The Recert Blog

The implementation of tourniquets in casualty care has revolutionized trauma management, particularly in military settings. This life-saving technique, perfected on the battlefield, is now paving the way for significant advancements in civilian emergency medical services (EMS). 

Public Safety Group sat down with Navy Captain (Ret.) Dr. Frank Butler to discuss the evolution and importance of tourniquet use in casualty resuscitation. Dr. Butler is a Navy SEAL who was the architect of Tactical Combat Casualty Care (TCCC) and is an author of the National Association of Emergency Medical Technicians (NAEMT)’s PHTLS: Prehospital Trauma Life Support, Military Tenth Edition. He recently received the Presidential Citizens Medal for his role in developing TC3.   

How Views on Tourniquets Have Changed
In 1992, when developing TCCC, Dr. Butler began looking at tourniquet use from the perspective of the Navy SEAL Medical Research program. The prevailing thought at the time, as taught in the Advanced Trauma Life Support (ATLS) course, was to avoid using tourniquets due to the high risk of ischemic damage to limbs, which could lead to the loss of extremities. This belief was deeply ingrained in trauma care training, and tourniquets were considered a last resort.  

While reviewing research from Colonel Ronald Bellamy from the Vietnam War, Dr. Butler discovered evidence that contradicted this teaching. Colonel Bellamy’s findings highlighted that bleeding to death from arm or leg wounds was a leading cause of preventable death in Vietnam, with potentially more than 3,400 deaths due to not using a tourniquet.  

The final turning point in Dr. Butler's stance on tourniquet use came to him through a chance injury. After injuring his knee on a family vacation, he was taken into surgery, where his leg was placed in a tourniquet. He was surprised to learn from his orthopedic surgeon that tourniquets were used daily in the operating room without causing leg damage. Dr. Butler used these learnings when writing TCCC. In 1996, the recommendation was put into place that everyone carry a tourniquet, which is safe to use for up to an hour. 

The Use of Tourniquets in Afghanistan
Between the introduction of TCCC in 1993 and the start of the War in Afghanistan in 2001, only several units (the Army Rangers, the 75th Ranger Regiment, the Navy SEALs, the Air Force Para Rescue community, and the Army's Special Missions Unit) adopted TCCC and tourniquets. When the war in Afghanistan began, most units did not have tourniquets, leading to a preventable loss of life. 

Unlike previous conflicts, forces in Iraq and Afghanistan saw improvised explosive devices (IEDs) become a common threat. Colonel John Holcomb was instrumental in recognizing that the Taliban used IEDs, particularly dismounted IEDs, to maim rather than kill, resulting in devastating injuries with multiple extremities lost. The increased use of tourniquets in these situations allowed medical personnel to save many lives, even when casualties suffered injuries to multiple limbs.  

Dr. Butler credits the adoption of TCCC with saving lives by preventing fatal hemorrhage on the battlefield. 

"Tourniquets were remarkable in that they saved thousands of lives in Iraq and Afghanistan. And they were perhaps the signature improvement in prehospital trauma care in Iraq and Afghanistan.” 

Why Tourniquet Conversion is Essential
TCCC guidelines state that tourniquet use is safe for up to an hour. But what happens after this hour is complete?  Proper tourniquet conversion involves transitioning from using a tourniquet to other methods of hemorrhage control, such as hemostatic dressings, to prevent limb damage from prolonged tourniquet application.  

During the conflicts in Iraq and Afghanistan, rapid evacuation times typically allowed for tourniquets to be removed before they caused ischemic damage, and no American service members were reported to have lost limbs due to tourniquet ischemia. However, an incident outside these theaters, where a tourniquet was left on for eight hours and resulted in limb loss, highlighted the need for revised guidelines. Colonel Stacy Shackelford's paper, adopted by the Committee on Tactical Combat Casualty Care, emphasized the importance of attempting tourniquet conversion within two hours of application, a guideline that has been in place for over a decade. 

Adapting Tourniquet Training for Civilian Use
In the early 2000s, the military began to incorporate tourniquet use, and by 2008, every American on the battlefield had a tourniquet and was trained in its use. However, the civilian sector was slower to adapt. 

One paper by Dr. Tress Goodwin at the Uniformed Services University found that in the 4 million EMS activations between 2008 and 2009, the number of tourniquets used was exactly 0. Successful attempts were made to educate the civilian sector, but there was not a widespread use of tourniquets. 

The Hartford Consensus and Stop the Bleed Campaign
After the 2012 mass shooting at Sandy Hook Elementary School in Newtown, Connecticut, the Governor of California asked trauma surgeon Dr. Lenworth Jacobs for his expertise.  

“Dr. Jacobs looked at those autopsies and tragically, most of those kids could not have been saved with tourniquets,” said Dr. Butler. “But Dr. Jacobs looked at the military experience and thought about that and realized that control of external hemorrhage with tourniquets and hemostatic dressings could absolutely save lives with very little risk to the trauma victim and minimal expense to the American Medical system.” 

Dr. Jacobs met with medical leaders from the FBI, the American College of Surgeons, and SWOT team advisors in Hartford.  

“The Hartford Consensus gave birth to the Stop the Bleed campaign. This was just a remarkable example of the civilian sector taking the concepts pioneered by tactical combat, casualty care, and transitioning those to the civilian sector. And it was dramatically successful. We’ve saved many, many thousands of lives in the civilian sector in the ensuing years,” said Dr. Butler. 

Stop The Bleed teaches that with severe extremity bleeding, hemorrhage control is a priority. Someone who is severely bleeding can bleed to death in as little as 3-5 minutes, which is often before EMS can arrive on scene. Although most extremity injuries do not require a tourniquet, a tourniquet should be applied when bleeding is life-threatening.  

Dr. Butler credits Stop the Bleed with giving everyday individuals the knowledge they need to make a difference, even in everyday accidents where an injury was not caused by violence. 

“When I go out on my bike rides, my emergency kit is a tourniquet and a cell phone. I’m prepared to stop any hemorrhage that I might have from a bicycle accident, and I’m also prepared to save somebody else,” he said. “If I come across somebody that’s been in an automobile accident, I can apply a tourniquet and save that person’s life. Think of hunters. Think of scuba divers. Anytime there’s a potential for significant trauma, there’s a potential need for a tourniquet. And if you have a tourniquet, you need to have somebody who’s trained to use it. And that’s why Stop the Bleed has been such a powerful program. It has trained Americans across the country, not just doctors, not just medics, but everybody to use tourniquets when it’s appropriate.” 

Understanding the Rationale Behind Medical Practices
PHTLS: Prehospital Trauma Life Support, Military Tenth Edition draws on the military's TCCC, explaining the reasoning behind the use of tourniquets and other critical interventions. Dr. Butler emphasizes that understanding the rationale for these medical procedures enables directors to adopt the most effective life-saving strategies. 

"It helps you understand why you're using prehospital whole blood, why you're using combat gauze, which intraosseous (IO) access device to use, and which tourniquet is best... If you are a civilian medical director, it seems to me that it would be imperative for you to be able to make an informed decision," he said. 

PHTLS: Prehospital Trauma Life Support, Military Tenth Edition also serves as a resource for civilian EMS directors, providing a thorough overview of the tools and techniques used in military environments. Although not all elements of TCCC are relevant to civilian situations, the military tenth edition equips trainers with the essential knowledge and skills to ensure their medics deliver the most effective trauma care to patients.