From the Battlefield to our Neighborhoods: A Path to Zero Preventable Deaths
Right now, as a medical student, my life is spent in the books. But before beginning my journey in medical school, I was an Army Ranger and deployed eight times to combat. Let me share a story from one of those deployments, about Zak Graner, and how tourniquets saved his life.
On October 1, 2010 my unit was on a mission and we were using an Afghan house as a defensive position. We were heavily engaged with the enemy throughout the morning with gunfire, snipers, mortars, and rockets. About 10 am, a mortar landed in the middle of the yard, wounding Zak, along with twelve others.
Shrapnel from the mortar ripped through his flesh, tearing open several arteries in his legs. While I was treating an even more severely wounded casualty, a Ranger Medic pulled him to safety and applied two tourniquets to his legs. However, that was not enough and he applied two more tourniquets. With four tourniquets applied, we were able to control the bleeding. About an hour later, a UK MEDEVAC helicopter picked up Zak and took him to a combat hospital. Amazingly, he made a complete recovery and even deployed again to Afghanistan the next year. This is one of thousands of stories on how a simple device saved lives in combat.
The wars in Afghanistan and Iraq have resulted in an unprecedented survival rate. However, there is still a 24–26% preventable death rate. We can define preventable death as a one in which the injuries sustained are not inevitably fatal — so the casualty could be saved with optimal medical care. There are three major causes of preventable death — bleeding from an extremity, collapsed lung that creates tension in the chest, and airway obstruction. The causes of preventable death are multifactorial, but by far, massive bleeding is the major cause. We’ve known this since the Vietnam War. Dr. Maughon, a Navy surgeon during the Vietnam War said this about self-help and first aid in an article “little if any improvement has been made in this phase of treatment of combat wounds in the past 100 years.” What is even more astonishing, nothing would change for the next 31 years after this article was published. At the beginning of the wars in Afghanistan and Iraq, combat medics still relied on Civil War vintage technology for pain management and used treatment methods not designed for the battlefield.
This occurred despite the development of Tactical Combat Casualty Care (TCCC). After the conflict in Mogadishu, the Rangers and the special operations community were reviewing the records of the wounded and killed in action in order to identify a better means to train for combat casualties. Luckily, about the same time, Dr. Butler and colleagues published their article “Tactical Combat Casualty Care in Special Operations,” it was perfect timing. Only a few units implemented this program before 9/11, its focus, good medicine with good tactics. There was heavy emphasis on identifying and treating the three major causes of preventable death — especially early tourniquet application. In my previous unit, the 75th Ranger Regiment, I was a physician assistant and was charged with overseeing medical training for the unit. We taught every single Soldier how to identify and treat the three major causes of preventable death. This enabled the 75th Ranger Regiment to eliminate preventable death in combat. A feat, never before accomplished by any unit in the history of combat. The 75th Ranger Regiment followed the recommendations from the Committee on Tactical Combat Casualty Care (CoTCCC) for bleeding. They recommended using one of two tourniquets, the Combat Application Tourniquet® (CAT) and the SOF® Tactical Tourniquet Wide (SOFT-TW).
Before 2006, although Rangers were using an effective ratchet tourniquet most prehospital tourniquets were improvised, and units were still being advised to use tourniquets as a last resort. Again, this was despite the recommendations from CoTCCC. After 2006, tourniquet use became widespread in the US military. So, how do we know tourniquets work? In Vietnam, death from extremity bleeding was 7.4% of total combat fatalities. In Iraq and Afghanistan, up to 2006, when tourniquets were just starting to be used, extremity bleeding caused 7.8% of total fatalities. From 2006 to 2011, the deaths from extremity bleeding was 2.6% of total fatalities, however some would argue that this was even lower, due to different papers using overlapping data. That’s a 67% decrease in fatalities from extremity bleeding.
