Page 22 - JSOM Summer 2020

Tourniquets Last to Tourniquets First

John F. Kragh Jr, MD *; James K. Aden 3rd, PhD ; Michael A. Dubick, PhD 3
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he Journal of Special Operations Medicine (JSOM) is Disclaimer
celebrating 20 years of publishing. The publisher, Lt The views expressed in this article are those of the authors and
TCol (Ret) Michelle Landers, noted in the newsletter that do not reflect the official policy or position of the US Army
JSOM was to provide articles to highlight how far Special Medical Department, Department of the Army, Department
Operations medicine has come in that period. The publisher of Defense, or the US Government. The authors are employees
planned to have new articles on selected topics matched with of the US Government. This work was prepared as part of
another article republished from an early edition so readers their official duties and, as such, there is no copyright to be
could compare and contrast for themselves how far we have transferred.
journeyed from 2001 to 2020. In these 20 years, tourniquets
changed from a means of last resort to a means of first aid. In Disclosure
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20 years, the Special Operations medicine community has wid- The authors have indicated that they have no financial rela-
ened and grown to become a leader of what we now call the tionships relevant to this article to disclose.
operational health community. Speaking for the operational
health community about care under fire, one of us quipped References
“We flipped tourniquet use on its head. It was absolutely last, 1. Andersen RC, Shawen SB, Kragh JF Jr, et al. Special topics. J Am
and now it’s absolutely first.” 2 Acad Orthop Surg. 2012;20S1:94–98.
2. Center for Homeland Security and Resilience, Inc. Stopping the
bleed: how Army surgeons brought tourniquets back into the
In JSOM’s volumes then and now, readers can see for them- medical mainstream. 5 February 2018 https://dodstem.us/sites
selves how the status of tourniquets for limb-wound bleed- /default/files/lab-narratives/US-Army-Institute-of-Surgical
ing content compares and contrasts. Then, tourniquets were -Research-Lab-Narrative.pdf. Accessed January 23, 2020.
sketchy, heretical, and yet aspirational. Now they have become 3. Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating
edgy and are mainstreaming. The public has adopted some of preventable death on the battlefield. Arch Surg. 2011;146(12):
the tourniquet content into civilian care, albeit very unevenly 1350–1358.
worldwide. The first-aid changes of the two decades, the op- 4. Leonard J, Zietlow J, Morris D, et al. A multi-institutional study
of hemostatic gauze and tourniquets in rural civilian trauma. J
erational health community’s enlarging tent, and the growing Trauma Acute Care Surg. 2016;81(3):441–444.
tourniquet science worked coherently together to transform 5. Teixeira PG, Brown CV, Emigh B, et al. Civilian prehospital tour-
the meaning of best care. Such transformation was only pos- niquet use is associated with improved survival in patients with pe-
sible with the community’s leadership and its support of its ripheral vascular injuries. J Am Coll Surg. 2018;226(5):769–776.
Journal. Tourniquet science was legitimized, developed, and 6. Lairet J, Bebarta VS, Maddry JK, et al. Prehospital interventions
broadcast. Some tourniquet knowledge gaps were filled, but performed in Afghanistan between November 2009 and March
2014. Mil Med. 2019;184(S3–4):133–137.
such filling was disruptive of education by burdening others 7. Sanko S, Mindlin D, Eckstein M. Abstract 74 Tourniquet use in a
like instructors, who had to rewrite lessons. Some caregiving civilian out-of-hospital setting: the Los Angeles experience. Ann
results of when a tourniquet was used or clinically indicated Emerg Med. 2015;66(4S):26.
were good or mixed. 7,8-12 Results were also notably poor in 8. Kragh JF Jr, Littrel ML, Jones JA, et al. Battle casualty survival
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training-relevant studies. 13,14,15,16-23 In its last-to-first transfor- with emergency tourniquet use to stop limb bleeding. J Emerg
mation, the tourniquet sometimes became an iconic yet lim- Med. 2011;41(6):590−597.
ited success, 24-26 a caregiving procedure to which others were 9. Kragh JF, O’Neill ML, Walters TJ, et al. Minor morbidity with
emergency tourniquet use to stop bleeding in severe limb trauma:
referred or compared, 6, 27-30 and a benchmark of rendered first research, history, and reconciling advocates and abolitionists. Mil
aid. 31-33 Other ways tourniquets became prominent included Med. 2011;176(7):817−823.
instructions learned, 34,35,36,37 investigations made, 14,38,39 and 10. Passos E, Dingley B, Smith A, et al. Tourniquet use for peripheral
policies executed. 7,40,41 It is now sweet and fitting that the vascular injuries in the civilian setting. Injury. 2014;45(3):573–
community and its Journal celebrate—but neither too much 577.
nor too long. Each breakthrough needs mop-up work. Results 11. Kragh JF Jr, Nam JJ, Berry KA, et al. Transfusion for shock in
US military war casualties with and without tourniquet use. Ann
have been mixed, perhaps due to uneven implementation or Emerg Med. 2015;65:290–296.
incomplete understanding of limb tourniquet science, which is 12. Scerbo MH, Holcomb JB, Taub E, et al. The trauma center is too
still under development. Let’s get to work. late: major limb trauma without a pre-hospital tourniquet has
*Correspondence to 3698 Chambers Pass, Joint Base San Antonio Fort Sam Houston, TX; or john.f.kragh.civ@mail.mil
1 Dr Kragh is a researcher of bleeding control at the Institute of Surgical Research (ISR), Fort Sam Houston, TX, and an associate professor in
the Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD. Dr Aden is a statistician at the Brooke Army
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Medical Center, Fort Sam Houston, TX. Dr Dubick is a researcher and chairperson of the Department of Hemorrhage Control and Resuscitation
at the ISR.
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