Bleeding Control Episode 1: Prehospital

In this episode of Frontline Surgery: Mastering Military Trauma, hosts Dr. Joshua Dilday and Dr. Rachel Russo are joined by Dr. Frank Butler and Dr. John Holcomb, to examine one of the most consequential shifts in battlefield medicine: tourniquet reassessment and conversion in the era of prolonged evacuation. The episode traces the evolution of tourniquet use from its controversial origins in TCCC to the hard lessons now emerging from the Russo-Ukrainian war, where contested airspace, drone threats, and ground evacuation timelines of six hours or more have fundamentally changed the risk-benefit calculus of leaving a tourniquet on.

The panel is direct: up to 75% of tourniquets applied in the field are not medically necessary in hindsight, and with prolonged evacuation now the norm rather than the exception, unnecessary tourniquet time is costing limbs and lives. The message is not to stop using tourniquets but to use them smarter, reassess them as soon as tactically possible, convert them within two hours when feasible, and never remove them after six hours without surgical backup. Dr. Butler also previews a new plain-language training package designed for non-medical service members, built on the principle that the knowledge is only as good as the person holding the tourniquet.

Literature Mentioned:
TCCC Quick-Look:What Kind of Bleeding Requires a Tourniquet?

TCCC Quick Look: Arterial Bleeding

From application to conversion: The development of a tourniquet reassessment algorithm for nonmedical military personnel by a North Atlantic Treaty Organization specialist team

Transcript

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The key thing is if you're trained to put a tourniquet on, you should be trained to take a tourniquet off. After two hours, you have to try to get that tourniquet off. You can convert it, you can check and see if it was really needed in the first place. But two hours is all that you can get for tourniquet time without risking tissue damage. Tourniquets are absolutely saving lives on the route. Enter the world of military trauma surgery with frontline surgery, where we bring you expert insights and real-world scenarios to help surgeons stay ready. Brought to you by the AST Military Committee. Join us as we engage in conversations with field experts, examine critical battlefield scenarios, and uncover the strategies that keep surgeons ready for anything. Stay prepared and stay sharp with Frontline Surgery, where every episode provides key insights into mastering military trauma care. Welcome to another episode of Frontline Surgery, Mastering Military Trauma Care. Again, I'm Joshua Dilde, joined by my co-moderator, Dr. Rachel Russo. Rachel, we have a phenomenal series kicking off today with the first episode in that series. And thank you so much for joining. I know this topic is a passion project of yours. I'm excited. You've really driven the ship on getting this one planned. So thanks for joining. I'm excited for this one today. Thank you. I'm excited too. We'll be talking about tourniquets today with some leaders in the field from over the past 30 years. Let's uh kick it off. Yeah, absolutely. You know, today we're we're gonna focus on just that. Battlefield medicine has changed over three decades. Uh, and one of those main changes is in the realm of pre-hospital hemorrhage control and with that, tourniquet use. Tourniquets have saved countless lives on the battlefield and have fundamentally changed the survivability from extremity hemorrhage. However, things are changing. And some lessons that are emerging from the Russo-Ukrainian war and conflict and some data that have honestly been talked about, presented, and honed in with these experts on the call today have highlighted an equally important concept, knowing when and how to reassess and convert tourniquets during that prolonged evacuation timeline. And in light of that, we are joined by some phenomenal guests today. We have Dr. Frank Butler, a leader in tactical combat casual DCA or TCCC in pre-hospital trauma systems, and repeat guests, a frontline surgery favorite, Dr. John Holcomb, a legend in his own right of trauma surgery with first-hand experience, managing prolonged tourniquet use in austere environments, both of which have intersect perspective frequently now, uh even in the recent conflicts and what we're seeing from some of the Russell-Eutane conflicts. So thank you so much for joining us, Dr. Holcomb, Dr. Butler. It's an honor. Thank you for being guests today. Pleasure. Great to be here. I'd like to start things off with a scenario for our listeners, with the mindset that a lot of the folks who were uh listening to our show are people who have not deployed before. And so we're thinking about what their experience might be like. We can imagine that they'll be supporting a combat operation in a contested environment. There's a dismounted patrol that's struck by drone-delivered fragmentary munitions, because that's what we're seeing these days. And medics might have to apply multiple extremity tourniquet hits while taking active fire, successfully controlling hemorrhage and saving lives while also trying to save their own. In this context, evacuations often delayed because air superiority is now contested by all of these uh drones that have the ability to survey evacuation routes. We have several casualties that are still remaining in transit for more than six hours or more before they're going to reach surgical care. And so by the time of these casualties finally arrive to the folks that are listening who would be able to take care of them. Many will have severe swelling, compartment syndrome, and metabolic derangements typical of ischemia reperfusion injury. So that's