D Maher
Abstract
Background: Despite its use from Alexander the Great’s war with Persia to current conflicts in the Middle East, the tourniquet has been considered both a lifesaver and invention of the Devil. This poor reputation developed through several conflicts, from the US Civil War to Vietnam. Concerns and unfortunate dogmas from these conflicts persisted, and tourniquets were not recommended in civilian practice. Despite this, tourniquets returned to military use in the 1990s via US Special Forces, who aggressively advocated their use.
Purpose: The purpose of this paper was to review the history of the tourniquet, its use and success in recent conflicts in the Middle East, and how this success has translated to both civilian medical services and the general public’s increasing awareness.
Results: Data collected in field hospitals in Iraq have shown pre-hospital tourniquet use was associated with increased haemorrhage control. No early adverse outcomes related to tourniquet use were reported. The US Army Institute of Surgical Research (2006) reported higher survival rates in patients with pre-hospital tourniquet use compared to hospital application (89% vs 78%). Similar outcomes are reported in civilian practice: during the Boston Marathon bombings, 27 tourniquets were applied, with no adverse outcomes reported.
Conclusions: When evidence from recent Middle East conflicts is examined, tourniquets are consistently highlighted as a safe, effective method for controlling severe bleeding from extremity injuries. Today, they are considered a life-saving device and innovation of recent conflicts, and are issued to all deploying servicepersons.
Key words: tourniquet, military medicine, military history, extremity injury, pre-hospital
Introduction
Each conflict requires new ideas, flexibility and agility; as does the medical response to war. Following almost two decades of war in the Middle East, it is challenging for a weary public to identify many positives from these conflicts. One favourable outcome is the progress that has been made in the treatment of injured soldiers and civilians.
Injuries experienced in the Middle East conflicts have differed from those injuries from previous conflicts. In previous wars, most soldiers were wounded by bullets and chemical agents, such as mustard gas.1 The emphasis on operations conducted on foot in Afghanistan has resulted in an influx of Dismounted Complex Battle Injuries (DCBI).2 DCBIs represent a collection of polytraumatic injuries, including bilateral high transfemoral amputations, open pelvic fractures and severe upper extremity injuries.2 Medical and technologic advancements made during recent conflicts have enabled more wounded service members to survive DCBIs despite their complexity.2,3
An authoritative paper published in Surgery reviewed combat casualty care statistics throughout military operations in both Afghanistan and Iraq. It found that from 2001–2017, mortality rates were reduced by 44%.3 The increasing survival rate of soldiers with DCBIs is due in part to the progress made in haemorrhage control in a period known as the ‘platinum ten minutes’: the ten minutes immediately following injury.4 One critical tool in effectively managing extremity haemorrhage in this short period is the tourniquet.
A tourniquet is a constricting or compressing device used to control venous and arterial circulation to an extremity for a period of time. Despite its use from Alexander the Great’s war with Persia, to today’s war in Afghanistan, tourniquets have been considered both a lifesaver and an invention of the Devil.
History of the tourniquet
The first documented use of a tourniquet was not for preventing exsanguination—severe blood loss— but rather was used by Hindu physicians in the 6th century BCE to treat Greek troops bitten by snakes unfamiliar to physicians.5 Its use soon became more common, with Romans using narrow bronze straps to control bleeding.6 It was at this point that the tourniquet started to develop a low opinion that persists today. Galen, the best known of the Roman surgeons, criticised the use of tourniquets as simply forcing more blood from a wound and this opinion was repeated for many years and even centuries later.6
Tourniquet development continued to be documented over the next several centuries. In 1674, Etienne Morel, a French army surgeon often credited with the first unambiguous claim of battlefield tourniquet use, described a tourniquet used at the siege of Besancon, France.7 The tourniquet included a belt that went through a woodblock. A stick was used in the loop of the belt around the limb and twisted as a windlass.7 This was known as a block tourniquet and provided the basis for the much-improved device of Petit, early the next century. Petit, one of Paris’s foremost surgeons, invented a new screw device for which he coined the word tourniquet, from the French tourner, to turn.7 It required no assistant and could be released readily and reapplied.
