He knew the homeowner possessed firearms, not that it worried him. In Colorado, a police officer nervous to visit a home with a gun was in the wrong line of work.
Officer Jonathan Key flicked off his patrol car’s headlights and slowed down as he neared the brick duplex on West Jewell Place. He planned to stop short of the home, four houses or so back, and walk the rest of the way. But before he had a chance to park, he heard a loud pop-pop-pop. Then all he could see were sparks and dust.
Did someone just shoot fireworks at my car? he wondered, his mind racing to make sense of the chaos.
It was, after all, July 5, the day after Independence Day. Perhaps some still-drunk yahoo thought it would be fun to light up a police car with a leftover roman candle.
Shaking off his initial confusion, Key fell back on his training. Assess the situation.Check for injuries. That’s when he noticed the blood. It arced from his left arm at the elbow, strong and steady, a thick red parabola. This was supposed to be a routine call, a welfare check on some middle-age guy upset about his failing marriage. What the hell was happening?
Key had been dispatched to the home 20 minutes earlier by the Lakewood Police Department, after a woman called 911 to express concern about her husband. The couple had been fighting all day, and the husband, after concluding the relationship was damaged beyond repair, said he no longer wanted to live. But there was something Key didn’t know.
The husband had later made a 911 call of his own, saying there was a guy outside his home with a gun, “ready to kill a bunch of people.” When the dispatcher asked the husband where he was located in relation to the armed man, his response was curt: “I’m the guy with the gun.”
Realizing he’d been shot, Key abandoned his car and retreated west, a trail of blood marking his path. Get to a safe place. Heading for a row of cars for shelter, he grabbed the mic attached to his uniform to radio for help.
Shots fired. I’ve been hit.
His driverless vehicle coasted east, bouncing off a green Subaru Outback before colliding with a red Ford pickup. From the bed of that truck, moments before, the distraught husband had fired three rounds from a semi-automatic rifle into Key’s car.
Key didn’t know if he was bleeding from an artery or a vein, but he knew he was losing a lot of blood, and quickly. His uniform had already soaked through. He also knew it didn’t take long, minutes in some cases, for severe bleeding to turn into fatal bleeding.
From his bulletproof vest, Key detached a tourniquet. Not many officers carried one, but a few guys in his department had previously been in the military, where tourniquets are standard issue. They had recently shown him how the device worked and piqued his interest. Shortly after, he completed a day-long course and learned how to use the modern tourniquet, which was designed for soldiers in combat to apply with one hand.
Are you kidding me? Key thought. I just got this training and I have to use it already. On myself.
All across Lakewood, wailing police vehicles screeched toward West Jewell Place, where the man, now holding a .44 Magnum, would soon be subdued, though not before wounding another officer. Meanwhile, 32-year-old Jonathan Key, who had no plans of leaving his young son fatherless, no intention of making his pregnant wife a widow, placed the tourniquet around his left biceps, above the wound, and turned the small attached rod to draw it tight.
The bleeding stopped.
Everybody bleeds. We bleed from inflamed gums, irritated noses and skinned knees. We bleed from nicks, from scrapes, from piercings. We bleed when paring knives slip, when surly cats scratch, when wayward baseballs miss gloves and find teeth.
Most times, the bleeding is minor, stopping on its own or with the aid of nothing more than a bit of cloth and a touch of pressure. Of more concern are the other times, less frequent but frequent enough, when the bleeding is anything but trivial. The bleeding may be internal: a blood vessel tears after a fall from a ladder; a spleen ruptures in a car crash. It may be external: a faulty machine severs a factory worker’s leg; a desperate man shoots a police officer in the arm.
Wherever it is and whatever the cause, severe bleeding can turn a dire situation deadly in a hurry if not brought under control. You might think that we had by now learned pretty much all there is to know about how best to curb blood loss, considering that we’ve been bleeding for millennia, and rarely by choice. Alas, there is still much to learn. Uncontrolled hemorrhage remains a major cause of preventable death following injury.