really the context that our conversation is going to be taking place in. So, Dr. Butler, given that scenario, and that's an extremely scary but unfortunately realistic scenario, we know tourniquets save lives. Um, but we also just highlighted the dangers of prolonged application when that evacuation timeline gets expanded. And we know that there's some data and experience coming out from recent international conflicts about involving tourniquet reassessment and conversion. But before we get there, I when I hear the name Dr. Butler, I immediately think of a lot of things, one of which is TCCC and Tactical Combat Casualty Care and all the work you've done in that space. Can you discuss why pre-hospital hemorrhage control matters and the effect that TCCC has had in that space over the past multiple decades? Sure. Uh when the TCCC project was first envisioned, uh it was taking into account the fact that uh the vast majority of people who die from combat wounds die on the battlefield before they ever get to John Holcomb or Rachel or yourself, a skilled surgeon. They die while they're being taken care of by the corpsmen or medic. And so that reinforces how important it is to get that piece of the care puzzle right. And so then if you follow that up with looking at uh the data on pre-hospital deaths, and uh with this this kind of a project, we made a pretty conscious decision that our metric for TCCC was going to be to prevent all preventable deaths that we could. You know, it's there's lot lots of metrics out there, but the one that we were looking for is how do we prevent every single death that we're able to prevent? And um by looking at the literature from the Vietnam era, uh, you see that one of the major causes of preventable death that's easily treatable by a medic is extremity hemorrhage. So um as we were trying to judge, I mean, if you flash back to 1992, which was when the project was starting, uh tourniquets were verboten. Uh I was a Ph or a ATLS instructor, rather, and I spent a couple years teaching medics not to put on tourniquets because that's what ATLS said. And then I hurt my knee and had to have knee surgery. And when I got to the OR, you know, laid down on the bed and the uh they started an IV and then they put on a tourniquet. And I actually started to sit up and protest and say, wait, what are you doing? And uh fortunately the anesthesia people know how to deal with obnoxious patients. So they gave me some medicine and I shut up. But that tourniquet stayed on for the next hour. And when I went back to see the orthopedic surgeon the next day, I said, I don't understand. We teach medics not to put on tourniquets, and yet you just put a tourniquet on my leg and left it there for an hour. And he said, We do it every day, it's not a problem. So all of a sudden we had to rethink the whole tourniquet issue. And it's amazing that uh at this stage of medicine and human evolution, that we had not the addressed the question of how to use them correctly. So the only evidence that I had was watching the orthopedic surgeons do their surgery, and what seemed to be a safe duration in their hands was an hour. And so the original TC3 paper said if you use a tourniquet for an hour and then get it off, you won't have a problem. Um so that's how we started saying put tourniquets on, save lives, but over the next 25 years of evolving tree TCCC, we've had to go back and look at that recommendation uh several times. And rather than just say, no, we're not gonna use tourniquets at all, uh, our objective was to try to use them smarter. So that this really came out of personal experience, uh which I think leads to the increase of passion that we've seen for for many years on how you've led the TCCC initiative. But I'm assuming that your knee surgery was not done in a combat scenario. If it was, that's a story I haven't heard yet. But a lot of times your data you're talking about is also turn to get used in the combat. How has how has that elevated the ability for point of injury care? And then from that, how did we get so much expansion into the civilian space? Yeah, well, you know, if you go back and you review the actual data about uh medic puts a tourniquet on and then there's a period of time and then he's evacuated. There's not a lot of data like that out there that I saw. Uh again, this was back in 1992. Even now, it's hard to get pre-hospital data because, as everybody here knows, the medics are getting shot at while they're trying to put the tourniquets on. They've got multiple patients to take care of, so they don't have a lot of time to write things down. And um you have to make the the best use possible of whatever information that you're able to derive from the casualty and the medic and the way that they present at the roll two hospital. Now, I I heard something when you were describing the initial rollout of TCCC. That tourniquet use was recommended in the context of using tourniquets for one hour. Now, can you talk a little bit about that one hour time frame and its importance during the initial um experience with the global war on terror and how things have evolved since then? You know, um, so again, I went back and looked at the original TC3 guidelines, and we didn't specify a maximum time in the guidelines themselves. The text of the paper said they're safe for an hour and uh didn't turn that into a specific recommendation. The next set of guidelines came out in 2003, and uh the duration of tourniquet use was addressed in those guidelines, but without a specific time, it said take the tourniquets off when you can. And the next big step happened ten years later. We actually had a service member in Africa who had a tourniquet applied and uh it was not taken off for way too long. And he wound up uh