3D printed open source tourniquet: Rationale, failure analysis and proposed next steps of the Glia tourniquets during the Gaza protests (May 11)

Tourniquets ready for packaging. Source: Glia. License: CC-By-SA

Why we need a 3D printed tourniquet

The Gaza Strip has faced three wars in the past decade with a total death count of at least 3,800 and 17,195 injuries. The majority of casualties were civilian[1–5]. Informal observations by physicians in Gaza indicate that many fatalities and casualties could have benefited from bleeding control techniques in the prehospital setting.

A terrible decision to deal with a terrible situation: Why we deployed before we were ready

Work started a year ago and reached the field trial stage by early 2018. Glia’s 3D printed tourniquet could be manufactured in Gaza at a cost of 25 NIS (USD$7) and worked well in the lab and in initial field trails. By February 2018, it was obvious that a mix of economic and political factors would make this year’s peaceful protests leading up to May 15th larger than ever before, which raised the potential of violent Israeli suppression of the protests. Our team decided to produce the latest prototype design in quantity and stop work on all other projects. The Hayat Center held weekly training for paramedics, which continues until today.

Tourniquet training at Hayat Center. Gaza, 2018. Source: Glia. License: CC-By-SA
Left: Obvious lower limb injury with marked blood loss in patient Abdulrahman Nofal in Gaza, April 17, 2018. This patient had hemorrhagic shock upon arrival at the ED. He survived with an amputation. Photo from Alray. Right: Distribution of injuries by location. Source: Palestinian Ministry of Health
Improvised tourniquet, Gaza 2018. Source unknown

Deployment on May 11, 2018

We prepared approximately 350 tourniquets. One hundred of these were used in the initial trial runs, trainings and other field testing. 150 were deployed to the field in two stages: 59 on May 11 at the main Gaza protest site, and 90 held in reserve for May 14th and May 15th. 100 more were delivered to the Hayat Center on May 12th for further training and distribution.

Field training on the use of trauma tourniquets. Gaza, 2018. Source: Glia Project. License: CC-By-SA

Failure #1: There are no ideal operating conditions

We dry-tested the tourniquets in laboratory conditions. Even in initial paramedic field trials, tourniquets were generally deployed in single-victim situations with controlled scenes.

Left: Israelis launch teargas at protestors using a vehicle-mounted launcher. Right: A gunshot victim with an open tib-fib fracture and partial amputation of his left leg proximal to the ankle is being lifted by his friend. His friend was stopped from lifting him so we could deliver rapid primary treatment before evacuation. Source: AFP via El Comercio[1][2]

Failure #2: The packaging was designed badly

Failure #3: We deployed an old model we knew had the potential for internal belt failure

New model tested to failure on manikin. Source: Glia. License: CC-By-SA
Top: Recovered windlass of old model used on patient that failed catastrophically. Note sharp edge in belt slot. Bottom: New model. Note curved edges.
First responder applying manual pressure after catastrophic tourniquet failure in patient with left proximal thigh gunshot wound. Source: Glia. License: CC-By-SA

Failure #4: An unexpected buckle failure

A buckle failed on a moderately critical patient while in the first phase of application (tighten belt and velcro) while using the latest model of tourniquet. We have not seen this in any of our testing and did not expect it. Another tourniquet was applied to the patient and behaved normally. I recovered the pieces of the tourniquet for proper dissection in our lab.

Conclusions

The first large deployment of open source, 3D-printed tourniquets in a battlefield setting has been well-received by patients, bystanders and first responders. We also revealed several moderate and critical errors in the device and our thinking that we will hopefully remedy over the coming days and weeks.

Edit log

2018–05–12 2304h UTC-04: Added rationale re: pediatrics

--

--

Get the Medium app

A button that says 'Download on the App Store', and if clicked it will lead you to the iOS App store
A button that says 'Get it on, Google Play', and if clicked it will lead you to the Google Play store
Tarek Loubani

Tarek Loubani

Tarek is an emergency physician at London Health Sciences Centre (Canada) and Shifa Hospital (Gaza). He is a member of the Glia team making open medical devices