How does this relate to the civilian sector? Of the 147,000 trauma deaths in 2014, 20 percent or 30,000 people could have survived. That is the world we live in; thousands of people die unnecessarily each year. We live in a country where bystanders know to call 911 and/or may console the victims of tragic accidents, but don’t really know how to treat bleeding. Is it a fear of infectious diseases or just like the military, there may be some “tourniquet phobia” out there in the civilian setting? Those of us who promote early tourniquet use have heard it all: “But, I learned that tourniquets are dangerous and should only be used only as a last resort!” This is a medical “urban myth” that has cost the lives of thousands of casualties and trauma victims. Many thousands of tourniquets have been used by the US military in Iraq and Afghanistan and zero limbs were lost from tourniquets. Furthermore, tourniquets are regularly used in orthopedic surgeries and two hours of tourniquet time is very safe.
Fortunately, stories like Zak’s are not limited to far off countries like in Afghanistan. Here in our country, we have moved forward. We have seen multiple stories of police officers, using tourniquets to save lives. They use tourniquets and other bleeding control devices on a daily basis, not only on each other, but on bystanders and criminals, as they are often the first ones on the scene.
Why is it I can teach people to recognize and treat life-threatening bleeding in combat, and to police officers, but to the average citizen in the United States it seems foreign. Compare this with CPR, where over 12 million people learn CPR each year. Most people are aware of CPR and automated external defibrillators, or AEDs. I would bet, if someone suffered a cardiac arrest in a non-CPR trained group, most people would have some sort of idea on how to do it. But, if you don’t, 911 operators are taught to give instructions over the phone. You can even get CPR instructions from Amazon’s Echo device. This happens, even though some studies from around the US, show survival rates from out of hospital cardiac arrest as low as 0.6 percent. The low incidence cardiac arrest in public places and the low survival rate does not impede our efforts to save the lives of those in cardiac arrest. And it shouldn’t, if we can save a life, we should put forth the effort.
We need put forth the same effort for hemorrhage control. In the wake of the Sandy Hook shooting, subject matter experts came together and published The Hartford Consensus. It provided guidelines for people in active shooter situations. The concept was easy, there should be early and definitive control of external hemorrhage and that tourniquets and hemostatic dressings would help make this possible. However, little is still known about these guidelines and how to stop bleeding. We put hours and hours into CPR, but a bleeding control course is as short as 2 ½ hours and easy to implement.
This year, a report titled: ‘A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury’ was published that helped identify the number of preventable deaths in the United States. From the report, there were eleven recommendations — all aimed at better coordination and efforts between the military and civilian experts in order to reach Zero Preventable Deaths in the United States.
Over two million people in the US have died from trauma since 2001 and there were over 400,000 potentially survivable deaths during the same period. Trauma is the number one cause of productive life years lost before the age of 75 — that’s greater than either cancer or heart disease combined. Imagine where and what these 400,000 people would be doing today. Where is the effort to stop the biggest cause of preventable death in the US?
Events like Sandy Hook, Boston, and Orlando have shown that an active shooter incident or acts of terrorism could happen anywhere, anytime. Dr. Christina Hernon present at the Boston Bombing coined the term — Disaster Gap. It is the time between the traumatic incident and emergency personnel arrive. It is also the time when people die from preventable causes. This gap is different for every event, to put this into perspective, you can bleed out and die in two-three minutes from your femoral artery. While a terrorist event will catch everyone off guard, as a PA and doctor in training, I can recognize that the response during the Disaster Gap could be optimized with bleeding control training for all.
Proper training and preparation, enables you to react and respond. How likely is it you’ll be present at an active shooter or terrorist act? Probably pretty small. But, how likely is it you will be present at a traumatic event caused by an accident? It could be a motor vehicle accident, a home accident, or at a place of employment. Are you prepared? Do you know how to prepare yourself?
There is a unique situation before us, we can stick with the status quo or we can change our approach to trauma care. We are at a crossroads. I am part of a community of medical professionals pushing hard for this movement for Zero Preventable Deaths. But, we cannot do it on our own. We cannot do it without each one of you. If we can eliminate preventable death in the chaos of war, why can’t we do it in the United States? Who among you have what it takes to stand up and lead and the United States to Zero Preventable Deaths from massive bleeding?
Thank you to Drs. Frank K. Butler, Russ S. Kotwal, and Dave W. Callaway for their review, many valuable comments, and additions. Thank you to Dr. Christina Hernon for her guidance and better understanding of the Disaster Gap.