losing his leg when he didn't need to have. The wound was not that bad, it likely could have been converted. And uh, we took that information. It's terrible that we have to have that kind of an event to spur us on to the next level of tourniquet expertise, but that's what happened. And uh Stacy Shacklet, uh who's uh JTS director uh previous to Jennifer Gurney, um took undertook the project of re-looking at what our recommendations about tourniquet use were going to be. And she came out with uh I mean that paper was written in 2014, and in retrospect, it is excellent. It said two hours is safe. After two hours, you have to try to get that tourniquet off. And you can convert it, you can check and see if it was really needed in the first place, but two hours is all that you can get for tourniquet time uh without risking tissue damage. And um that has been part of the curriculum since 2014. So it begs the question of how is it that uh when you look at the Ukrainian military, all of whom are trained in treat TCC, they didn't do that. They put the tourniquets on and left them on. And uh that's a good topic for conversation, as John has mentioned many times. Um, if you count on the medics to do this conversion function, it didn't serve the Ukrainians well because many of their medics were targeted by the Russians and killed because they were medics. And so the tourniquets had to be attended to by their equivalent of combat lifesavers or even by um the non-medical service member. And I think we absolutely have to look at the Ukrainian experience and put ourselves in that picture frame and say this could be us next week. Um, we could have Marine Corps infantrymen with no medical training having to take care of a tourniquet for six hours or ten hours. And that has led um to the the great work that uh Dr. Holcomb and Dr. Dorlach and both of you and others have done trying to emphasize the things that we knew you have to get the tourniquet off in two hours if you want to preserve good limb function, but maybe we hadn't said it strongly enough in the course. So now we're going back and trying to do ad hoc training that reinforced those important points. Not every leg needs a tourniquet, and even the arms or legs that do need a tourniquet, when there's time, when there's enough people to help, you can use direct pressure and hemostatic devices to take the tourniquet off. It's just that we got so spoiled in Iraq and Afghanistan with our rapid evacuations, nobody had any tourniquet problems, so people didn't really focus on that tourniquet conversion bit. But it's important, and um the Ukrainians have paid a huge price to remind us of that, and we have to pay attention. Well, that's a huge there's a ton to unpack. And for those on the call who who already know this, there's actually three X Rush on the call. Dr. Rachel Russo has done a ton of work in this field. Dr. Holcomb has done a ton of work in this field, and for personal experience. So for the remainder of the podcast, I'm actually going to hand over the reins, and I would love to hear the three of you unpack that. I heard conversion, I heard not every wound needs a tourniquet. Basically, uh, just because a tourniquet's there doesn't need to be put on. You said two hours. Our scenario talked about a multi-day evacuation. Dr. Holcomb, Dr. Russo, can you unpack some of that, what Dr. Butler said about all that with the experience that you've done, the work you've done, the papers you've written on that. Where are we now with tourniquets? Yeah, let me jump in for just a second. And I think Frank has outlined the problem very clearly. It is very clear from looking at the available data that 50 to 75% of the tourniquets put on pre-hospital in hindsight. And this is not a negative comment, it's it's just that's these are the data, right? When you get into a MTF, FST, wherever an OR table is, good lights, people aren't shooting at you, they're at waist high. In hindsight, 50 to 75% of the tourniquets are not needed. That means that 50 to 75% of the tourniquets put on can be easily converted to a gauze dress. So if you take 100 tourniquets, up to 75% of them can be easily taken care of with a standard gauze dressing because you didn't need a tourniquet anyway. The 25% or 50% that do need a tourniquet, as Frank said, might be handled with a hemostatic dressing and an ace route, something like that. Because the tourniquet will help facilitate that hemorrhage control in either a vein or an artery. And so we talk a lot about time, right? And people start hanging their head on time, and time is really important. Zero to two hours, two to six, and greater than six is kind of where we've settled with Rachel helping lead that effort with a NATO paper that she'll talk about in just a second. But but the key thing is if you're trained to put a tourniquet on, you should be trained to take a tourniquet off. We had a meeting last week in Warsaw with our Ukrainian colleagues, focused on extremity injury. And there was 100% consensus on that statement. It's not magic to take a tourniquet off. The first tourniquet I saw was in 1993. Didn't know anything about TC3 at that time. Guy came in with his leg essentially blown off, put his own tourniquet on. I was trained as Frank was, tourniquets are bad. So my I started taking a tourniquet off in the emergency, in the ED of a tent in the emergency department area, and the blood squirt across the room. You're like, holy shit, I should put that tourniquet back on. Right? It wasn't, it wasn't uh a difficult decision process. The same thing is I take tourniquets off all the time in the emergency department today, right? We take them off all the time. And if they don't bleed, you take them off. If they do bleed, you put it back on. It is that