reflected at least
(CoTCCC) subsequently recommended the C-A-T and some decrease in extremity hemorrhage deaths as a re-
the SOFTT as the preferred battlefield tourniquets. sult of the 2005 push to expand the use of tourniquets
in the U.S. military.
Third, the TCCC Transition Initiative was funded by the
USSOCOM and conducted by the USAISR. This effort,
led by Sergeant First Class Dom Greydanus, was basi- By the end of 2011 . . . preventable
cally the medical equivalent of a rapid fielding initiative. deaths from extremity hemorrhage had
It provided TCCC training and equipping to deploying dropped from the 7.8 percent noted in
special-operations units and incorporated methodology the previously mentioned Kelly study to
for determining the success or failure of the newly intro- 2.6 percent, a decrease of 67 percent.
duced TCCC measures. The TCCC Transition Initiative
(and the U.S. Army) chose the C-A-T as the tourniquet
to field. Holcomb, Champion, and others have documented that
casualty survival in Afghanistan and Iraq was signifi-
The TCCC Transition Initiative was a resounding suc- cantly higher than that observed in World Wars I and II
cess and documented 67 uses of tourniquets in special- and the Vietnam conflict. This increased survival was
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operations units with good effect and with no loss of the product of both increased use of personal protective

150 Journal of Special Operations Medicine Volume 15, Edition 4/Winter 2015