But why is that? Why aren’t we better at preventing blood loss at the scenes of accidents, shootings, explosions and car crashes? Well, let’s just say that trauma care, unlike many areas of medicine, isn’t exactly a hotbed of innovation. In fact, it may not have advanced at all over the past decade if not for two things: the war in Afghanistan and the war in Iraq.
“Wars always advance trauma care, and those advances come back to the civilian world and help civilians,” says Dr. John Holcomb, former head of the U.S. Army’s Institute of Surgical Research, who served 23 years as a military trauma surgeon. “In between wars, what should happen is that we enhance trauma care in the civilian sector, so that when a war starts, and it will again, because human nature hasn’t changed, we can start the war with the highest-quality trauma care possible for soldiers, sailors, airmen and marines.”
If the past is any indication, however, peacetime innovation is unlikely. Throughout history, new ideas on how to keep victims of major trauma alive have almost exclusively come from wars. “He who would become a surgeon should join the army and follow it,” the Greek physician Hippocrates wrote thousands of years ago. The same could be said today. The currency of change in trauma medicine remains the blood of soldiers.
In the civilian world, injuries are the leading cause of death for people under age 45, accounting for more than 10,000 annual deaths in Canada and nearly 190,000 in the U.S. Because it is a disease of young people, trauma is far and away the leading cause of life years lost.
The rise in recent years of mass-casualty events, such as the 2013 bombings at the Boston Marathon, has prompted some interest in improving emergency medicine. It is becoming increasingly common, for example, for paramedics, firefighters and police officers in the U.S. to carry military-grade tourniquets. And as the recent attack on Parliament Hill showed, even Canada isn’t immune to an active-shooter emergency. Still, funding for trauma research in North America pales in comparison to money invested in studies for cancer, HIV/AIDS and many other diseases.
The paucity of trauma research outside war also means soldiers are far more likely to die from survivable wounds at the beginning of a lengthy conflict, before medical personnel have opportunity to adapt to particular wound patterns, such as the havoc wreaked on limbs by improvised explosive devices. In the Vietnam War, bleeding from extremities was the number one cause of preventable death, accounting for between seven and eight per cent of all fatalities. Thirty years later, during the early stages of the wars in Afghanistan and Iraq, the percentage of soldiers dying from wounds to legs and arms was virtually the same.
Eventually, however, that figure dropped by two-thirds, to less than three per cent, thanks in part to innovative products to control hemorrhaging on the ground, such as bandages that promote blood clotting, which allowed soldiers to survive long enough to reach operating tables in combat surgical hospitals. But the change responsible for saving the most lives, hundreds or even thousands by some estimates, was not the introduction of a brand new device but rather the modification of an ancient one that, for reasons based more on myth than fact, had long ago fallen out of favour.
“The tourniquet would be number one,” says Colonel Homer Tien, a Toronto surgeon who leads trauma research for the Canadian Forces.
The clatter of the Chinook helicopter, both blades spinning, added to the racket from the other eight or nine aircraft preparing for takeoff to create a thunderous roar. The noise was nearly deafening, Spc. Andrew Harriman noticed as he walked up the ramp at the rear of the helicopter.
It was not only loud on the ramp but dark as well, the red lights inside the door above doing little to guide Harriman and the soldier to his right, who was also boarding the Chinook. Nearing the entrance, the other soldier became entangled in a long wire that, somehow, had wrapped itself around the trigger of the machine gun mounted at the top of the ramp. Harriman had one foot in the helicopter when four .30 calibre rounds burst toward his left leg.
The bullets ripped through Harriman’s calf, six inches below the knee, breaking the fibula, destroying the tibia, pulverizing muscle and tissue and nerves. Harriman felt the leg snap. He fell off the ramp, landing in the blackness beneath the Chinook. His screams for help went unanswered, his voice no match for the din of the giant machines all around him. The soldiers close enough to have heard the shots had their backs turned to him, thinking they were under attack and taking positions to return fire.