simple. We can train everybody, all service members in uh in the US lingo to take tourniquets off, replace, or convert them. To me, that is the most important thing. And and Frank and I spent a lot of time on that. Frank's really led that effort. Rachel, you've written this paper recently from the NAT, the NATO group, right? We went through all of that. Frank was on that paper as well. Are your thoughts there? Yeah, absolutely. Um, I want to link together, I think, some of these different concepts and uh talk about them in the context that I think would be helpful for our listeners. Um when TCCC initially evolved, it wasn't adopted right away. And so when we think about the period of time uh during the conflicts in Iraq and Afghanistan when TCC and tourniquets were not being widely used, we saw a lot of potentially preventable deaths still. Now, once TCC and tourniquet use was adopted widely, thousands of lives were saved from extremity injury. And when you're talking about the context of air superiority and um rapid evacuation within an hour or two to skilled uh surgical teams, the use of tourniquets in that time, even if they were applied to someone that didn't need it, maybe they weren't helped by it, but they weren't harmed by it either. And so it was an acceptable risk to use tourniquets widely for that two-hour period. Now, in the context that we're seeing in the Russo-Ukrainian war and that denied airspace environment, where we're looking at tourniquet use being for longer than two hours, approaching that six-hour time frame to get to that same definitive care, that risk-benefit uh scenario starts to really change. So when you get out past the two hours, the tourniquet has to be life-saving in order to save a life. And so if it's applied to someone who doesn't need it, now you're talking about the risk of that tourniquet being on, potentially leading to limb loss, or worse yet, systemic ischemia reperfusion injury that can lead to loss of lives. That's really what we're seeing and what we're trying to prevent. So it's that uh rhabdomyelysis, that um washout of ischemic metabolites that led to an overload of potassium that was causing all these patients to have compartment syndrome, muscle loss, become dialysis dependent, and die when they didn't need the tourniquet in the first place, I think is what led to some of the papers that you guys have really worked on and some of the new training in this next generation of TCCC on who needs a tourniquet and who doesn't. And then, of course, needing to empower people who are at all levels of medical and non-medical training to remove tourniquets whenever it's safe to. And that's one thing that I wanted to kind of emphasize too, because I think there's been a big shift in that mindset is that TCCC was really care under fire. So when you talk about some of those early things that were rolled out about putting tourniquets on people who had not fully been evaluated yet, and the folks who are applying tourniquets are doing so while they're being fired at. So they're not taking the time to look and see exactly where the wound is, cut off all of the patient's clothes and expose them, and then try other methods of hemorrhage control. So when you have a tourniquet that's placed in that scenario, really, as soon as the patient and the provider are in an area that's safe where they have the time to expose the patient, look at the wound, move the tourniquet down to two inches above the wound, then that is the time frame in which we're looking at tourniquet conversion being appropriate. Anybody should be able to do that. So, Rachel, that's exactly right. And it's important that we not give people the mistaken impression that they need to wait two hours. Right. You don't need to wait two hours. You need to wait until it is tactically appropriate for you to go back and relook at the wound. And that may only be five or 10 minutes. Right. And if you cut away the trousers and you look and see that the wound is a bullet hole that's not bleeding, then you don't need the tourniquet at all. And as John says, you can cover it with a bandage or a hemostatic dressing. Um, no harm, no foul. I just want to clarify on that because there are some civilian sinners that require a trauma. Surgeon or a surgeon to be the one that does the tourniquet conversion. I'm pretty sure I heard all three of you say that if you're trained to put a tourniquet on, you should be trained to take it off. And if it's a three-day transport, you're not talking about a surgeon doing the initial conversion. Is that right? I just want to clarify that. You're saying anybody can do this. Let me be very, very clear about that. You are exactly correct. And to the point, because of all of this discussion that's now been going on for about three years, where the Ukrainians are teaching us this, right? We haven't had prolonged evacuations since World War II, really. And so this is this is what was taught in World War II. This same discussion happened. At the end, during World War II, at the end of World War II, the guidance was no tourniquets, right? And so there were thousands of soldiers, U.S. soldiers who died in Vietnam because of that, of that mistake in policy that came out of World War II. This exact discussion. The Ukrainians know that there are unnecessary, in hindsight, amputations happening. There are a lot of them. I've asked them specifically at all levels, at all levels, from their surgeon general on down to the medics that are taking care of patients. Do you think tourniquets are set is saving lives? Yes. Do you want to get rid of tourniquets? No. That's the answer from our Ukrainian guys that are living this every day. So the message is keep putting tourniquets on, convert and replace them as soon as you