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."
Since the release of the 2003 report on combat medicine, doctors and medics throughout the armed forces - including many who served on the committee that wrote the report - have clamored for the Pentagon to make tourniquets standard equipment. Several weeks ago the Army Medical Department approved a new soldier first-aid kit that includes a modern tourniquet, and on Jan. 6 the U.S. Central Command, which oversees all American military operations in Iraq and Afghanistan, issued a policy saying that every soldier in the war zone should carry a tourniquet.
But compliance with Central Command's policy was left up to individual units, and no dedicated funding has been approved by the Army or the Pentagon. Fielding of the new first-aid kit has been delayed while the Army conducts tests to determine the best pouch to put it in, which could take several months. The standard-issue "field dressing" bandage - a gauze pad with cotton straps that was singled out by the 2003 report as inadequate - remains the only piece of medical equipment the Army routinely issues to each of its soldiers.
The Central Command policy also says that each soldier in Iraq should carry a hemostatic dressing, a chemically treated dressing that helps stanch bleeding. But few do, and Army officials say manufacturing difficulties and supply shortages are responsible. Officials with both companies that manufacture Army-approved combat tourniquets - Phil Durango LLC and Tactical Medical Solutions LLC - say no such logistical complications exist with tourniquets.
Army officials say they cannot determine how many soldiers are carrying tourniquets in Iraq without polling individual divisions, brigades or battalions. But queries by The Sun show that many units don't have them.
About 500 soldiers from the 2nd Battalion, 34th Armor Regiment of the Army's 1st Infantry Division arrived in Kuwait a month ago, and none of them had been issued a tourniquet, according to a spokeswoman at the regiment's home base in Fort Riley, Kansas. The Army's 24th Transportation Company, also from Fort Riley, deployed to Iraq a month earlier without issuing any additional medical supplies to its 180 soldiers.
A soldier with the Army's 977th Military Police Company wrote an e-mail in February to Operation AC, a Delaware nonprofit group that ships air conditioners and other supplies to deployed troops, asking whether it could send tourniquets, saying the devices are not available in Iraq. Phil Durango, the manufacturer, donated 250 tourniquets, and Operation AC shipped them a few weeks ago, according to Frankie Mayo, president of the group.
"For me, it's an easy question deciding whether to spend $18 or $20 on a tourniquet or risk having to tell someone that their son bled to death from an extremity wound," said Navy Capt. Frank K. Butler, command surgeon of the U.S. Special Operations Command, which comprises roughly 50,000 Special Forces troops, Army Rangers, Navy SEALs and other military specialists. "But unit commanders have a lot of priorities."
One Army soldier in Iraq, assigned to the 44th Medical Command, which oversees all of the Army's hospital and medical operations in the war, told The Sun he had never heard of Central Command's policy requiring everyone to carry a tourniquet. Another soldier, part of a logistics operation in Baghdad, was also unaware of the policy but said he wasn't concerned because he could fashion a tourniquet from the Ace-like bandage he had been issued. Army doctors say the bandages are not suitable as tourniquets.
Mark Esposito, founder of Phil Durango, said his company has received large orders for tourniquets from regular Army units deployed to Iraq, such as the 3rd Infantry Division, but he could not recall any orders from the Army's National Guard or Reserve units, which had 156,000 soldiers on active duty at the end of February and account for 43 percent of the roughly 150,000 soldiers in Iraq.
"There is no doubt that tourniquets are effective and lifesaving," Tarpey, the 3rd Infantry Division surgeon, said in an e-mail last month from Iraq. "Many units continue to deploy without effective tourniquets or modern pressure dressings. As far as I'm concerned, this is a problem."
One difficulty for the Army, several doctors said, is that making tourniquets standard and urgent equipment requires erasing a stigma surrounding the devices that has been ingrained in many soldiers since basic training. Even as Special Operations troops began to change their attitudes toward tourniquet use in recent years, soldiers in the "big Army" continued to be trained using civilian guidelines, which say that tourniquets should be a last-resort treatment and that they can often lead to nerve damage or amputation.