Unable to see, Harriman reached for the injury to assess the damage. Blood gushed through his fingers.
Even if he was soon found, it would take 20 minutes, minimum, to fly to the emergency room at Camp Warhorse in Baqubah, more than enough time to bleed out. Of all the 300 or so soldiers here in the village of Quba, it was Harriman, only 23 but already a senior combat medic, who knew the dangers of uncontrolled blood loss.
He had seen his share of carnage since arriving in Iraq seven months earlier, none worse than on a mid-January morning in the south of Diyala Province. A flatbed truck travelling with his unit, carrying about 30 Iraqi soldiers, had gone up in smoke and fire after tripping an anti-tank mine. Harriman was the first medic on the scene, and he was greeted with utter chaos: dead bodies, severed limbs, desert sand wet with blood. He scrambled from soldier to soldier, using all 11 of his tourniquets to give each man a fighting chance of survival. His actions saved many lives that day, including the life of a man who lost two legs and an arm in the blast.
Now it was time to save his own life. Harriman pulled a tourniquet from a pocket, though he wasn’t sure where to place it. It was supposed to go two or three inches above the wound, but he couldn’t see a thing, including the exact location of the injury. He knew it was on the lower leg, but how low? Putting the tourniquet on the knee wasn’t an option; the pressure would crush the joint.
Harriman had no way of knowing how this situation would play out. He didn’t know soldiers would find him seconds later. He didn’t know he would soon be bouncing from Camp Warhorse to Germany and then back home to the U.S. He didn’t know he would undergo eight surgeries over the next four weeks, or that he would eventually walk again without trouble, though his running days were over.
At that moment, lying in the dark with a hole in his leg, his only concern was the problem at hand. Stop the bleeding. To be safe, he placed the tourniquet fairly high, midway up the thigh. It usually took three turns of the rod to create enough pressure to halt blood flow, but he couldn’t see if that did the job. So, despite the excruciating pain of further compressing the tissue beneath the already tight black strap, Harriman twisted the rod twice more.
The bleeding stopped.
It did more harm than good. It damaged soft tissue, destroyed nerves. It starved limbs of blood and oxygen and led to amputations. It was, the Journal of the Royal Army Medical Corps suggested in 1916, an invention of the devil.
Throughout its history, which dates back to the Roman Empire, the tourniquet has had its share of detractors. In the Second World War, many medics believed the device was the primary reason wounded soldiers were losing limbs. That stigma persisted, and tourniquets were used sparingly during the Vietnam War.
The problem, however, was not with the concept but rather with the application. Tourniquets were inconsistent in make, often improvised with belts, tubing, cloth, sticks or whatever materials were on hand. They were applied too far from the wound. They were too narrow, or too tight, or too loose. Worst of all, they were left on far too long, for many hours or even days, allowing gangrene to set in.
“For years, tourniquets were considered an absolute last resort,” says Dr. Peter Pons, an emergency physician in Denver and the associate medical director for the National Association of Emergency Medical Technicians. “What we learned from the wars in Iraq and Afghanistan is that a proper tourniquet can be used safely and effectively.”
In 2005, the U.S. Army Institute of Surgical Research tested seven tourniquets. It eventually settled on the Combat Application Tourniquet, or C-A-T, a lightweight device with a wide, self-adhering band that uses a one-handed windlass system to apply consistent pressure around the circumference of a limb. Every deployed soldier now carries one.
A 2011 military study of 862 tourniquets applied on 651 limbs found that a superior product combined with quick transport to combat hospitals saved lives with minimal risk. The survival rate was 87 per cent. No amputations resulted solely from the use of tourniquets.
The wars in Iraq and Afghanistan have also resulted in the creation of numerous other products and practices to control blood loss. Since 2008, the first aid kit of every U.S. soldier has contained hemostatic gauze impregnated with kaolin, a clay that prompts the body’s blood coagulation response. More recent innovations include a pocket-sized injector filled with tiny sponges that expand when inserted into a wound, an abdominal-aortic tourniquet for pelvic wounds and a junctional tourniquet for injuries too high on a limb for the C-A-T.
