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NousDefionsDoc
10-13-2004, 11:11
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.

NousDefionsDoc
10-13-2004, 11:15
So the next question should be, when do we remove the tourniquet? The rule of thumb should be to remove the tourniquet as soon as tactically and or medically feasible. Does the tactical situation now allow time for more conventional means to control the bleeding, such as direct pressure, pressure dressings, or pressure points? Has there been a lull in the firefight or has contact with the enemy been broken? Are there now medical personnel available who have more experience in controlling hemorrhage with additional supplies like hemostatic bandages or hemostatic powder? If so, they can be utilized and the tourniquet can be loosened, but make sure the tourniquet is still in place incase the other means of hemorrhage control doesn’t work. Also make sure that any resuscitation fluids are given BEFORE loosening the tourniquet.

This is a second myth we are busting. The myth that the tourniquet should never be removed once applied. Now, there may be certain times when the bleeding cannot be controlled by any other means, and the tourniquet will need to be left in place. In these instances it is better to risk potentially sacrificing the limb rather than to lose the casualty to fatal bleeding. If the soldier is in shock, do not remove the tourniquet. Finally, if the tourniquet has been on for 6 or more hours, don’t remove it.
So now we know that tourniquets are not the universal limb destroying devices we believed them to be in the past. How do we integrate their use into every soldier’s common tasks?
Unit leaders need to be accountable for this training, both in garrison and during their mission planning. They must insure that every soldier is trained on the application of a tourniquet. The equipment for tourniquets, or actual tourniquets that work, need to be issued to all soldiers in both combat arms and support units. Reinforced training needs to be placed on the training schedule and every soldier must demonstrate his skill in applying an effective tourniquet.
If we can integrate this task into our daily business we can save more soldiers’ lives on the battlefield. Statistically, up to 9 percent of soldiers killed in action (KIA), die from extremity bleeding. These are lives that we should be able to save.
Steps for improvised tourniquet application:
1. Place the tourniquet between the heart and the wound, leaving at least 2 inches of uninjured skin between the tourniquet and the wound.
2. Wrap the tourniquet around the extremity.
3. Tie a half- knot on the anterior surface of the extremity.
4. Place a stick or similar object on top of the half-knot, tie an additional full-knot on top of the stick and twist until the bleeding stops.
5. Secure the stick or windlass in place so it will not unwind.
6. Mark the casualty with a “T” on their forehead. Record the date and time the tourniquet was applied on a field medical card or anything that can be transported with the casualty.
7. If an amputation is present put a dressing on the stump, and try to preserve the amputated part.
8. Transport the casualty to a medical facility as quickly as possible. Do not cover the tourniquet while transporting the casualty.
We must put this plan into action. We must place a special emphasis on this training at the individual soldier level, especially now given the events in the world today. We must equip our soldiers with the supplies to save their own and their battle buddies’ lives. Remember that extremity hemorrhage is the leading cause of preventable death on the battlefield.
Recommendations:
The United States Army Institute for Surgical Research evaluated nine tourniquets, three were effective in 100% of the subjects. These included one pneumatic and two strap type tourniquets; the Emergency Medical Tourniquet (EMT) (Delfi Medical Innovations); the Combat Application Tourniquet System (CATS) (NSN: 6515-01-521-7976) (Phil Durango, LLC); and the Special Operation Forces Tactical Tourniquet (SOFTT) (NSN: 6515-08-137-5357) (Tactical Medical Solutions LLC), respectively.

The two strap tourniquets used a built in windlass as the mechanism for tightening. Of the two successful strap type tourniquets, the CATS was less painful, easier to use, smaller and lighter than the SOFTT (59 grams vs. 160 grams). The design of the SOFTT limited the ability of the windlass to tighten the tourniquet, i.e., it was limited to approximately 3 turns. This limitation can be overcome through training the user to pull the tourniquet snug before attempting to tighten with the windlass. The EMT pneumatic tourniquet was wider and thus significantly less painful than any device tested and is much less likely to induce nerve damage compared to either of the strap tourniquets. The EMT weighs 215 grams and when packaged is similar in size to the SOFTT.

Based on these facts it is recommended that the CATS be issued to each individual soldier, and the EMT pneumatic tourniquet be considered for issue to combat medics. Further, it is recommended that the EMT be issued for all medical evacuation vehicles and echelon I-III medical facilities.

Log into AKO (http://www.us.army.mil) and copy paste the below into the address window to access:

Read the complete USAISR findings: https://www.us.army.mil/suite/doc/1252084

View a picture of the CAT Tourniquet: https://www.us.army.mil/suite/doc/1252083

Note - if you have to ask what an AKO account is - you don't have one and can't access it.

Thanks Java

swatsurgeon
10-13-2004, 16:17
Finally, a fellow believer.
As per the 2004 update by Capt. Frank Butler for Tactical Combat Casualty Care being taught to all of the fine armed forces medic and other personnel, tourniquets are both appropriate and life saving. If anyone wants I can reproduce his lecture/slides....so it was written, so it shall be done (the application of a tourniquet that is)!!
I teach their use for civilian casualties in Tactical Emergency Medical Care as well as rural medicine transport care. They have a place and the myths need to be busted, IMHO.
T-2

Razor
10-13-2004, 16:59
Just out of curiosity, what are the facts behind the concept of 'bad blood' flowing back to the heart and causing problems after releasing a tourniquet that has been applied for a long period? Is that the reason for the 6 hour time limit cited above?

rogerabn
10-13-2004, 19:03
Good post. In fact tourniquets are left on for up to three hours in surgery. We generaly try not to exceed 120 to 150 minutes. When a tourniquet is released the pooled blood that reenters system is not "bad blood" it is certainly deoxygenated and hypercarbic. Typically I see a dramatic rise in ETC02 leveals immediatly after tourniquet release. This is usually blown off within a minute or two. For extended ortho surgeries we release for short period of time and then reinflate the tourniquet without any long term ill effect.

swatsurgeon
10-13-2004, 21:54
Razor,
It's the build up of acids and potassium due to the cellular injury/death that comes from 2 sources. First, the tissue destruction from the trauma, second, from the hypoxic/ischemic tissues from lack of blood flow.. The release is like giving a bolus of "bad humors" that the heart doesn't like. Most of the bodies enzyme driven functions loose ~30-40% efficiency when the pH is < 7.28-7.30, and > 60-70% reduction when the pH is < 7.2...this is a problem with tourniquets. This is where the idea of an occasional release was born. Fact is we have kept some tourniquets on for 6-8 hrs, relizing the limb is non-salvagable and just keep it on, ice the extremity and amputate and the high potassium and/or acid "washout" never occurs. The answer to your question is different for injured (traumatic) vs non-injured (operated on) torniquet time. Any limb without adequate blood flow for >/= 6 hours can still survive but we have to do compartment fasciotomies because of the ischemia/reperfusion injury to the muscle. The nerve may be shot but the limb can survive. I'll put pics on tomorrow of this.

NousDefionsDoc
03-08-2005, 10:32
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."

NousDefionsDoc
03-08-2005, 10:33
New policy

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."

Device's stigma

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."