Military trauma specialists have since determined that civilian training is of limited value on the battlefield and that prompt use of a tourniquet - tightening it around an arm or leg above a wound to stop bleeding - offers a soldier's best chance of living long enough to be evacuated for treatment. Research also shows that tourniquets can be used for several hours without causing permanent nerve or tissue damage.
Meanwhile many soldiers in Iraq, like Bernstein, don't have any tourniquet.
Bernstein was riding in the passenger seat of a Humvee near Kirkuk on Oct. 18, 2003, part of a three-vehicle convoy of the 173rd Airborne Brigade, when Iraqi insurgents ambushed the convoy with rifle fire and rocket-propelled grenades. According to Joshua Sams, a former Army specialist, who was driving the Humvee that day, Bernstein was shot through his left thigh at an angle, leaving an entry wound about 1 1/2 inches above his knee and an exit wound about 4 inches above his knee.
Sams, who had been trained under the Army's "combat lifesaver" program to treat trauma injuries, tried to use the cotton straps from a standard field dressing to put a makeshift tourniquet on Bernstein's leg, but the material broke apart under the pressure. By the time he could apply something more substantial - using the sling from an M4 rifle and the nozzle from a fuel can to twist it - Bernstein's blood had soaked the ground and Sams could not detect a pulse.
"I couldn't find a stick," Sams recalls. "There was nothing around but grass, and the bag from the Humvee only had bandages and things. "
Army officials declined to discuss Bernstein's death or release an autopsy report or other record, saying privacy laws prohibited it. But the official records available do little to clarify what happened. The officer's death certificate, for instance, lists the cause of death as "shrapnel injury of the leg," according to Bernstein's father, though Sams and other survivors don't recall his vehicle being hit by anything but bullets.
Everyone associated with the incident who could be contacted - Sams, three other soldiers who survived the ambush and Bernstein's father - recalls hearing the story that Bernstein's artery retracted into his abdomen and continued to bleed after he was injured, making a tourniquet useless. But four doctors who specialize in trauma injuries, commenting on descriptions of Bernstein's wound provided by Sams and two other soldiers who were at the scene, doubt that explanation.
"An injury like that is fairly common. I'll probably see one or two tonight," said Dr. Norman McSwain, a trauma specialist and professor of surgery at Tulane University who served on the military's combat medicine committee. "And it sounds like a tourniquet would have been effective."
"I've treated God knows how many of these things, and the vessel might retract an inch or two at the most," said Champion, a retired chief of trauma at Washington Hospital Center in Washington, D.C., and former director of research at the Maryland Shock Trauma Center. "If a tourniquet is available and applied properly, with an injury like that you have several hours. The bottom line is, it's not acceptable to die from that kind of an injury."
Brian Hart, whose son, Pfc. John Hart, died in the same ambush from a bullet wound in his neck, lobbied heavily for better armor on military vehicles after the incident. The bullet that killed Bernstein pierced the metal skin of his unarmored Humvee before hitting his leg, and the incident became a prominent example of the deficient armor on many American military vehicles. Hart said his son often complained that the 173rd Airborne Brigade's budget was too tight, and two soldiers who survived the ambush said that at least one of the squad's M249 machine guns failed after firing a few rounds.
"I always just assumed that they had the best equipment available," Hart said. "It turns out they don't even have some basic supplies. It's unbelievable."
Most of the military medical officials interviewed cautioned against re-evaluating combat injuries, saying that even a seemingly routine injury can take a deadly and unexpected turn in wartime. But they were unanimous in saying that tourniquets have proven themselves indispensable in combat and that the troops in Iraq and Afghanistan need more of them and have to be trained how and when to use them.
"Every soldier in Iraq should have a small, lightweight and functional tourniquet carried with them at all times," said Col. John B. Holcomb, a trauma surgeon and commander of the Army's Institute of Surgical Research, who said he keeps one in his pocket during tours in Iraq. "The training is doable, the equipment is cheap and it's directed at the largest source of preventable deaths in combat."