[NousDefionsDoc]

Baltimore Sun
March 6, 2005
Pg. 1

Deaths Because Of Blood Loss From Wounded Extremities Could Be Reduced If All Soldiers Carried $20 Tourniquets, Some Doctors Say

By Robert Little, Sun National Staff

Even after the bullet cut through his leg and severed his femoral artery, 1st Lt. David R. Bernstein had a chance. The shooting stopped quickly, and a soldier trained in combat medical care was at Bernstein's side almost immediately. Helicopters landed, and minutes later the young platoon leader was surrounded by four surgeons and all the equipment of a modern battlefield trauma center.

Bernstein died that night in Iraq, despite getting the best emergency medical care the Army had to offer. But doctors who specialize in combat injuries, and who reviewed details of the case provided by The Sun, question whether the 24-year-old West Point graduate might have lived if the Army had had something else to offer: a $20 nylon-and-plastic tourniquet.

"What was available in the Civil War, correctly applied, would have been quite adequate here," said Dr. Howard Champion, a senior trauma adviser to the military and one of the nation's leading trauma specialists. "Unfortunately, they were left with less than that."

Since at least a month before the war in Iraq began, medical experts in the Army and other services have called on the Pentagon to equip every American soldier in the war zone with a modern tourniquet. The simple first-aid tool - a more sophisticated version of the cloth-and-stick device used by armies for centuries - could all but eliminate deaths caused by blood loss from extremity wounds, the most common cause of preventable death in combat, they argue. The cost would not likely exceed $2 million, or about two-thousandths of a percent of the $82 billion proposed for the war this year.

Yet many of the nation's soldiers - tens of thousands, some doctors and Army medical officials estimate - continue to enter battle without tourniquets. And some bleed to death from battlefield injuries that would not be life-threatening if a proper tourniquet were available, according to more than a dozen military doctors and medics who spoke to The Sun on the condition they not be identified.

Army and Pentagon officials contacted by The Sun were at a loss to explain why every American soldier is not carrying a tourniquet, referring questions to other departments or declining to comment. Maj. Gen. Joseph Webb, the Army's deputy surgeon general, said that the service has embraced the concept of issuing tourniquets to everyone in Iraq and that he was surprised to learn that some don't have them. He also said he is not familiar with the purchasing and logistical procedures necessary to make it happen.

Even though the Army has approved a new soldier first-aid kit that would include a tourniquet and manufacturers say they are ready to produce as many as 100,000 tourniquets a month, the Pentagon has not placed an order. One obstacle seems to be the slow-churning military bureaucracy, which has forced soldiers to wait on the development of new training manuals and a pouch for carrying the tourniquet.

'No good reason'

Said Capt. Michael J. Tarpey, surgeon for the 3rd Infantry Division's 1-15 Infantry Battalion, in a paper he submitted recently to the Army Medical Department: "There is no good reason why wounded soldiers are continuing to die on the battlefield from extremity bleeding."

The Army has long known the importance of tourniquets in combat. Every medic is equipped with some type of tourniquet, or a cloth "cravat" bandage that can be used as an emergency substitute.

However, Army medical officials have found that soldiers in modern combat are frequently separated from their medics and that fashioning a tourniquet out of a shirt or bandage is impractical for a soldier with a severed artery, who could bleed to death within minutes.

Since a few Army Rangers bled to death in Somalia in 1993, military leaders have equipped every soldier in select units with modern tourniquets, typically a nylon strap with a plastic or aluminum windlass device for constricting around an arm or leg.

Today, every Ranger and nearly all of the 50,000 Special Operations troops go into combat carrying a modern tourniquet. Some of the military's primary war-fighting divisions, such as the 82nd Airborne Division and the 3rd Infantry Division, have outfitted soldiers with tourniquets within the past year. Marines have carried some type of tourniquet for several years.

In February 2003 - a month before the invasion of Iraq - a committee of more than two dozen of the military's top doctors and medical specialists issued a report calling for every American in the war zone to carry a modern tourniquet and receive training in how to use it. It called for a new doctrine for treating battlefield casualties, including greater emphasis on quickly preventing blood loss in combat.

"The importance of achieving rapid, definitive control of life-threatening hemorrhage on the battlefield cannot be overemphasized," said the report, issued by the Committee on Tactical Combat Casualty Care.

Many of the Army's Reserve and National Guard units, maintenance and supply soldiers, and infantry soldiers, however, don't have modern tourniquets. The Army has never added any type of tourniquet to its standard equipment list for soldiers, and the Pentagon has never dedicated money to buy them. Squads of 10 or more soldiers sometimes go into battle without a single tourniquet among them, The Sun has found. Many soldiers don't even carry the $2.05 cravat bandage, which the military has used as an improvised tourniquet for hundreds of years.

Modern innovations such as blood-clotting bandages, body armor and surgical teams close to the front lines have combined to make the war in Iraq one of the least deadly in history. About 11,200 service members have been wounded in Iraq since early 2003, and about 1,500 have died, a ratio of nearly 8 to 1. The ratio in the Vietnam war was roughly 4 to 1.

But according to the doctors and medics interviewed by The Sun, those innovations have not prevented American fighters from bleeding to death from arm and leg wounds - deaths that a proper tourniquet can often prevent.

Bodies of soldiers have arrived at aid stations in Iraq with makeshift tourniquets crafted from belts, wire or some other material that proved to be inadequate, they said. One photograph circulating among Army doctors shows an unidentified soldier with a tourniquet on his leg fashioned from a bungee cord. According to a doctor who showed the picture to The Sun, the improvised tourniquet failed, and the soldier bled to death.

The number of such deaths is not clear, in part because the Army has only begun to keep statistics about the precise nature of combat wounds. But units outfitted with modern tourniquets and trained to use them have reported dozens of cases in which they saved lives, soldiers and doctors say.

Members of the 1st Squadron of the 4th U.S. Cavalry applied five tourniquets in one firefight last year, according to Tarpey, the surgeon, and all of the patients survived.

The Army's 75th Ranger Regiment, whose 1,900 premier light-infantry troops were among the first soldiers in Iraq and Afghanistan, has not reported a single case of a soldier's bleeding to death from an extremity wound since Rangers began carrying modern tourniquets several years ago, according to Maj. Jeffrey S. Cain, an Army doctor who deployed with the unit in Afghanistan and now works at the Army's training program for combat medics.

Through the end of January, the Army Medical Department reported 211 cases of service members who survived amputation of a hand, foot, arm or leg, and doctors who spoke with The Sun said they assume that most used tourniquets.

Sgt. Heath Calhoun of the 101st Airborne Division was one of the first, when a rocket-propelled grenade struck his vehicle in Mosul on Nov. 7, 2003, and amputated both his legs. Soldiers in his division had not been supplied with modern tourniquets, but a medical bag was available that contained two cravats, which soldiers fashioned into tourniquets and applied to his legs, twisting them tight with sticks.

"Luckily those guys didn't hesitate in putting those tourniquets on," said Calhoun, who recently retired from the Army and lives with his wife and two children in Clarksville, Tenn. "Waiting 45 minutes for a medevac, I have no doubt that those tourniquets saved my life."