The first recorded recommendation for issuing a tourniquet-like device to soldiers occurred during the US Civil War by Samuel Gross in 1862.8 Unfortunately, many criticisms of its use arose during this conflict, often as the result of inadequate training or delays in the transport of patients to field hospitals, which frequently took days. Given these delays, the rudimentary surgical training, wound contamination and lack of antibiotics, limb amputation was frequent and would subsequently be attributed to the use of tourniquets.8 World War I saw a similar attitude develop, where a British medical manual, Injuries and Diseases of War, spectacularly criticised tourniquets and those who used them: ‘The systematic use of the elastic tourniquet cannot be too severely condemned. The employment of it, except as a temporary measure during an operation usually indicates that the person using it is quite ignorant both of how to stop bleeding properly and also of the danger to life and limb caused by the tourniquet.’9
In World War II, allied surgeons, Wolff and Adkins, looked at over 200 wounded service members who had tourniquets applied.10 Their research resulted in them being among the staunchest advocates of the use of tourniquets in combat casualty care after they found not a single case of gangrene, thromboembolic events or nerve damage directly attributable to the use of such devices.10 They concluded that properly applied extremity tourniquets reduced blood loss, were associated with a low risk of complications and saved lives. Following this conflict, tourniquets continued to be used in Korea and, to a lesser extent, Vietnam. Some medical professionals believed that their use may lead to more amputations, which contributed to their falling out of favour with both civilian and military medical personnel.11
With such an extensive and storied history, one may ask why tourniquets are viewed as a medical innovation following a period of war in the Middle East. While tourniquets have been used to control traumatic haemorrhage for millennia, their use has long been debated, and opinions on their effectiveness to prevent haemorrhage while minimising long-term injury and tissue damage have alternated between robust support and absolute denigration.
The leading cause of potentially preventable deaths on the battlefield in Vietnam was exsanguinations from compressible extremity injuries, representing approximately 7–9% of US casualties.1 Another set of data, recorded by a deployed surgeon, estimated that over 2600 lives, or 7.4% of casualties, may have been saved with better pre-hospital care, specifically tourniquets.11 Despite this, concerns and unfortunate dogmas outweighed any endorsement or lessons learnt from past conflicts, and civilian trauma experts did not recommend tourniquets. Consequently, they fell out of favour with the military so-much-so that in a report to The Red Cross they were described as ‘an instrument of the devil that sometimes saves a life’ and viewed as a last resort intervention.12
In the 1970s and early 1980s, medics at the US Army’s basic medical specialist course were instructed that in almost all instances, amputation would follow tourniquet use and that a tourniquet should only be used after direct pressure, limb elevation and pressure point application had been employed and failed by the continuation of bleeding.13 This highlights the thinking at the time: the decision to use a tourniquet was one to sacrifice a limb to save a life. This doctrine was reinforced in Emergency War Surgery, a prescribed military surgery textbook that stated, ‘Tourniquets are rarely needed for the control of haemorrhage and should be used only when all other methods fail. A tourniquet properly applied can save life but endanger limb’.14 This opinion was repeated in further revisions of the text and were widespread among both military and civilian professionals for the remainder of the century.
The turning of the tide
Despite their widespread criticism, tourniquets returned to military use. In 1991, Operation Desert Storm lasted just over one month, leaving no time and minimal data to refine casualty care. A retrospective analysis of wounds treated in hospital indicated that of the 143 soldiers injured and actively treated in US Army hospitals during Operation Desert Storm, three soldiers (2.1%) died.15 Each case presented with haemorrhage from limb injuries contributing to the cause of death.15 Following this, US Special Forces began to use tourniquets aggressively. Their use would be justified and supported in a series of publications by Mabry, a US Army Special Operations Forces medical officer, who compared the outcomes of casualties with and without tourniquet use.16 Mabry’s research suggested that 7% of fatalities could be attributed to penetrating extremity trauma.16 Other cases where wounded soldiers survived extremity injuries, ‘pre-hospital haemorrhage control through the application of a tourniquet was crucial’.16
This work attracted the attention of Captain Frank Butler, a former Navy Seal platoon commander, ophthalmologist and Director of Biomedical Research for Naval Special Warfare Command. He and others organised efforts to critically assess and analyse the needs of tactical combat casualty care. After reviewing Mabry’s work from Somalia, and Wolff and Adkin’s World War II findings, Butler recommended testing tourniquets to perfect the design.17 Tourniquets continued to be screened and tested in 2003, prior to Operation Iraqi Freedom. Recognising that waiting for further information and testing results could result in needless loss of life, Army Surgeon, General Kevin Kiley, recommended the Combat Application Tourniquet (CAT) as standard issue for all US service members deployed on operations.17
