The Tourniquet Gap

The 2016 White House Stop The Bleed (STB) initiative was created to address specific medical issues surrounding the alarming increase in U.S. mass casualty Incidents (MCIs). Supported by recommendations from the Hartford Consensus1and lessons learned during military combat,2,3 the STB initiative seeks to: 1) train laypersons to provide hemorrhage control; and 2) strategically place hemorrhage control supplies in public spaces at highest risk for an MCI.

National health organizations and industry leaders have embraced this well-constructed initiative. From this effort, there’s been some increase in STB training initiatives as well as active public awareness campaigns. There have also been large donations of hemorrhage control supplies for placement in public spaces. 

However, there remains a significant, and as of yet unaddressed, gap in this initiative: Most laypersons can’t use the currently available tourniquets without proper training.4,5

The Delay in Public Health Campaigns

It’s well-known that there’s a delay in public health campaigns between the educational intervention and the increase in desired health behaviors.6 We’ve seen this delay in bystander CPR efforts.7 Seeing a measurable difference requires a significant investment in education before a community will appreciate an increased rate of bystander CPR. 

This dilemma has been directly linked to the public’s fear of harm (for both the patient and the layperson) related to inadequate training8 for the medical emergency at hand.

Knowing this, medical professionals and industry leaders worked hard to engineer an AED that untrained persons could operate.9,10 Engineering efforts like this were also successful in the development of auto-injectors for naloxone.11

Following the same reasoning that led to the acceptance of AEDs and auto-injectors, why can’t we develop a more suitable, intuitive tourniquet for the lay public? 

An Effective Lifesaving Device

There’s no doubt that current commercially available tourniquets are effective when used correctly. Thanks to research by military medical leaders and scientists,2,3 we have substantial evidence that, in the hands of well-trained personnel, tourniquets save lives. 

The same lesson has been demonstrated in the civilian setting when tourniquets are placed in the hands of trained law enforcement, fire and emergency medical personnel.12—14 The significant difference between the professionals in harm’s way and the lay public, then, is specialized, specific and determined training.

Appropriate Engineering Technology

Only in relatively recent times has the U.S. military switched from using a World War II-designed strap and buckle tourniquet.15 These devices lacked the mechanical advantage necessary for adequate arterial occlusion that modern devices employ.

Since the early 2000s, improved devices have been developed by researchers, service members and industry to save lives. This cooperative effort to create and deploy the right tools has been accomplished on a global scale.

Unfortunately, a true layperson tourniquet has yet to be designed. Recent research points out that today’s commercial tourniquets, in the hands of untrained users, have successful application rates of 16—20%,4,5 which are far below the rates for successful layperson operation of an AEDs or autoinjectors.9-11

By applying appropriate engineering technology to hemorrhage control devices, we may save thousands of lives in this country, and beyond.

Educating the Public

The greatest value to public safety and health is large-scale education.16 However, until we reach a critical mass of trained individuals, bystanders are ill-equipped and ill-prepared to respond when the next emergency occurs.

If we’re going to ask the lay public to respond, aren’t we, as medical professionals, obligated to provide them with best tools to manage their problem? In the simplest terms, we need to create a bleeding control device that’s “so easy even a child could use,” and provide the training to use it correctly.


  1. Jacobs LM, McSwain Jr NE, Rotondo, et al. Improving survival from active shooter events: the Hartford consensus. J Trauma Acute Care Surg. 2013;74(6):1399—1400.
  2. Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating preventable death on the battlefield. Arch Surg. 2011’146(12):1350—1358.
  3. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001—2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6):S431-S437.
  4. Goolsby C, Branting A, Chen E, et al. Just”in”time to save lives: A pilot study of layperson tourniquet application. Acad Emerg Med. 2015;22(9):1113—1117.
  5. Ross EM, Mapp JG, Redman TT, et al. Placement of three tourniquet types by laypersons: A pilot study. Unpublished Data.
  6. Farquhar JW, Fortmann SP, Flora JA, et al. Effects of communitywide education on cardiovascular disease risk factors: The Stanford five-city project. JAMA. 1990;264(3):359—365.
  7. Panchal AR, Panchal BD, Stephens J, et al. Survey analysis of a statewide CPR initiative: Willingness in comparison to median income and training. Circulation. 2014;130(Suppl 2):A123.
  8. Hamasu S, Morimoto T, Kuramoto N, et al. Effects of BLS training on factors associated with attitude toward CPR in college students. Resuscitation. 2009;80(3):359-364.
  9. Williamson LJ, Larsen PD, Tzeng YC, et al. Effect of automatic external defibrillator audio prompts on cardiopulmonary resuscitation performance. Emerg Med J. 2005;22(2):140—143.
  10. Mosesso VN Jr, Shapiro AH, Stein K, et al. Effects of AED device features on performance by untrained laypersons. Resuscitation. 2009;80(11):1285-1289.
  11. Elzey MJ, FudinJ, Edwards ES. Take-home naloxone treatment for opioid emergencies: A comparison of routes of administration and associated delivery systems. Expert Opin Drug Deliv. 2017;14(9):1045-1058.
  12. Schroll R, Smith A, McSwain NE Jr, et al. A multi-institutional analysis of prehospital tourniquet use. J Trauma Acute Surg. 2015;79(1):10-14.
  13. Kue RC, Temin ES, Weiner SG, et al. Tourniquet use in a civilian emergency medical services setting: A descriptive analysis of the Boston EMS experience. Prehosp Emerg Care. 2015;19(3):399-404.
  14. Inaba K, Siboni S, Resnick S, et al. Tourniquet use for civilian extremity trauma. J Trauma Acute Care Surg. 2015;79(2):232-237.
  15. Kragh JF Jr, Walters TJ, Wesstmoreland T, et al. Tragedy into drama: An American history of tourniquet use in the current war. J Spec Oper Med.2013;13(3):5-25.
  16. Hansen CM, Jollis JG, Dupre M, et al. Improved rates of bystander and first-responder intervention are associated with improved survival after out-of-hospital cardiac arrest following statewide quality improvement initiative. Circulation. 2014;130(Suppl 2):A23.
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