Page 69 - JSOM Fall 2024

Limb Hemorrhage Control Failure with Counterfeit Tourniquet

A Ukrainian War MEDEVAC Case Report

Emanuele Lagazzi, MD *; Rostislav Bublii, MD ;
2
1
Michele Bonetti, MD ; Michael A. Samotowka, MD 4
3

ABSTRACT
Rapid and effective tourniquet application is crucial in Tourniquet Wide (SOFTT-W), but lack evidence of effective-
life-threatening limb hemorrhage to minimize mortality. How- ness, is a growing concern. These devices may lack the neces-
ever, the widespread availability of counterfeit tourniquets is sary quality control measures and can potentially compromise
a growing concern, as these devices may lack essential quality patient care. While most U.S. Armed Forces personnel use
control measures, potentially compromising patient care. We tourniquets such as the CAT and SOFTT-W, armed forces from
describe one case where the delayed mechanical failure of a allied countries and the civilian population might buy and
Combat Application Tourniquet (CAT)-like tourniquet caused use counterfeit or unregulated devices on global e- commerce
the death of a Ukrainian soldier during evacuation to an urban platforms because of their immediate availability and reduced
trauma center. In April 2022, a 19-year-old male underwent price. A recent study comparing the CAT with CAT-like tourni-
a bilateral below-the-knee amputation from an antipersonnel quets bought on Amazon or AliExpress showed that counter-
landmine. Massive hemorrhage prompted the use of bilateral feit CAT-like tourniquets apply significantly lower force upon
CAT-like tourniquets. During transportation, the right tour- application and have a higher rupture rate. 5
niquet’s windlass broke, resulting in a brisk hemorrhage. Due
to the high patient-to-healthcare-personnel ratio, the bleeding While limited anecdotal evidence exists in media reports about
remained unaddressed for an unknown amount of time, result- the risk of “catastrophic failure” and impaired effectiveness
ing in death from hemorrhagic shock. This study underscores of counterfeit tourniquets resembling the CAT, there is a
6,7
the need for robust quality control measures and the establish- paucity of data in the scientific literature describing the use
ment of strict regulations against deploying counterfeit tourni- of these devices in combat settings. In this case report, we
6,7
quets to avoid preventable deaths. present a case where the complete mechanical failure of an
uncertified tourniquet caused the death of a Ukrainian soldier
Keywords: tourniquet; MEDEVAC; Ukraine; limb hemorrhage; during medical evacuation (MEDEVAC) due to uncontrolled
prehospital care severe limb hemorrhage.

With this report, we aim to contribute to the limited body
of evidence showing the impact of counterfeit tourniquets
Introduction
on patient outcomes and inform military personnel in allied
In military medicine, the rapid and efficient application of countries about the importance of using tourniquets with well-
life-saving medical devices is crucial to minimizing mortality established effectiveness in life-threatening limb hemorrhage.
and morbidity. To date, hemorrhage remains the leading po-
tentially preventable cause of death in military trauma. The Ethical Oversight
1
use of tourniquets for the temporary control of life-threaten- This study was approved as exempt by the hospital’s Institu-
ing limb hemorrhage during care under fire and prolonged tional Review Board because of the de-identified nature of the
field care is of paramount importance, often allowing patients data and the impossibility to ask the patient for informed con-
to reach advanced surgical care alive. Furthermore, the ef- sent because of the lethal outcome. Specific locations, units,
2
fective use of tourniquets when indicated is associated with and personnel details were not shared owing to the sensitive
increased systolic blood pressure upon arrival at the trauma nature of the data. This study was reported according to Sur-
center or far-forward surgical team, a lower incidence of gical CAse REport (SCARE) guidelines. 8
3
4
limb-related complications with short tourniquet times, and
3
decreased mortality. 3
Case Presentation
In this framework, the wide availability of tourniquets that Trauma System
resemble well-known commercial devices, such as the Combat To this date, military casualties in Ukraine are managed in
Application Tourniquet (CAT) or Special Operations Tactical accordance with the current medical military doctrine in the
*Correspondence to Emanuele Lagazzi, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, 165
Cambridge St., Suite 810, Boston, MA 02114 or emanuele.lagazzi@bmc.org
1 Dr. Emanuele Lagazzi is affiliated with the Harvard Medical School, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Mas-
sachusetts General Hospital, Boston, MA; the Italian Trauma League ODV, Genoa, Italy; and the Department of Surgery, Humanitas Research
Hospital, Rozzano, Italy. Dr. Rotislav Bublii is affiliated with the Department of Surgery, Dnipro City Hospital Number 4, Dnipro, Dnipropetro-
2
3
vsk Oblast, Ukraine. Dr. Michele Bonetti is affiliated with the Italian Trauma League ODV, Genoa, Italy, and the Division of Anesthesia and In-
tensive Emergency and Pain Medicine, Schwartzwald-Baar Klinikum, University Hospital of the University of Freiburg, Villingen-Schwenningen,
Germany. Dr. Michael Samotowka is affiliated with the Division of Trauma, Novant Hospital, Charlotte, NC.
4
67
67