Page 20 - JSOM Spring 2024

Life Over Limb

Why Not Both? Revisiting Tourniquet Practices
Based on Lessons Learned From the War in Ukraine

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Jessica L. Patterson, MD *; Robert T. Bryan, DO ; Michael Turconi, BSc ;
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Andrea Leiner, APRN FNP-BC ; Timothy P. Plackett, DO, MPH ;
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Lori L. Rhodes, MD ; Luke Sciulli, NRP, ATP ; Stephen Donnelly, MD ;
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Christopher W. Reynolds, MS ; Joseph Leanza, MD, MPH ; Andrew D. Fisher, MD, MPAS ;
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Taras Kushnir, MD, MPA ; Valerii Artemenko, MD ; Kevin R. Ward, MD ;
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John B. Holcomb, MD ; Florian F. Schmitzberger, MD, MS 16
ABSTRACT
The use of tourniquets for life-threatening limb hemorrhage the open war against an overwhelmingly well-trained and
is standard of care in military and civilian medicine. The superiorly equipped enemy.
United States (U.S.) Department of Defense (DoD) Commit- —Ukrainian physician in charge of
tee on Tactical Combat Casualty Care (CoTCCC) guidelines, tactical medical training for a brigade of
as part of the Joint Trauma System, support the application rapidly mobilized armed forces in early 2022
of tourniquets within a structured system reliant on highly
trained medics and expeditious evacuation. Current practices Tourniquet use for limb trauma on the battlefield dates back
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by entities such as the DoD and North Atlantic Treaty Organi- to ancient Greece. Until recently, tourniquets were consid-
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zation (NATO) are supported by evidence collected in counter- ered a dangerous, last-resort intervention. Brief periods of
insurgency operations and other conflicts in which transport increased usage swung the pendulum to times of condemna-
times to care rarely went beyond one hour, and casualty rates tion, as poor equipment, misuse, and prolonged times to de-
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and tactical situations rarely exceeded capabilities. Tourniquets finitive care resulted in increased morbidity and mortality.
cause complications when misused or utilized for prolonged As Richey noted in 2007, “opinions have alternated between
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durations, and in near-peer or peer-peer conflicts, contested strong endorsement and outright vilification of the device.” In
airspace and the impact of high-attrition warfare may increase the twenty-first century, however, the tourniquet debate is re-
time to definitive care and limit training resources. We present garded by most as closed. The body of evidence from the past
a series of cases from the war in Ukraine that suggest tourni- 30 years shows a clear mortality benefit when high- quality
quet practices are contributing to complications such as limb tourniquets are used for life-threatening limb hemorrhage
amputation, overall morbidity and mortality, and increased within specific guidelines and a system that promotes training,
burden on the medical system. We discuss factors that contrib- data collection, and process improvement. 7,8
ute to this phenomenon and propose interventions for use in
current and future similar contexts, with the ultimate goal of Kragh et al. identified major factors facilitating successful
reducing morbidity and mortality. implementation of tourniquet practices to be a “critical den-
sity of both tourniquets and trained users” and establishing
Keywords: tourniquets; amputation; traumatic injury; war- an ability to evaluate data from experiences on the ground. 9,10
related injuries The modern movement was initiated by the U.S. Special Op-
erations Command in the early 1990s, led by Dr. Frank Butler
and the Naval Special Warfare Biomedical Research and De-
velopment Program. 9,11 Analysis of prior conflicts identified
Introduction
limb hemorrhage as a leading cause of preventable death on
There was no time . . . there was no equipment. The chal- the battlefield. 11,12 In response, military physicians and Special
lenge was almost impossible: to make civilians ready for Operations Forces (SOF) leaders created a system promoting
*Correspondence to Jessica.Patterson@tuhs.temple.edu
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1 Dr. Jessica L. Patterson is an Associate Professor of Emergency Medicine and Dr. Lori L. Rhodes is an Assistant Professor of Surgery at Temple
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University, Philadelphia, PA. Dr. Robert T. Bryan is Chief Executive Officer and Michael Turconi is Operations Manager of Ethos Solutions,
Philadelphia, PA. Andrea Leiner is Deputy Director of Global Response Medicine, Marco Island, FL. Dr. Timothy P. Plackett is an Assistant Pro-
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fessor of Surgery at the University of Chicago, Chicago, IL and the Chief of Surgery for the 374th Hospital Center, Fort Sheridan, IL. Luke Sciulli
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is a Senior Research Analyst at Carnegie Mellon University, Pittsburgh, PA. Dr. Stephen Donnelly is a Clinical Assistant Professor of Emergency
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Medicine at Oregon Health and Science University, Portland, OR. Christopher W. Reynolds is a Medical Student at the University of Michigan,
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Ann Arbor, MI. Dr. Joseph Leanza is an Assistant Professor of Emergency Medicine at Boston University, Boston, MA. Dr. Andrew D. Fisher is
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a General Surgery Resident at the University of New Mexico, Albuquerque, NM. Dr. Taras Kushnir is the Senior Emergency Medicine Doctor
of the Department of Quality Control of Lviv Regional EMS Center, Lviv Oblast, Ukraine. Dr. Valerii Artemenko is a Captain of the Medical
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Forces, Armed Forces of Ukraine. Dr. Kevin R. Ward is a Professor of Emergency Medicine and Director of the Weil Institute for Critical Care
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Research and Innovation at University of Michigan, Ann Arbor, MI. Dr. John B. Holcomb is a Professor of Surgery at the University of Alabama,
Birmingham, AL. Dr. Florian F. Schmitzberger is a Clinical Instructor of Emergency Medicine at the University of Michigan, Ann Arbor, MI.
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