Another change credited with saving the lives of many soldiers is the evolution of blood transfusion in Iraq and Afghanistan. In the beginning of the wars, soldiers with massive blood loss were given saline, then red blood cells, then maybe plasma ─ but rarely platelets, the cells that allow blood to clot. The results were dismal. By 2010, when almost all transfusions were performed with equal parts plasma, platelets and red blood cells, those outcomes had vastly improved.
“Every major trauma centre in the United States does this now, and most in Canada and even in Europe,” says Lt. Col. Andrew Cap, chief of blood research for the U.S. Army Institute of Surgical Research. “We understand the importance of maintaining the clotting function and not getting behind on that, and that concept has totally permeated trauma care around the world.”
Yet another example of how civilian lives have been saved by blood spilled in war. With the war in Iraq over and the conflict in Afghanistan nearing its end, some military physicians wonder if the civilian world will return the favour by continuing to invest in trauma research. Or will innovation once again stagnate until the next bloody conflict? It took several years of bloodshed in Iraq and Afghanistan to learn that a tourniquet ─ $30 worth of nylon, plastic and velcro ─ could be the difference between life and death on the battlefield. For many young soldiers, that was a lesson learned far too late.
The day was coming to an end, and the soldiers were looking forward to the comforts back at the air base when they received new orders. Insurgents had just fired rockets at the city of Kirkuk. Find them.
Minutes later, the 14 soldiers were sitting in three Humvees driving down a dark back road when the insurgents found them. The convoy was pummelled with rocket-propelled grenades and gunfire. The first two vehicles managed to speed through the ambush; the last one didn’t make it.
Spc. Joshua Sams, the driver of the third Humvee, turned off the headlights and accelerated. He leaned low and left, away from enemy fire, his body hanging out the doorless, driver-side opening. He could hear other soldiers in the vehicle returning fire. Swerving to avoid a grenade, Sams missed a turn in the road and was thrown from the vehicle as it plowed into a field.
His body armour caught on the Humvee, which dragged him 20 metres before coming to a stop. Sams tried to move but couldn’t. His arm was stuck under a wheel of the 1,100-kilogram vehicle.
The gunfire had stopped, and in the quiet Sams shouted for help.
Out of the dark stumbled 1st Lt. David Bernstein, a popular soldier whose love of physical fitness had earned him the nickname Super Dave. Bernstein attempted to climb into the Humvee but fell back onto the ground. He tried again; he fell again. Finally, on his fifth attempt, Bernstein managed to get behind the wheel and back up the vehicle, freeing Sams, before tumbling out and into the dirt once more.
Sams went to Bernstein and discovered the lieutenant had been shot in the left leg, above the knee. He tied a field dressing around the wound, and left briefly to check on the other two soldiers in the back of the Humvee. One was dead, shot in the neck, but the other was unharmed. Sams told him to stand guard in case the insurgents attacked again.
He returned to Bernstein, kneeling down to take a better look at the wound. His pants were instantly drenched in blood. Sams realized the lieutenant wouldn’t last long if he didn’t stop the bleeding. He looked for a stick to use in a make-shift tourniquet but couldn’t find one. So he grabbed the nozzle from a can of fuel and used that to twist a field dressing tight around the leg. It didn’t work.
Sams cut the strap off a rifle and twisted it around Bernstein’s leg, but it was too short and kept coming undone. His options exhausted, Sams tied a field dressing over the rifle strap to secure it. Without access to a proper tourniquet, it was the best he could do.
Soldiers from the other Humvees had by then returned and spotted them. As they approached, Sams checked Bernstein for a pulse. There wasn’t one. The 24-year-old lieutenant ─ high school valedictorian, fifth in his class at West Point, future recipient of a Silver Star for bravery in action ─ had lost too much blood.
His heart had stopped.