Analysis of Special Operations Forces casualties killed in action during the Global War on Terrorism from 2001–2004, revealed that 13% of casualties died from traumatic limb haemorrhage amenable to a tourniquet.18 Up until this point, little training was provided in the use of tourniquets, but in 2004, liberalised use was encouraged.18
Early results were positive. In a retrospective case- control study, Beekley et al. reported that 57% of deaths may have been prevented by earlier tourniquet use in a Baghdad hospital.19 Equally importantly, no adverse outcomes, including subsequent amputation, were attributable to tourniquet use.19 A prospective study, also in Baghdad, reviewed 2828 casualties. The survival rates were higher for those who had pre-hospital use of tourniquets compared to those with hospital use (89% vs 78%), higher with use before shock onset versus after shock onset (96% vs 4%), and higher with tourniquet use versus without tourniquet use (87% vs 0%).20
Further evidence from the remainder of the campaign underscored the importance of battlefield tourniquet application. A trade-specific, retrospective analysis reviewed records of 313 cavalry scouts wounded in action across both Iraq and Afghanistan.21 Tourniquet application was recorded in 24 (7.7%) of cases for open fracture, vascular insult or traumatic amputation.21 When tourniquets were applied, 96% of soldiers survived their battlefield injuries.21
This cumulative military experience overwhelmingly supports the liberal use of pre-hospital tourniquets. Experience from the recent Middle Eastern conflicts suggests that tourniquets may be routinely used to control severe extremity haemorrhage safely and effectively, with strong evidence to support their life- saving capacity for limb-injured casualties. These developments have triggered recent reconsideration of the role of tourniquets in civilian trauma.
Civilian EMS adoption
Retrospective studies, along with the personal experiences of medics and resus teams in Iraq and Afghanistan, have resulted in a rethink of pre-hospital care in civilian trauma. Battlefield injuries may have similar characteristics to civilian traumatic injuries resulting from motorcycle accidents, natural disasters, agricultural incidents and terrorist attacks. Consequently, lessons from the care of military trauma injuries can be translated for the civilian environment to improve the quality of trauma care that civilian practitioners can offer their patients. The medical director of the Mayo Clinic Trauma Centre, Dr Donald Jenkins, retired from the Air Force to head the National Trauma Institute, estimates that over half of American ambulances now carry tourniquets and properly train staff to use them—a considerable improvement from the previous decade.22 Civilian data analysing tourniquet use in rural North America found them to be safe and effective in controlling haemorrhage in 98% of cases, echoing findings from the battlefield.22 Tourniquets are relatively inexpensive and are now carried by many paramedics, similar to how deployed military personnel carry a tourniquet on their person.22
It is not only people with medical backgrounds who are using tourniquets to aid those afflicted by traumatic incidents. The 2013 Boston Marathon bombing killed three and wounded hundreds.23 As people lay badly bleeding in the smoke after the bombings, rescuers used improvised tourniquets made from belts and other materials to tie off bleeding and severed limbs. In the hours following the attack, pictures flooded social media sites showing victims being carried from the scene with severed limbs, clamped by tourniquets. The Boston Trauma Collaborative reported that out of 66 patients with extremity injuries, 27 tourniquets were applied. All 27 patients survived.23
This increasing public awareness of the role of tourniquets may have arisen from the military’s experience in the Middle East. Dr Mooney, the Trauma Director at Boston’s Children’s Hospital at the time of the Boston Marathon bombings, advised that some children’s lives would have been lost at the scene without the use of tourniquets by EMTs and civilians.24 He went on to say, ‘These kid’s lives were saved by the first responders… That’s sort of an Iraq and Afghanistan thing, that people have started to re-learn that tourniquets are OK. Ten years ago, it was a total no-no’.24
Conclusion
Many lessons have been learnt from two decades at war, with tourniquet use potentially being the most critical medical lesson. A growing body of evidence shows that tourniquet use for severe bleeding from extremity injuries is a safe, cost-effective measure for reducing mortality and morbidity. The challenges presented in controlling life-threatening extremity haemorrhage in the field or civilian practice leave little margin for error. Effective medical leadership should focus on providing solutions for first responders who face the potentially dire situation of maintaining life until further medical support is available. Tourniquets are one such effective solution.
Corresponding author: Dominic Maher d.maher@aflred.org.au
Authors: D Maher1
Author Affiliations:
1 The Alfred Hospital
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