Page 24 - JSOM Spring 2024

Tourniquet time principles can be summarized as follows: less that “as soon as the situation allows, a re-evaluation of the
than 2 hours is safe, the rate of complications increases after need to use the tourniquet and a decision on its conversion
2 hours, and more than 6 hours has high rates of irreversible should be made.” The memorandum specified that conversion
complications (although recent evidence suggests that the risk should be performed within two hours by “medical workers
of major limb-threatening complications may increase as soon or military personnel with appropriate training (senior com-
14
as 4 hours after tourniquet application). In recent years, the bat medics, combat medics, and other military personnel who
doctrine has been that tourniquets left on more than 6 hours have received training in tactical medicine or follow the in-
37
had such high rates of arrhythmias and rhabdomyolysis that structions of a medical worker).” Feedback from sources on
amputation was almost mandatory. 31 the ground in direct training operations with Servicemembers
noted that this topic was frequently discussed and concern
If tourniquet timelines exceeding 4 hours are the norm rather over what skills they were allowed to perform on the battle-
than exception, there is no precedent in recent warfare, and field was prevalent.
the data available strongly indicate that preventable morbidity
and mortality due to tourniquet complications will be high. Lessons learned to date in the war in Ukraine have already
32
The reality of prolonged evacuation times as an unchangeable galvanized experts in the field with calls to action to revisit
ground truth must be accepted as the norm for this war and tourniquet conversion through proposed changes to guidelines
anticipated for other near-peer conflicts. and increased training requirements on tourniquet need, con-
21
version, and replacement. To address the lack of consensus
Rigid Protocolization of Concepts on how to best train conversion, the CoTCCC recently voted
The Ukrainian medical system heavily utilizes standardized to add tourniquet conversion as a Tier 2 skill, encouraging
national protocols. This trend has been reflected in the ap- flexibility in training the full breadth of TCCC concepts to
proach to battlefield medicine with TCCC concepts regarded a relevant audience. Rigid protocolization by partner nations
as best-practice standards and adapted into rigid protocols in that limit adaptability of concepts to different ground realities
the current Ukrainian system. This can be seen through the should be discouraged.
topic of tourniquet conversion.
Standardization of Training and Availability of Medics
The current U.S. DoD TCCC guidelines structure protocols When deploying protocols outside the systems that produced
to four tiers of capability: all-Servicemember (ASM), combat and refined them, differences in the definition and training
lifesaver, combat medic/corpsman, and paramedic/SOF medic/ qualifications of “medic” become a complicating factor. As
provider. Every tier is provided with didactic and practical noted above, tourniquet conversion was recently added to Tier
35
instruction on tourniquet application, but most methods of 2 in the U.S. DoD. However, the paradigm in the Ukrainian
tourniquet conversion have been historically taught to com- war has been that conversion is a skill only performed by med-
bat medics and higher. Tourniquet conversion is a broad term ical personnel, and a systemic gap highlighted by this is differ-
referring to the act of assessing and removing a tourniquet ent definitions and training of medics.
and can include removal, tourniquet-to-tourniquet conversion,
and tourniquet-to-dressing conversion. In his after action re- If the casualty cannot be rapidly evacuated, Ukrainian pro-
port of a 2022 Tourniquet Coverstion Webinar hosted by the tocols (at the time of the onset of the war) dictated that only
Special Operations Medical Association, Dr. John Kragh sum- Servicemembers trained at the combat medic level or higher
marized that a major point covered in the webinar was that should attempt tourniquet conversion/replacement in the
conversion “is an obscure task versus tourniquet application; field once out of CUF, ideally within 2 hours but not after
tourniquet conversion is often unclear, unfocused, skipped, or 6. However, this paradigm is only successful in a tactical en-
1,2
forgotten.” 33 vironment with a robust availability of trained field medics
near the POI. Whether due to tactical considerations, a lack of
Historically, there has been no clear consensus even among critical density of personnel with this training, or other factors,
experts regarding exactly who should and can convert a tour- if sufficient personnel trained to reassess tourniquets in the set-
niquet per TCCC doctrine, nor how to apply best evidence to ting of prolonged evacuation times do not exist near the POI,
peer-nation protocols. Although removal, the most basic form casualties will suffer complications. 3–7
of conversion, may be taught with application—and Dr. Kragh
noted anyone can try to convert—most guidelines based on The experience of a Ukrainian physician tasked with training a
TCCC at the onset of the war specified conversion as a medic brigade of rapidly mobilized armed forces on tourniquet prac-
or more advanced level skill. 34,35 Regardless of the core prin- tices per national protocols at the beginning of the large-scale
ciples of TCCC, in practice by the end of GWOT, tourniquet invasion reflects this reality. Per their anonymous report, train-
conversion was rarely performed in the field. Experts noted ing was approached as follows: “The main rule was to put the
that lack of clear consensus and training guidelines would be- tourniquet as high and tight as possible whenever there was
come an issue in a conflict without air superiority, as demon- massive bleeding. We used to say, ‘your job is to use the tourni-
strated in Ukraine. 14,21 quet; do not take it off, but call the medic who will know what
to do.’” (anonymous personal communication, Ukrainian phy-
Ukrainian law through mid-2023, per the Ministry of Health, sician, Ukraine, 2023).
protocolized available guidelines into law by stating that
tourniquet conversion should be “performed exclusively by The standardization of qualifications to become a medic in
medical workers or specialists who have received appropri- Ukraine is an understandable challenge given the rapid mobi-
ate training.” There is currently a robust dialogue occurring lization since the large-scale invasion. The system is complex,
36
within Ukraine on the topic; a recent memorandum by the with several ministries, agencies, and branches in the armed
Ministry of Armed Forces re-addressed conversion by stating forces and civilian system that regulate training. Down to the

22 | JSOM Volume 23, Edition 1 / Spring 2024