can. As Frank said, don't wait two hours. And we that has for the last 12 years been part of TC3 training. But when you take something and you teach it in a classroom environment, you can know that the principal is right, but did the person that you're training, or the people that you're training, did they really capture the point that you made? And the answer to that is no, because these Ukrainians all had TCCC training. So we've gone back and relooked at how this is presented to people who are going into combat. And Dr. Holfman, Dr. Dorlack, and I tried to go back and come up with an ad hoc, well-focused training package that said, look, here's a problem that we're having. It's causing legs to be lost, it's causing lives to be lost, it's causing people to be on dialysis. We know what to do to fix it, but we're not doing it. And so that presentation went out a year and a half ago, and it was good, but it was maybe written too much at the doctor level. We're talking about basic uh infantry people taking off tourniquets. You can't write a paper for Josh Dilday uh at his level and expect Joe Infantry guy to understand that. So we went back just in the last few months and redid that presentation and made it aimed towards the non-medical E3. Um my grandson is exactly that. And I sent it to him and said, Mitch, are there any words in this talk that you don't understand? And the answer was yes. Uh pulsatile. He didn't understand pulsatile. So he took it out. And so this presentation that we have now and that we'll share after the uh discussion, it should be good for anybody. And so to flip over to the civilian side, at the recent Maddox conference in Las Vegas, Dr. Kinji Anaba from LA County got up and said, we're having this big problem putting on way too many tourniquets, you know, they're coming into the uh hospital and they've got these tourniquets that they don't need. And I so I sent this presentation to him, and it is designed for combat medics, but it could perfectly well be used by a civil civilian EMT. They can look at a depiction of a wound uh or a video. We we sent them John's video from Iraq that shows arterial bleeding. All you have to do is see it. If you see it and it's in the right context, you'll remember it. And so we're hoping that this focused training package will help to overcome the uh terrific tourniquet overuse that we're still seeing. The overuse in the civilian world is exactly the same in the military world. It's exactly the same. It is. Uh, and for the same reasons. But they've not had as many problems because transport time is very short in the civilian sector relatively. And so uh Dr. Anaba made the point that, hey, we're not having a lot of morbidity, but we're putting on tourniquets that could cause a problem if there was a delay in transfer. In the urban environment, the transport times are pretty short. But uh in rural Texas, where I'm the associate EMS medical director, routinely, two to three hour transports. Routinely. So we we teach this conversion and replacement in Washington County, Texas. And and that is the majority of the country, actually. I think it's interesting that LA was so focused on this. LA is known, like you said, for having short transport time. There's seven level one trauma systems. Yeah. Uh Kenji, Dr. Nava is representing the COT at that that question. But but I think it goes to show that there is clearly, even at the transport times, there's enough of an educational disconnect that all it takes is that one hour to go to two hours, or like what Dr. Russo mentioned at NATO, the six hour. And I think this is an important aspect of the knowledge is only as good as the end user. And it seems like that that's the point that we're getting at. Triple C was a phenomenal initiative to save countless lives. The climate has changed now to tweak to make sure that it can be even expanded as far forward as what the new battlefield is gonna require, can save even more. And going back to that point that you're talking about is the whole point is to design is to save those who can be saved. The zero preventable deaths, is obviously we like to quote that all the time. And it's so important because the era of helicopter transport and ground warfare may be over because of the drone threat. You know, how do you know if you are the pilot of a um 47 coming in to pick up a casualty? There's there's not a drone waiting for you right outside the uh casualty area. Uh that happened to the Ukrainians a few times, and the helicopters stopped flying. 90% of evacuations are by ground drones now in Ukraine. Yeah. 90%. Um and in Navy uh and surface combat warfare, you don't have the drone threat, presumably, although we haven't seen that demonstrated yet. There could be a drone threat, depending on where you are. But in uh shipboard casualties, even under the best of circumstances, it's going to take you a few hours to get off that ship and to a trauma surgeon. And so um the Navy needs to be paying very close attention to the lessons that we're learning from the Ukrainians. Thanks. I want to try to see if I can take this down a level so that we can really get into the practical applications for the listeners. Whenever I give this talk, also on the civilian side, I get a lot of questions because nobody, and that is a medic or anyone who is uh trained to put on a tourniquet, wants to miss that potentially life-threatening injury so that we can get to that zero preventable deaths. So, how do they know if an injury is potentially life-threatening or not? You know, Rachel, I think uh I you know, this um teaching slides that Frank has talked about, we put a bunch of pictures together uh with one video that shows pulsatile bleeding from a guy's radial artery. Um which of course you can bleed