Robert Little on the lack of tourniquets for troops

Reporter answers readers' questions on tool's availability to soldiers in field

March 14, 2005

John Stevens, Towson: I learned in [the] Boy Scouts how to make a tourniquet out of a belt or scarf and a stick. What's the difference between something like this and the $20 tourniquets? Won't both do the same thing?

Little: This is the most common question I've received, even from soldiers and Marines, and probably warrants a detailed answer.

A tourniquet made from a sling or cloth, twisted tight with a stick, is entirely adequate when applied properly and has proven so for centuries. Medics and corpsmen still carry a triangular cloth "cravat" bandage, and those cravats have been used effectively as tourniquets scores of times in the last two years.

There are two shortcomings of the cloth-and-stick method, however, including the fact that it requires some training and improvisation. Even a seasoned medic can have trouble crafting a proper tourniquet to staunch the bleeding from a high leg wound, and less-seasoned soldiers have complained they couldn't find a stick in the Iraqi desert.

More importantly, though, is that soldiers aren't equipped with a cloth and stick either, and they are often injured in convoys or patrols, where medics or trained soldiers can't get to them for 15 minutes or longer -- more than enough time to bleed to death.

If every soldier were equipped with a cloth and stick, it would go a long way toward solving the problem, but a ready-made tourniquet with a built-in tightening device is much better, and that's what the U.S. Central Command is asking for.

David Bergeron, Eldersburg: Hasn't direct pressure, direct pressure and elevation, and pressure points been found to be far more effective than tourniquets by our EMS systems and the studies done by the military at Fort Sam [Houston] in Texas -- all without the risk of tourniquet shock?

Little: Military trauma care has undergone somewhat of a revolution in the last few years, as surgeons and other combat medical specialists determined that civilian EMS training -- while effective -- is often inappropriate for a combat setting, where transportation and supplies can be scarce, bullets might be flying and trained responders might not be immediately available.

Most combat deaths occur before a wounded combatant reaches medical treatment. So, military doctors have determined the most effective trauma medicine involves moving doctors as close to the battle as possible and training the fighters to concentrate on simple "care under fire," such as stopping bleeding, opening an airway or relieving chest pressure. That's often good enough to keep people alive until more definitive care is available.

1st Lt. Marco Fincato, Baltimore: A tourniquet can be made out of nearly anything, including bootlaces, wires or the bandage that we all wear on our gear. Why is The Sun targeting the U.S. military for something like this when they clearly don't have all the facts?

Little: A lot of the military's top surgeons and doctors are trying very hard to change that way of thinking. As many as 2,500 service members died in Vietnam from wounds where an effective tourniquet might have helped, according to the current literature. And doctors continue to see cases where soldiers and Marines have died because their colleagues had not given enough advanced thought to how, and with what a tourniquet might be applied.

Improvised tourniquets can certainly be effective, but they often are not, particularly on thigh wounds with arterial bleeding. Bootlaces, wire, rope or similar material is often not effective in such cases. A belt is better, but is not ideally suited to the purpose, and can actually promote blood loss if not applied properly.

The bandages that soldiers carry -- either the standard field dressing or the newer cerlex and "Israeli" dressings that some units have -- are almost never adequate for arterial bleeding. Soldiers have died in Iraq because people don't believe that, and some military doctors are literally screaming trying to convince people of this.

To further underscore the point: The Army tested nine tourniquets last year, all of them professionally designed and commercially manufactured specifically to stop bleeding from severe extremity wounds. Only three of them worked.

Vin, New York City: What's a new nylon tourniquet look like? What's the "ratchet" look like? How do you cut it off after it's sunken into swollen tissues?

Little: The one I've seen looks like a 2-inch-wide belt with a thick, plastic buckle and Velcro, and it attaches like a nylon watch band. A free-floating strip of nylon is stitched inside the belt and connected to a plastic stick, which can be twisted to further tighten the belt once the Velcro is used to make it snug. After the stick is twisted enough times, another smaller Velcro strap is used to hold the stick in place.

I've never asked how one might be removed, but I imagine you could simply release the stick and pull off the Velcro.

John Greene, Kent, Wash.: Why is this happening? As a former army medic, it sickens me that this is occurring. Where is the accountability from both the Pentagon and corporate medical companies who sell out our troops? Whatever happened to taking care of your people and leaving no man (or woman) behind?

Little: In the months it took to report this story, I never encountered any disregard or indifference for the welfare of the nation's soldiers. To the contrary. But what I did encounter was a confused and disjointed military bureaucracy that had no available mechanism for recognizing and capitalizing on an important idea.

Kathleen Frizzelle, Columbia: No question, just kudos for the public service you provided when you broke this story! My son, who is with the 1st Cavalry, and who graduated with 1st Lt. [David R.] Bernstein, has completed a year's tour of duty in Baghdad and fortunately never needed an (unavailable) tourniquet. For our young men and women, though, who are in Iraq now, or heading there in the near future, you have provided an invaluable service!

You will probably never know how many lives you have saved because of your article, but please know that there are many grateful parents, spouses, children and siblings out here! You have made a difference! This is what good journalism is all about!

Little: I wouldn't have written about this issue if I didn't think it was a situation that needed some attention brought to it. And I'm gratified to think it might have made a difference.

But please remember, there are a lot of experts in the Army and other services who have spent their lives worrying about these types of things. All I really did was listen to and write about them.

David Murphy, Hampstead: Often in civilian cases with severe trauma, the tourniquets are inadequately tied or used inappropriately. The most important aspect of the "cheap" tourniquets is will there be "non-cheap" training? This has to go hand in hand.

Little: You're right. I focused on supplying tourniquets for my story, but many of the military's doctors are also pushing for an entirely new training regimen for treating combat casualties. Besides teaching every soldier to apply a tourniquet, they also argue that every soldier should know how to insert a plastic tube into a patient's throat to open an airway, apply a modern blood-clotting dressing and use a needle to relieve chest tension on a patient with a common battlefield condition called tension pneumothorax.

Body armor, protective eyewear, and other innovations have made the battlefield more survivable than ever, but more training in some relatively simple trauma treatments could make it safer still, they say.

Jane Sellman, Baltimore: When I was in college, I used to have four of five term papers to write every semester. I managed to get them done in a few weeks. Why does it take so long to write a manual about tourniquets? It takes up maybe two pages in a first-aid manual.

Little: I'll bet you finished some [term papers] in one night, right? The Army has plenty of skilled writers available. It's determining and getting approval for precisely what to write that takes time -- more time in the military than most places. Far more time.