U.S. military widening use of tourniquets

As the Pentagon begins a hurried effort to distribute modern tourniquets to every soldier and Marine in Iraq and Afghanistan, the Army and the Marine Corps also have decided to make the simple medical tools standard equipment for more than 1 million service members throughout the world.

The move comes as new data from the two war zones show that modern tourniquets are saving lives in combat - and that soldiers without them have died, perhaps unnecessarily.

About 38,000 nylon-and-plastic tourniquets should be arriving at a staging area in Qatar this month, the first of 172,000 being rushed to the war zone, according to the device's manufacturer. A new first-aid kit containing a tourniquet also will be expedited later this year to every unit preparing to deploy to Iraq or Afghanistan, and then to the entire Army, according to medical officials in the service. The Marine Corps, meanwhile, expects to order more than 200,000 tourniquets, replacing an older model carried by Marines that has proven ineffective.

Emphasis on the $20 medical tool comes more than two years after a committee of military surgeons and medical experts urged the armed services to distribute tourniquets widely and to promote them as a first course of treatment in combat. And it follows a March 6 report in The Sun detailing cases in which doctors questioned whether soldiers might have lived had they been equipped with tourniquets.

Value becoming clear

Military medical officials say the value of modern tourniquets, with built-in ratchets for tightening around an arm or leg, is only beginning to become clear. Data collected from Iraq have not been compiled into a meaningful body of information, they say.

But a glimpse at portions of that data suggests that some of the 1,270 Americans killed in combat since the wars in Iraq and Afghanistan began might have lived if the military's emphasis on tourniquets had come sooner.

Maj. Alec C. Beekley, who served as a staff surgeon with the 31st Combat Support Hospital in Baghdad last year, identified 174 patients there in 2004 whose injuries benefited - or could have benefited - from tourniquets. And as the year progressed and modern tourniquets became increasingly common, he said, it became clear the devices were saving lives.

"It was my experience that if they came in with an extremity wound and they had a tourniquet on, they had a fighting chance," said Beekley, stressing that his data offered only a snapshot and could not be considered typical, absent more information from other hospitals. "If they didn't have a tourniquet, or they had a tourniquet that wasn't effective, they died."

Beekley, who now serves as a trauma specialist at the Madigan Army Medical Center in Tacoma, Wash., recalled the cases of two soldiers who might have benefited if proper tourniquets had been used - one who arrived at the hospital with makeshift tourniquets that failed, and another with a double amputation and no tourniquets. Both soldiers died.

"I don't know what other injuries they might have had, so I can't say whether a good tourniquet would have made the difference," Beekley said. "But soldiers who came in with tourniquets on, even if they were hard to resuscitate, they generally were able to survive."

Military medical specialists say the new tourniquet distribution campaign has created another challenge: persuading service members to use them. Many soldiers in the combat zones, even as they receive shipments of new tourniquets with instructions to carry them on their uniforms, have been trained for years that tourniquets are dangerous, often lead to amputation and should only be used as a last resort.

Guidelines change

The Army has since changed its guidelines for tourniquet use. Now it tells soldiers to use them quickly and liberally to control bleeding on the battlefield. And it tells soldiers to use the modern, ready-made tourniquets rather than improvising with a belt or scarf, an age-old technique that has proven impractical and sometimes fatal in modern combat.

A new Basic Combat Training program on tourniquet use was implemented this month. Division surgeons are being sent a training package to distribute throughout their units.

And the Army also is scrambling to make sure its new outlook on tourniquet use spreads throughout Iraq and Afghanistan as fast as the devices themselves.

"We even have doctors out there who've been trained that the tourniquet is the absolute last course of treatment," said Maj. Jeffrey Cain, a doctor who works at the Army's school for combat medics at Fort Sam Houston in Texas. "We have to change that quickly."

The confusion runs to the very top of the service. After The Sun's report in March, Army Secretary Francis J. Harvey sent the newspaper a letter noting that every soldier carries "an individual pressure dressing that doubles as a tourniquet."

Yet military surgeons have published papers for more than two years saying that standard-issue dressings do not make effective tourniquets, and the Ace-like "Israeli bandage" carried by some soldiers failed a tourniquet test at the Walter Reed Army Institute of Research several years ago.

The Army's Institute of Surgical Research conducted a test of nine tourniquets last year, all of them commercially made specifically to stop bleeding from extremity wounds, and found that only three worked reliably.

"This research is absolutely critical to our deployed soldiers, because having an ineffective tourniquet is just as bad as not having one at all," Lt. Gen. Kevin Kiley, the Army surgeon general, said in testimony before a subcommittee of the House Appropriations Committee.

Army Rangers and other special operations troops have carried modern tourniquets for several years, a response to the lessons learned in Mogadishu, Somalia, in 1993, where several Rangers bled to death.

A committee of surgeons and medical specialists throughout the armed services issued a report in February 2003 calling for every American soldier in combat to carry a tourniquet, and in December 2003 that report was published as a chapter in a book sanctioned by the American College of Surgeons to train trauma specialists.

In July 2004 the Army's Institute of Surgical Research issued its own recommendation that every soldier in the Army carry a modern tourniquet, and the U.S. Central Command issued a directive in January saying every soldier deploying to Iraq and Afghanistan should carry one.

Despite those directives, compliance was left to individual units, and tourniquets have only now been designated a standard-issue item by the Army.

The number of tourniquets in the war zones has increased the past two years, but many of the roughly 170,000 soldiers and Marines in Iraq and Afghanistan do not have one.

First Lt. Jeremy B. Hyldahl, medical supply officer for the Army's 1st Infantry Division, estimates he bought about 80,000 tourniquets from a North Carolina manufacturer during a recent one-year tour in Iraq, and says he was hounded by Navy, Air Force and civilian units once word spread that he could procure the devices.

He also estimates that more than half of those tourniquets are no longer in Iraq, having been carried home by people rotating out of the combat zone.

Kiley told the congressional committee last month that 112,697 of the Army's approved tourniquets had been shipped to Iraq before the latest delivery effort began. He did not speculate how many are still there, but he said any shortages will soon be resolved.

"Every soldier in Iraq will have a tourniquet by the end of June or sooner," Kiley told a subcommittee of the House Appropriations Committee. "And every soldier in the Army will receive a tourniquet as part of their new first aid kit, beginning this fall."