Tourniquets Lifesavers on the Battlefield

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Tourniquets Lifesavers on the Battlefield
By
Donald L. Parsons, PA-C, LTC (RET), Thomas J. Walters, Ph.D

General Albert Sidney Johnston was one of the senior commanders in General Robert E Lee’s Army at the battle of Shiloh on 7 April 1862. He was advised by his command surgeon that all troops should have a tourniquet issued to them prior to the battle. While leading his troops in the battle, General Johnston was wounded in a large leg artery and died from a severe hemorrhage, even though he had a tourniquet in his pocket that could have presumably stopped the bleeding and saved his life.
Hemorrhage continues to be the leading cause of death on today’s battlefield just as it was during the Civil War.

Although tourniquet use is discouraged by most medical training programs for use in the civilian community, they may be life saving on the battlefield. The standard approach to hemorrhage control may become more difficult in combat because of factors like limited medical supplies, prolonged evacuation times, and the tactical situation. In Vietnam 2500 casualties died on the battlefield because they bled to death, and the only wounds these soldiers had were extremity wounds. While we have made major advances in medical technology we have not been able to decrease the number of deaths due to bleeding on the modern battlefield.

Today there is a new approach to care in combat. We have separated from the civilian approach to trauma and developed an approach that includes both good tactics and good medicine. Since hemorrhage continues to be the leading cause of preventable death we needed to rethink our approach to controlling this problem in combat. There needs to be a shift in our thinking. The days of not providing self-aid and just lying there and yelling “Medic” are over. It is conceivable that a soldier may be wounded and no combat lifesaver or medic is available, or the tactical situation may prevent them from attending to the casualty.

We must have the ability at the individual soldier level to provide care at the point of wounding.
“The hemorrhage that takes place when a main artery is divided is usually so rapid and so copious that the wounded man dies before help can reach him”.
The early treatment of war wounds by COL H.M. Gray, 1919
The use of tourniquets have proven to be the most effective means to stop bleeding in the combat environment, however, there is much confusion about the use of tourniquets among soldiers, medics, and medical officers on a number of tourniquet-related issues. What is an appropriate combat tourniquet? The current strap and buckle tourniquet in the inventory (NSN 6515-00-383-0565) does NOT work. Reports have been submitted from as far back as WWII that indicates this device is ineffective. If you find this device in your medical equipment get rid of it. It does not work. Much work has been done to develop a tourniquet that does it all. It should: stop bleeding easily, be applied with one hand, and be light and small enough to be carried on each soldier’s web gear. To this day no device has been proven to meet all of these challenges . However, we know that the old fashioned use of a cravat and windlass (stick) works very effectively. It is relatively inexpensive, small, lightweight, and if a small windlass is provided you have everything you need to make a tourniquet.

Next we need to address when it is appropriate to use a tourniquet. In a combat situation if a soldier is wounded and still under effective hostile fire, a tourniquet is the most appropriate means to control bleeding. Why? When a soldier is wounded by enemy fire, using direct pressure to stop bleeding may take several minutes, and while holding direct pressure on the wound, the soldier or medic is unable to do anything else. If a soldier is able to apply a tourniquet to himself, he may then be able to continue to return fire. The best medicine on the battlefield is fire superiority. It may be essential to the mission to have as many weapons trained upon the enemy as possible. In addition, it is difficult to maintain direct pressure on a wound while transporting a casualty under fire. To further emphasize this point, it is imperative for every soldier who may be involved in combat to have an appropriate tourniquet readily available at a standard location on their battle gear. This allows every soldier to be equipped and trained to stop bleeding on themselves or their battle buddy immediately. Other circumstances where tourniquets may be used are wounds where bleeding cannot be controlled by conventional means or traumatic amputations with severe bleeding, regardless of the tactical situation.
So now that we know when to apply a tourniquet. How tight should it be? It needs to be tight enough to stop the bleeding completely. Few individuals appreciate how tight a tourniquet must be to stop bleeding, especially in the leg.
“In the case of lower extremity wounds, which give rise to the most severe hemorrhage controlled by tourniquet, it has been my observation, that too few doctors, much less their assistants, have a concept of the constricting pressure required about the thigh to abolish the flow of blood” Emergency Treatment and Resuscitation at the Battalion Level by MAJ Meredith Mallory 1954

It is a mistake to think that some bleeding is good because it will provide some blood to the limb. This is wrong; it can actually make the situation worse. The practice of occasionally loosening the tourniquet to get some blood to the limb frequently results in a dead patient. Do not do this.

How long can we leave it on? The myth from medical training in the past says that once a tourniquet is applied, the soldier is going to lose his limb. In reality, tourniquets can be left on for several hours without permanent damage being done. Thousands of orthopedic surgeries are performed every day with tourniquets left in place for up to two hours without limb damage or loss. However, the longer the tourniquet is left in place the more potential damage that will ensue. If a limb with a tourniquet applied is kept cool, but not allowed to freeze, it extends the time a tourniquet can be left in place substantially. Nevertheless, we do not know at what point limb loss becomes inevitable; there are too many variables to consider.