Page 130 - JSOM Summer 2019

An Ongoing Series

Improvised Inguinal Junctional Tourniquets

Recommendations From the Special Operations
Combat Medical Skills Sustainment Course

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Win Kerr, ATP, NREMT-P *; Ben Hubbard, ATP, NREMT-P ; Bryan Anderson, PA-C ;
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Harold R. Montgomery, ATP ; Elon Glassberg, MD, MHA ; David R. King, MD, FACS ;
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R. David Hardin Jr, MD, FACS ; Ryan M. Knight, MD ; Cord Cunningham, MC SFS, DMO 9
ABSTRACT
Effectively and rapidly controlling significant junctional hem- are aware of the advances in hemorrhage control through train-
orrhage is an important effort of Tactical Combat Casualty ing and exposure, but it remains unclear whether these junc-
Care (TCCC) and can potentially contribute to greater sur- tional hemorrhage control devices are widely carried. Through
vival on the battlefield. Although the US Food and Drug Ad- ongoing course feedback and instructor/student ingenuity, we
ministration (FDA) has approved labeling of four devices for present some IJT principles and methods deemed potentially
use as junctional tourniquets, many Special Operations Forces useful in the austere environment where robust packing lists
(SOF) medics do not carry commercially marketed junctional are not feasible. These IJT methods were developed because
tourniquets. As part of ongoing educational improvement of feedback from SOCMSSC students. This feedback indicates
during Special Operations Combat Medical Skills Sustain- that many SOF medics do not carry commercially marketed
ment Courses (SOCMSSC), the authors surveyed medics to junctional tourniquets (CJTs), due to cost, size, weight, and
determine why they do not carry commercial tourniquets and utility compared with other items with more potential utility.
present principles and methods of improvised junctional tour- If the principles of junctional hemorrhage control are well un-
niquet (IJT) application. The authors describe the construction derstood, it is possible to recreate junctional tourniquets from
and application of IJTs, including the use of available pressure everyday items, many of which the SOF medic has reliable
delivery devices and emphasizing that successful application access to in times of emergency.
requires sufficient and repetitive training.
Caution
Keywords: tourniquets; tourniquets, improvised; hemor-
rhage, junctional; training; austere Effective improvisation at any task requires a higher-level un-
derstanding in combination with ingenuity. Prior rehearsal is
needed in order for improvisation to be achievable in times
of combat and high stress when cognitive and fine motor
Introduction
skills are compromised. IJT construction and application
A substantial number of potentially survivable deaths on the take practice. Like all skills in medicine, the proper applica-
battlefield are due to junctional hemorrhage. Any effective tion of these devices is perishable. Multiple training sessions
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and rapidly placed method of controlling significant junc- are necessary as competency at these skills can be achieved
tional hemorrhage is an important effort of TCCC as stressed only through repetition. The principles described herein are
through the MARCH algorithm (Massive hemorrhage, Air- intended as an example of what is possible for the medic or
way, Respirations, Circulation, and Head injury/Hypother- combatant who does not currently carry or have access to
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mia). Four devices currently exist that are FDA labeled and a CJT. TCCC guidelines describe the application of CJT in
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marketed for use as junctional tourniquets. Most SOF medics detail. 4
*Correspondence to winkerr@gmail.com
1 Mr Kerr is an instructor at the Special Warfare Medical Group (Airborne) in Ft Bragg, NC. MSgt Hubbard is an AFSOC PJ stationed at Ft
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Bragg, NC. 1LT Anderson is assigned to the 3rd Infantry Regiment in Ft Stewart, GA. Mr Montgomery is with the Joint Trauma System, De-
fense Health Agency. Dr Glassberg is a surgeon with the Israeli Defense Forces and is affiliated with the Bar-Ilan University Faculty of Medicine
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(Safed, Israel) and the Uniformed Services University of the Health Sciences (Bethesda, MD). LTC King is a physician in the US Army; director,
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Fellowship Program in Trauma, Acute Care Surgery, and Surgical Critical Care Massachusetts General Hospital; and associate professor of sur-
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gery, Harvard Medical School, Boston, MA. LTC Hardin is with Acute Care, Trauma, and General Surgery, Joint Medical Augmentation Unit
(JMAU), Joint Special Operations Command. Dr Knight is an Army emergency medicine physician currently stationed at Ft. Benning, GA. COL
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Cunningham is chair, Committee on En Route Combat Casualty Care, Joint Trauma System, JBSA FSH, TX.
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