to death. I you know, I we uh have all taken off plenty of tourniquets in the emergency department. And and yes, we are all surgeons. Um but if the bleeding starts again, you put it back on and go to the operating room. If I were you know, I teach the medics and say if the bleeding starts again, you know, put it back on, put it two centimeters, two inches above the wound, um, try to c you can try to convert it to a hemostatic dressing. But but most of them, because most of them aren't indicated to begin with, medically indicated, uh come off pretty easily. To my in my personal experience, it's pretty easy to tell the difference. Um and and when we teach the medics, once they start doing it, they're very uncomfortable doing it, to your point. Once they've done it a couple times, they become much more comfortable. So it's just it's to me, this is an easier thing to teach than intubation, cricothyrotomy, chest tube, uh, et cetera. I mean, it is an easier thing to we have all taught all those things to medics uh many times in our careers, and this is easier to do than that. Yeah, that's exactly right. And when I talk about it, I try to simplify it down as much as I can. Say if the patient is unconscious or losing consciousness because of blood loss, then put a tourniquet on. Or if they're conscious and the blood is coming out such that you can't stop it any other way, put a tourniquet on. And if you can stop it with pressure, if you can stop it with a uh dressing, then it probably doesn't need a tourniquet and you can reassess it over time as the patient's further resuscitated because it's a dynamic environment where things change. So you just have to keep checking on. Yeah, I think your resuscitation point is really good at that point. So you want to make, if you're gonna take a tourniquet off, you want the patient resuscitated, right? You don't take the tourniquet off when their butt pressure is 60 and they're in profound shock because there's not gonna they're not gonna bleed. So keep the tourniquet on, resuscitate the patient. This is all in the TC3 and all the papers that we all we have all written together. Uh but so you take a tourniquet off and a resuscitated patient, and let's say they'd have a head ingredients talking to you. Okay, so now they've got the tourniquet on, and we are ready to reassess them again. We're in a safe place. We've exposed the uh patient and find that this is an isolated injury. Uh the tourniquet has been placed high and tight, and the injury is, let's say this is the leg, uh below the knee. What do we do to move that tourniquet down? Where do we put it? So these are not the same tourniquets that were on for six hours that you mentioned previously. Because that's a good point. Is how long has that tourniquet been on? If they've been on for six hours, uh, we're gonna wait until the patient gets turned over to one of you guys before uh the tourniquet's taken off. And that's uh such an important point for the medics. Uh one of John's papers has an individual who has on a high-and-tight tourniquet, like you just mentioned, that was applied for 11 and a half hours. His arm doesn't look good, but he's alive. Um and so the problem with that tourniquet was it was never needed in the first place. But once it's been applied, after six hours, eleven hours, the medic can't take it off because they're not able to resuscitate the person to take care of the metabolic, metabolic problems that are going to be created when all those ischemic products come back into the central circulation. So leave the tourniquet on if it's been longer than six hours. Yeah, our our Ukrainian guys have taught us that, and and we'd know this from uh from what we used to do open aortic surgery. You leave it, you leave a tourniquet on or a clamp on for six hours. If you take it off immediately, especially on the lower leg, on the leg, then the patient will die from the potassium that comes flooding out there right away. They'll go into cardiac corrosion. Uh, that would be a shame for a patient with no other injury other than this tourniquet. If they survive that potassium load, then they'll go into renal failure from the from the mybe. So I think from everything that we have gathered so far, and it's consistent with what we have put together in the NATO paper, was that if the first time you are able to reassess that tourniquet for conversion is six hours after it was applied, stop, do not take the tourniquet down. Right. If we're lucky enough that they can get to it in that first two hours for tourniquet conversion, what's the first step? Well, just uh to go back for a second to, you know, as people who are trained in medicine and and trained to pursue evidence, you track the evidence down, you put it together, you think it through, you get some smart co-authors who show you what you've missed, and you write the paper. You know what? That's not gonna save any lives at all, you know, unless you can take the information in your paper and somehow very quickly, not waiting for three years until their next TC3 training cycle, you've got to take this training and infuse it to the people who are going to where the war is right now. And so that's what we've tried to do with these presentations. It's not just the information that we're transmitting, it's how we transmit the information and to whom. And so we're we're trying to, as we look at different formats, one thing, I mean, I I'm as technologically illiterate as anybody, but I can handle PDF files. You know, my phone can handle them. Everybody's phone can handle PDFs. So this is not a PowerPoint, this is a PDF presentation that anybody that's got an electronic device can look at wherever they are. They can download it and look at it on the ship over to wherever