Page 70 - JSOM Fall 2024

country, which involves a four-tier healthcare system based on Changes in Prehospital Trauma Care
an adapted version of the North Atlantic Treaty Organization after 1 Year of Conflict
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(NATO) system of care. In brief, in the standard NATO sys- This case report details a preventable death caused by the com-
tem, the levels of care consist of role 1 (pre-medical level, with plete mechanical failure of a non-certified CAT-like tourniquet
resuscitation and stabilization measures), role 2 (basic medical during prolonged evacuation to address life-threatening lower
care and surgical capabilities), role 3 (specialized medical care limb bleeding. Notably, this incident occurred during the early
and surgical capabilities), and role 4 (highly specialized medi- stages of the war in Ukraine. Over the past year, to prevent
cal care). 10,11 In the ongoing conflict in Ukraine, combat zones such deaths, the prehospital system has undergone significant
are located near major cities with fully operational high-level changes, including the increased use of TCCC guidelines and
trauma centers. This geographical setting favors the use of a modifications to the chain of evacuation.
role 4 level of care, with patients being evacuated to highly
specialized care directly from the combat theater. In this set- The wider adoption of TCCC-inspired guidelines has improved
ting, patients may not have access to specialized medical care the management of life-threatening limb injuries occurring at the
during the evacuation to a high-level trauma center. Addition- zero line (i.e., within 200m from enemy lines) through buddy-
ally, tactical and logistical issues may lead to prolonged trans- on-buddy and medic-driven interventions. Additionally, the
portation times. For these reasons, the use of tourniquets that establishment of early stabilization points equipped with ba-
can maintain adequate hemostasis for extended periods is cru- sic surgical capabilities situated near the front line allows for
cial in patients with life-threatening limb hemorrhage. While the early conversion of tourniquets or surgical management of
the CAT remains the current standard of care for Ukrainian bleeding before evacuation to higher levels of care.
soldiers in controlling life-threatening limb hemorrhage, the
use of CAT-like tourniquets purchased from e-commerce plat- These changes have altered the military patient population
forms has become more common due to the increased demand presenting at level I trauma centers, with fewer soldiers ar-
for tourniquets and the limited availability of certified medical riving with tourniquets in place for massive limb hemor-
supplies in the field. rhage. However, the Russian bombing of highly populated
targets, such as cities and hospitals, 13,14 has shifted the limb
Clinical Case hemorrhage injury model to the civilian setting, making the
In April 2022, a 19-year-old male experienced bilateral trau- prompt use of high-quality tourniquets crucial throughout
matic below-the-knee amputation after stepping on an an- Ukraine. 13,14
tipersonnel landmine on the eastern front in the Donetsk
region. To control the massive hemorrhage from the ampu- Discussion
tated lower limbs, a medic applied two CAT-like tourniquets
bilaterally at the level of the thighs at the point of injury, In this case report, we describe a case where the use of non-
following the Tactical Combat Casualty Care (TCCC) guide- certified CAT-like tourniquets purchased from an e-commerce
lines. While both legs were amputated at the time of injury, platform (OLX.UA) resulted in catastrophic mechanical fail-
12
the bleeding appeared to be more brisk from the right leg. Fol- ure during MEDEVAC, leading to the death of a Ukrainian
lowing the tourniquet application, the bleeding was stopped soldier due to lower limb hemorrhage.
successfully. The airway, breathing, and circulation appeared
intact, so the decision was made to transport the patient via In military trauma, limb hemorrhage remains a leading cause
medical train to a role 3 facility (a level I urban trauma cen- of preventable death, with tourniquets playing a fundamen-
15
ter) in the Dnipro region. The distance from the eastern front tal role in managing life-threatening extremity bleeding in the
line to the hospital was 120km, with an estimated transport prehospital setting and during transportation to higher levels
time of 3 hours by train, followed by a 20-minute trans- of care. 15,16 Additionally, tourniquets are fundamental compo-
fer by military ambulance from the station to the hospital. nents of each soldier’s individual first aid kit (IFAK) and are
During transportation, the plastic windlass of the CAT-like used in all phases of treatment, from care under fire to pro-
tourniquet on the right leg deformed and broke, leading to longed field care. 12,15,17–22
a brisk arterial hemorrhage. Because of the high number of
patients in the carriage and the limited availability of health- In this framework, prioritizing the use of tourniquets with
care personnel, the active bleeding went unaddressed for an clear evidence of quality and effectiveness is essential. Com-
unknown duration, resulting in significant blood loss. Once plete mechanical failure of the tourniquet due to the rupture of
the bleeding was noticed, it was only partially controlled one or more of key components has been linked to the inability
through packing and direct compression, as no additional to stop arterial blood flow. Additionally, ineffective tourni-
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tourniquets were available on the medical carriage. The pa- quet placement, as defined by Kragh et al., involves continued
tient arrived in critical condition at the Dnipro station, where bleeding or a persistent distal pulse and has been associated
he was then transported by military ambulance to the level with an increased risk of venous congestion, expanding hema-
I trauma center. Upon arrival, the patient was pale, severely tomas, compartment syndrome, and death. A previous study
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hypotensive, and tachycardic. Despite resuscitation efforts showed that counterfeit CAT-like tourniquets have a higher
and the initiation of appropriate procedures according to the rupture rate and apply significantly lower pressure on a man-
Advanced Trauma Life Support (ATLS) protocol, the patient nequin compared to genuine CAT. Although there are limited
5
died within 10 minutes of arriving in the emergency depart- data on the use of counterfeit CAT-like tourniquets in clinical
ment. A secondary survey revealed no injuries apart from settings, it is reasonable to assume that the use of tourniquets
the bilateral traumatic amputation of the lower extremities. without evidence of adequate strength might increase the risk
Cause of death was determined to be hemorrhagic shock. The of adverse events due to breakage or insufficient pressure on
patient’s medical, surgical, family, and social histories were the injured limb. Lastly, the use of reliable and effective tour-
non-contributory. niquets is particularly important during prolonged evacuation

68 | JSOM Volume 24, Edition 3 / Fall 2024