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further assessment include more testing, further devel- 2. Kelly JF, Ritenour AE, McLaughlin DF, et al. Injury severity
opment of junctional tourniquet models, and refinement and causes of death from Operation Iraqi Freedom and Oper-
in test plans. More testing is needed in the field to bet- ation Enduring Freedom: 2003–2004 versus 2006. J Trauma.
2008;64:S21–26; discussion S26–27.
ter simulate the battlefield. On the battlefield, junctional 3. Holcomb J, Caruso J, McMullin N, et al. Causes of death in
tourniquet use typically occurs in tactical casualty care US Special Operations Forces in the global war on terrorism:
after physical exertion by the medic and in a stressful 2001-2004. US Army Med Dep J. 2007:24–37.
setting. Inclement weather or nighttime darkness may 4. Eastridge BJ, Hardin M, Cantrell J, et al. Died of wounds
affect testing results as well. The present study showed on the battlefield: causation and implications for improving
combat casualty care. J Trauma. 2011;71:S4–8.
that no single model of junctional tourniquet had supe- 5. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battle-
rior performance in all assessment categories; therefore, field (2001-2011): implications for the future of combat casu-
a larger test plan than the present 14 users may be ad- alty care. J Trauma Acute Care Surg. 2012;73:S431–437.
equately powered to differentiate performance among 6. Blackbourne LH. 1831. US Army Med Dep J. 2011:6–10.
the models and could allow a better understanding of 7. Butler FK. Tactical Combat Casualty Care: update 2009. J
Trauma. 2010;69(suppl 1):S10–13.
tourniquet use in varied settings. Characteristics of op- 8. Tovmassian RV, Kragh JF Jr, Dubick MA, et al. Combat ready
timal junctional tourniquets should include speed, ef- clamp medic technique. J Spec Oper Med. 2012;12:72–78.
fectiveness on a variety of junctional areas, and on the 9. Croushorn J. Abdominal aortic and junctional tourniquet
umbilicus (overlying the aorta). Testing should now in- controls hemorrhage from a gunshot wound of the left groin.
J Spec Oper Med. 2014;14:6–8.
clude ease-of-use assessment so that every use can avoid 10. Klotz JK, Leo M, Anderson BL, et al. First case report of
a long learning curve. SAM Junctional tourniquet use in Afghanistan to control in-
guinal hemorrhage on the battlefield. J Spec Oper Med. 2014;
14:1–5.
Conclusion 11. Kragh JF Jr, Parsons DL, Kotwal RS, et al. Testing of junc-
Within the five assessment categories, multiple models tional tourniquets by military medics to control simulated
groin hemorrhage. J Spec Oper Med. 2014;14:58–63.
of tourniquet performed similarly well; SJT and AAJT
performed best in four categories, JETT was best in
three, and CRoC was best in two.
MAJ Chen finished a research fellowship at the US Army
Funding Institute of Surgical Research (USAISR), Fort Sam Houston,
Texas, in 2014. He serves as an Israel Defense Force (IDF)
This project was funded with internal USAISR funds Medical Corps (MC) officer as a general surgeon.
and the Defense Health Program (Proposal 201105:
Operational system management and postmarket sur- MAJ Benov is currently an IDF Research Fellow at USAISR,
veillance of hemorrhage control devices used in medical Fort Sam Houston, Texas. He serves as an IDF-MC officer as
care of US Servicepersons in the current war). a general surgery resident in Meir Medical Center, Kfar Saba,
Israel. E-mail: avi.benov@gmail.com.

Disclaimers CPT Nadler serves as an IDF-MC officer as a general surgery
resident.
The opinions or assertions contained herein are the pri-
vate views of the authors and are not to be construed MAJ Landau serves as an IDF-MC officer as a resident in
as official or reflecting the views of the Department of plastic surgery.
Defense, the US Government, the Ministry of Defense,
or Israel Government. The authors are employees of the CPT Sorkin serves as an IDF-MC officer.
US Government or the Israel Government. This work
was prepared as part of their official duties and, as such, Dr Aden is a statistician at the USAISR, Fort Sam Hous-
there is no copyright to be transferred. ton, Texas. He has coauthored several papers on operational
medicine.

Disclosures COL (Ret) Kragh is a tourniquet researcher at the USAISR,
Fort Sam Houston, Texas. He is an orthopedic surgeon who
The authors declare no conflicts of interest. was the 3d Ranger Battalion’s Surgeon from 1990 to 1993. He
has published many papers on operational medicine.
References
COL Glassberg serves as an IDF-MC officer as a general
1. Kragh JF Jr, Murphy C, Dubick MA, et al. New tourniquet surgeon.
device concepts for battlefield hemorrhage control. US Army
Med Dep J. 2011:38–48.

42 Journal of Special Operations Medicine Volume 16, Edition 1/Spring 2016