TO IMPROVISE OR NOT TO IMPROVISE, THAT IS THE QUESTION

The decision to improvise tourniquets has been a subject of debate for many years, with substantial research emerging only recently. During the 2013 Boston Marathon Bombing, first responders resorted to using improvised tourniquets due to the unavailability of commercial ones. These improvised tourniquets lacked windlasses, yet no fatalities were reported among the treated casualties. However, a 2015 study indicated that non-windlass improvised tourniquets failed in 99% of controlled conditions. The use of an improvised strap-and-windlass tourniquet showed only 68% effectiveness, which is below the 80% reliability threshold (1). Casualties survived in spite of the ineffective improvised tourniquets.

This incident suggests that commercial tourniquets such as the CAT (Combat Application Tourniquet) or SOFT-TW (Special Operations Forces Tactical Tourniquet) are significantly more effective than improvised alternatives. Should an improvised tourniquet be necessary, incorporating a windlass-based method is advisable.

Even commercially applied tourniquets can fail when used without proper training. Common reasons for failure include insufficient tightness (74.1%), incorrect application technique (44.4%), and improper positioning (16.7%). Studies have shown that the effectiveness of the CAT tourniquet, which is highly efficient when used by trained responders, dropped to approximately 10% when applied by untrained individuals (2). It is reasonable to infer that improvised windlass tourniquets would exhibit similarly high rates of failure under similar conditions compounding their failure rates.

These high rates of failure make it difficult to justify NOT including a commercial tourniquet such as the CAT (Combat Application Tourniquet) or SOFT-TW (Special Operations Forces Tactical Tourniquet) in your emergency medical kit. Moreover, improvising tourniquets will require significant training and practice to be even moderately (68%) effective. Courses such as CTOMS Academy - Emergency Bleeding Control can help minimize common tourniquet errors when supplemented with practice.

In the event of an emergency in an Asian restaurant, two bamboo chopsticks can serve as an effective windlass without breaking before achieving occlusion (3). Just so you know! 

Sources:

1.    Altamirano, M. P., Kragh, J. F., Aden, J. K., & Dubick, M. A. (2015). Role of the windlass in improvised tourniquet use on a manikin hemorrhage model. J Spec Oper Med, 15(2), 42-6.

2.    Elliot M. Ross, Julian G. Mapp, Theodore T. Redman, Derek J. Brown, Chetan U. Kharod, David A. Wampler, The Tourniquet Gap: A Pilot Study of the Intuitive Placement of Three Tourniquet Types by Laypersons, The Journal of Emergency Medicine, Volume 54, Issue 3, 2018,

3.    Kragh JF, Wallum TE, Aden JK, Dubick MA, Baer DG. Which Improvised Tourniquet Windlasses Work Well and Which Ones Won’t? Wilderness & Environmental Medicine. 2015;26(3):401-405.