Physicians at the Texas Trauma Institute Develop Innovative New Tourniquet for Combat and Civilian Use
In the fall of 2010, 3rd Battalion 5th Marines, known as 3/5, deployed to the Sangin Valley in the Helmand province of Afghanistan. The valley, dubbed a death trap for the number of lives its battles have claimed, is surrounded by steep inclines covered in lush green poppy plants.
Infamous for their use in the production of heroin, the plants served a second, more strategic purpose in the region – abundant coverage for burying large containers full of powerful homemade bombs, known as improvised explosive devices or IEDs.
Memorial Hermann-Texas Medical Center emergency medicine physician and United States Navy Reserve Lt. Keith Gates, M.D., who was serving as a battalion surgeon there at the time, describes these IEDs as a new breed of explosives: “The insurgents wanted to engineer a device that would be as emotionally devastating and demoralizing as possible,” he said. “They knew we carried tourniquets on the field that were capable of saving lives when their explosives would take off part of an arm or a leg. So they designed these bombs to hit higher, all the way up to the pelvis, rendering a traditional tourniquet useless. Those who were hit would often bleed to death in the field within minutes.”
Traditional tourniquets work by applying pressure to a limb circumferentially. The pressure on the skin and tissues is transferred to the walls of blood vessels, causing them to become temporarily occluded, which is effective in stemming the flow of continuous bleeding from a trauma. But these IEDs were causing high-level, bilateral amputations, with legs being blown off at the hips, so medics were unable to wrap a tourniquet around them.
These injuries typically presented with multiple pelvic fractures in addition to the uncontrolled bleeding of the femoral arteries, which dive upward at the pelvis and sit vulnerable in this region.
“We needed a tool that would clamp down on these arteries to stop the bleeding and also hold the fractured pelvic bones in place,” Dr. Gates said. “Unfortunately, the military didn’t have anything that could address these issues.
There were a few devices on the market but they were heavy, confusing to assemble and cumbersome, so the Marines wanted nothing to do with them. Still, Marines were dying regularly from these injuries – 3/5 had suffered the highest casualty rate of any Marine unit during the past 10 years of war, with 25 dead, 184 wounded and 34 losing at least one limb over the course of the deployment.” Frustrated, Dr. Gates sat in his hut in Afghanistan and began jotting down notes and sketching his own ideas. Once satisfied, he faxed his vision to Col. (Ret.) John B. Holcomb, M.D., director of the Texas Trauma Institute at Memorial Hermann-TMC and chief of the division of Acute Care Surgery at UTHealth Medical School. Then, he waited.
Memorial Hermann-Texas Medical Center emergency medicine physician and United States Navy Reserve Lt. Keith Gates, who is also an assistant professor at UTHealth Medical School, poses with Col. (Ret.) John B. Holcomb, M.D., director of the Texas Trauma Institute at Memorial Hermann-TMC and chief of the division of Acute Care Surgery at UTHealth Medical School. The two hold a plaque commemorating the evolution of the JETT, from Dr. Gates’ first sketches to the final product.
Just two days after his tour of duty ended, Dr. Gates found himself sitting in Dr. Holcomb’s office admiring a prototype for the Junctional Emergency Treatment Tool, or JETT. He was pleased. Applied circumferentially around the body like a belt, the JETT can be tightened around the pelvic region to compress fractures in place and apply inward pressure to the area without impeding respiration. The device also includes two pressure pads that can be positioned directly over the vessels supplying the lower extremity and can be tightened to block blood flow from the femoral arteries of either or both lower limbs. The device is designed to allow for patient movement without dislodging or reducing pressure, which makes it ideal for use in a hostile or pre-hospital environment. Even more, it is compact, lightweight and durable – all necessary components for a device intended to be carried into combat.
“As soon as I saw Dr. Gates’ sketches, I knew this was something worth looking into,” Dr. Holcomb said. “It was a relatively simple device that addressed a big problem, plus it was created by someone who was actually working in the field, treating these patients. He knew exactly what it needed to accomplish.”
