Page 75 - JSOM Summer 2018

TABLE 3 Select Comments From the After-Action Reports Noting FIGURE 3 Junctional Emergency Treatment Tool
Challenges Using the Junctional Tourniquet (North American Rescue; http://www.narescue.com)
Case No. After-Action Report Comments
7 “The patient had such extensive damage so high up
into groin that application of the JETT was the only
thing that I could do, and it did stop the little remaining
external bleeding; however, I have no confidence in
the thing. Every movement of the patient resulted in
almost having to totally reapply it. This may have been
understandably due to the anatomical changes that
resulted from the blast. However, I firmly believe that
the Abdominal [and] Aortic Tourniquet is a FAR better
option. In this particular case, especially, it would have
succeeded being superior to even the most proximal
external wound . . .”
9 “. . . commercial junctional tourniquet noted to be
completely ineffective in stopping or slowing arterial
bleed or generating sufficient pressure to occlude arterial
pulse. Improvised junctional tourniquet with Combat
Gauze, Kerlix, and ACE wrap provided rapid, effective
control of bleeding . . .”
12 “Patient presented with a wound on his left arm that
was hemorrhaging. Although a tourniquet had been
attempted, it was ineffective due to the location and The concept of JTQ is valuable, with a potential to have a
body habitus of the patient . . .” significant impact on the battlefield, but each of the FDA-ap-
JETT, Junctional Emergency Treatment Tool. proved JTQs currently has idiosyncrasies that can make it
difficult to use in the tactical setting. The variability of these
FIGURE 1 Combat Ready Clamp. devices also has implications for training. Increasing dissemi-
(Combat Medical Systems; http://www.combatmedicalsystems.com)
nation of JTQs and better training at the unit level may help
prehospital providers become more comfortable with the de-
vices. Another solution could be a JTQ requiring fewer steps
for use. Our findings from this limited data set suggest the cur-
rent JTQs used by the military may still require improvement
and innovation, and training for correct use may be needed.
Although this series is limited in size, this data set does con-
tain feedback information from the users. In reviewing the
AARs of the failed attempted uses, users noted several device
issues (Table 3). One AAR (case 7) specifically noted that the
AAJT may have been a preferable modality in this situation
because the broad-based pressure achieved with the abdom-
inal tourniquets more readily achieved hemostasis than the
point application of pressure achieved by the JETT. This may
be comparable to the “high and tight” limb tourniquet place-
ment. Optimal JTQ application will likely require adjustments
for each patient based upon his or her specific injury pattern.
FIGURE 2 The SAM Junctional Tourniquet
(SAM Medical Products; http://www.sammedical.com/products) This data set is significantly limited by the quality of docu-
mentation provided in the database, specifically by the rather
high rate of missing data points and inability to link patients
between the databases. Moreover, the ISS was extremely high
(75) in one failed case. The ISS was unknown in two other
failed cases, which makes it difficult to ascertain whether de-
vice failure was secondary to the injury lethality in a patient
with a nonpreventable death rather than secondary to device
challenges.

Conclusions
We report 12 cases of prehospital use of JTQs in Afghan-
istan. Our findings from this case series suggest this device
may have some utility in achieving hemorrhage control strictly
at junctional sites (e.g., inguinal creases). However, they also
highlight device limitations. This analysis demonstrates the
need for continued improvements in technologies for junc-
tional hemorrhage control, prehospital documentation, data
fidelity and collection, as well as training and sustainment of

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