they're going. So it's not just the information we're trying to transmit. We've got to be smarter about how we get it to the people that need it. And um the first presentation that we sent out was exactly your point about you look at an arm or leg and you look at the amount of bleeding that you see, does that need a tourniquet? Okay, let's say it does. So you tighten it back up, and now we're gonna take a second, gather our materials, and we're gonna try to convert that tourniquet to hemorrhage control with a hemostatic dressing. These hemostatic dressings, if you look at the bleeding models that those things were tested on when John was at the Institute of Surgical Research, he had a very smart guy working for him named Bijan Curebody, and he developed a standardized severe hemorrhage model, and we tested the new hemostatic agents uh against animals that had exactly that level of bleeding, and they were. So if you've got a combat gauze or a chita gauze or a sea locks gauze, and you apply it directly to that bleeding spot with pressure, that bleeding's gonna stop. Those were femoral artery laceration models, if I remember correctly. Yeah. Five minutes of pressure with those dressings and the femoral arteries stop bleeding. They were holes, holes in the femoral artery. Yeah. Now, can can I ask a controversial question? Because I've heard I've heard tourniquets okay for two hours, and then I heard six hours, don't take it off, whether it need to be on or not. What about four hours? I'm now seeing this patient. It's four hours. I couldn't get off before. I'm it's four hours. What do I do? I mean, just to just to be specific here, because I can see that that's a lot of time gap between two and six hours. Yeah, I I think, I mean, everybody's gonna have a little bit different answer here. Uh Rachel, your question about how to actually do it, I think number one, make sure the patients resuscitate it and then uh take, yeah, look at the wound and move it down closer to the wound, I think to your first question. Just to your question, you know, the the between two and four or six hours is is really an un a dated unknown period. Um many of these tourniquets are not applied tied to their venous tourniquets. So uh I think if I was training medics today, I would say take a look at it, maybe loosen a little bit, make sure you got a lot of fluids, you know. Um, but you gotta be careful because that patient may drop their blood pressure from that potassium blood, may arrest. It's an unknown period. People are pretty comfortable at six hours, they're comfortable at two hours. Rachel, I think the paper, the NATO paper said we don't know between two and six. And you know, Rachel, this goes back to the point that we made earlier on. Don't wait until the two-hour mark to try to convert this tourniquet. As soon as you have the tactical opportunity to look at that wound uh more carefully, you should be able to take it off at 45 minutes. You shouldn't have to wait till three or four hours. That really should be the tactical exception. Um if you have been paying attention and really thinking about your casualty, you should be able to get it off within the two-hour um period. Yeah. I agree with that. I think the point is we got to really emphasize the train point is never get try to never get to two hours. Right. Um after that, it's difficult. Our uh NATO paper does say between the two and six hours to seek medical attention because it is a difficult decision, like you say, and it's often context dependent. It's do you have the medical skills available to provide uh surgical hemostasis if that's needed, to provide dialysis if that's needed, to give calcium and bicarbonate if that's needed. Um it is also dependent on the patient's other injuries and the constellation of the injuries that are on that extremity. Um, because it has so many variables, really, you need a higher level of expertise to be able to assess it. So I think that uh for the non-medical personnel, really assessing uh the tourniquet for its appropriateness should happen at the point that the tourniquet is applied and then during that first two hours. I think it's a great answer, Rachel. I think uh just like anything when we when we teach folks, it's better to stay out of trouble than get out of trouble. Once you're past two hours, it's trouble. Absolutely. It's a really bad situation for that. I'm just I'm picturing the the uh the ACLS algorithm where it goes into those arrhythmias and it says it's your expert console expert cardiologist. So when I walk into the ICU, I just pray that I'm not at that point uh in the algorithm. But the reason I bring it up, and these are conversations that are ongoing, and I'm sure we will have a podcast episode on that. You you mentioned, hey, get to a surgical capability, but we just framed that conversation. Where is it in that continuity of care in terms of logistics, both distance and time? So it's gonna be a dick conversation, but I think your point, both of your points are extremely well taken. Try not to get there. And if your data that up to 75% are inappropriately placed to begin with, then the majority of the time we don't have to get there. And then if you can convert those who are needed, if you can convert them with resuscitation, then then then hopefully the data in that controversial expert medical care scenarios are really the minority of these combat casualties. I want to make one last comment as we start wrapping up here in our Ukrainian colleagues have taught us a lot. We've learned a lot from them already. Um, their innovation decision loop is measured in weeks. Right? They see a problem and they work on the problem, they deploy a problem, and then they collect the data, see, and they keep going. So that's measured