With prototype in hand, Drs. Gates and Holcomb set off to see if it actually worked. They recruited professor and vice chairman Andrew R. Burgess, M.D., chief of Orthopaedic Trauma Services at UTHealth Medical School, to help them recreate the injuries on cadavers, breaking pelvic bones and then running them through CT scans to ensure the fractures resembled real-life injuries. Dr. Burgess is so fluent in his field that an entire classification of pelvic fractures has been named after him: the Young-Burgess.
Satisfied that the fractures were representative of those suffered in combat, the team opened the cadavers’ chests and pushed water through the aortas, using a pump that mimics the flow of a living human heart – normal blood pressure and heart rate and all.
Finally, they compared application of the JETT to other types of tourniquets to see which best stopped the bleeding and in what manner they addressed the pelvic fractures.
“It was clear we’d made something worthwhile,” Dr. Gates said.
A short 18 months after that first fax from Afghanistan, the JETT was officially FDA approved.
“It was a testament to how well the device worked – and how badly it was needed,” Dr. Holcomb said.
“Without a Doubt”
Nurse-paramedic Rudy Cabrera, R.N., B.S.N., C.F.R.N., E.M.T.-P., applied the JETT to a civilian patient in June, a move that undoubtedly saved the patient’s life.
The JETT holds incredible promise in the business of saving lives. A limited number have already been deployed in combat in Afghanistan, and on June 11, it was “without a doubt” the reason one local Houston man is alive today.
Twenty-eight-year-old Terry Light was using a circular saw when he lost control of the tool. It hit his thigh and severed a large artery near the pelvic region. Local paramedics applied a regular tourniquet to the wound which helped temper the bleeding, but it was unable to block it completely.
Memorial Hermann Life Flight® was called and Life Flight nurse-paramedic Rudy Cabrera, R.N., B.S.N., C.F.R.N., E.M.T.-P., who’d been trained to use the JETT by Drs. Gates and Holcomb personally, applied it on the scene. The bleeding stopped immediately.
“We were told by the operating surgeon that without a doubt, had the JETT not been applied, the patient would have bled to death while being transferred to the trauma center,” Dr. Gates said.
Injuries such as these are uncommon in the civilian world, but when they do occur, the associated fatality rate is alarmingly high.
“There just aren’t reliable tools available to first responders for these injuries,” Dr. Gates said. “If Rudy hadn’t had access to the JETT, he would have had to use his fists to plug the artery. With the bumps from the helicopter and the practical challenge of transferring the patient between stretchers, it would have been all but impossible.”
To date, feedback regarding the JETT is that it “worked as advertised,” meaning it stopped the bleeding immediately and entirely. The device has undergone multiple internal reviews by the Department of Defense and was recently selected as one of the Top 20 Innovative Products for 2013 by the EMS World Training Conference.
It is now carried on all Memorial Hermann Life Flight helicopters, and Drs. Gates and Holcomb hope to see it broadly deployed in Afghanistan soon.
“We have a few out there, but we need it to become standard use,” Dr. Gates said.
A recent report regarding the use of these types of tourniquets in Afghanistan revealed that since mid-July, there have been eight reported uses of a junctional tourniquet device and all of those were JETTs.
Of those instances, six patients survived and two died. One of the fatalities was in shock before the device was applied. The importance of a tool like the JETT for a war like Afghanistan cannot be underestimated. Dr. Gates illustrates it this way: “We’ve determined that if you get a tourniquet in the field – you’ve got a 95 percent chance of survival. If you get it in the ER, you’ve got an 80 percent chance of survival. If you don’t get one and it is indicated, you have a zero percent chance of survival.”
Now, imagine all the devices like this that aren’t even invented yet.
The Texas Trauma Institute is built on a foundation of a long-term collaboration between the Memorial Hermann-Texas Medical Center Campus and UTHealth Medical School. The Institute is a Level I trauma center for both adults and pediatrics and is the only verified burn center in the city. The Institute brings together a world-class team of clinicians, researchers and educators armed with the latest in research and technology to deliver comprehensive, life-saving services.