in weeks. Um, they're very creative, very innovative. They do not want to get rid of tourniquets. Tourniquets are absolutely saving lives on the battlefield. Let me make that very clear. Because there's some chatter out here that tourniquets need to go away, just like after World War II. The people that say that are wrong. Okay? The guys that are on the battlefield are saving lives with tourniquets. There's no question in their minds. They also are working, the Ukrainian guys are working really hard on replacement and conversion. What they told me last week was they're seeing decreased amounts of the post-tourniquet syndrome coming into the surgical facilities. Now, there's no numerator and denominator there. There's changing warfare going on, there's changing numbers, they're changing climate, you know, lots of changes are happening. But but their Ukrainian guys, from medics to the colonels, are uh convinced that tourniquets are saving lives, and that by all of this work that everybody's done, Rachel, that you've done, Frank, and many others have decreased that tourniquet syndrome by early replacement and conversion. I just wanted to uh highlight kind of one last thing to dispel some uh rumors that I often encounter when I'm talking to pre hospital providers. Um, it is totally possible to put a tourniquet on below the knee or below the elbow. So if the injury is Isolated to the foot or to the hand or to the radial artery, it does not need to go at the upper extent of the upper extremity. Um, there are two bones, so sometimes it needs a tighter tourniquet to crank it all the way down. But 75% of the time, no tourniquet is needed at all. So when the tourniquet is needed, put it right next to the wound, just above it. That's all it needs. That's great. We should call that the two the myth of the two bone problem. There's some serious urban myths about tourniquet use, and that's one of them. Yeah. The other one is is lifting the tourniquet every hour to give the wound a drink. Right. Right? Yeah, got rid of that for a while ago. Don't do that. Either put it on or take it off. I met a special forces guy in the ICU, just out of the ICU at Walter Reed. And when we talked, I looked at his injuries, and all he had was an X fix on. The uh, he just had a leg wound. And I said, Well, why were you in the ICU? He said, Well, I was in pretty bad shock. And I said, Wow. Did they have a delay uh to putting on a tourniquet? He said, No, they got it on right away. But then they had to let it down every 15 or 20 minutes to let some blood return to the leg. And this guy came very close to bleeding to death because of that ill-advised uh intervention. Yeah. That was a long time ago. We called that scheduled exanguination back in the day. And uh that was not good for the patient. Scheduled exanguination is not good for the patient. We we should have an outtakes on the when tourniquet's gone bad. The sandwich tourniquet, I've seen before, one above and below. Uh one for the artery, one for the vein was the rationale I heard. Uh yeah, that's great. Rachel, that we've talked a lot. I mean, I think you're the perfect person to sum up. I mean, you you're both the moderator here, but you're an expert in this field, which is why you're leading this initiative. Uh, Rachel, if you could sum up kind of the the entire systems perspective of what we've talked about today, just kind of uh the put the capstan on this episode for us, I think it would be great. Sure, thanks so much. Well, and then for everybody um who's listening and wants to learn more, all of the papers that we're talking about and the new educational uh materials are gonna be in the show notes for you for more reference. So you don't have to memorize everything we're saying. And it's broken down to the fourth grade reading level for non-medical providers. So if there's additional feedback you want to give us about how to make it even more clear, our ears are open for you. In general, to sum up all of the things that we've talked about today, modern warfare has forced military medicine to rethink our previous assumptions about evacuation timelines. And the lessons that we have learned from our partnership with Ukraine remind us that these interventions that were initially designed for rapid evacuation environments can carry new risks in large-scale combat operations. So while tourniquets remain life-saving tools, they must be applied thoughtfully, reassessed frequently, and integrated into the broader system of prolonged casualty care. Well, thank you so much for joining us on Frontline Surgery. This this was a phenomenal episode. I mean, obviously we're biased, but this is one that we've been trying to get into work since day one. Rachel has led the charge. She's got a clear vision. And the fact that hemorrhage control continues to be you can't have a hemorrhage control podcast or paper without stating the quote that, you know, it's the number one preventable cause of death on the battlefield, right? That's the opening line in every statement. So we've got to, we'll close with it here. But it it remains one of the greatest success stories in military medicine with TCCC and tourniquet use. And now we're seeing the next generation of conflict is teaching all these new lessons on prolonged care, reassessment, conversion, adaption, and understanding when to apply, maintain, and importantly, convert these tourniquets are just as important as knowing how to place them. Until next time, stay sharp and stay ready. Thank you. Thank you for tuning into this episode of Frontline Surgery. We hope today's discussion has provided valuable insights into military trauma care. Be sure to join us next time for more expert perspectives and battlefield ready knowledge. Until then, stay ready.