Tourniquet simulation

Education in emergency response to trauma is a global health priority [1]. Mortality rates are nearly twice as high in patients with trauma in low-income as compared to high-income countries [2]. With uncontrolled bleeding as the number one cause of death from trauma, tourniquet application has been the focus of training programs, like the “Stop the Bleed” campaign in the United States [3]. Although understanding how to apply a tourniquet is a life-saving intervention, use of a windlass tourniquet may not be intuitive [4].  The windlass tourniquet in its simplest form is the “stick-and-rope.” Winding the stick in the tourniquet creates a mechanical advantage for providing compression. Simulation of the windlass technique can be used to teach management of uncontrolled bleeding. Here we describe a low-cost simulation model that combines low- and high-fidelity techniques to train healthcare personnel on windlass tourniquet application.

The Innovation

The “bleeding arm simulation” requires minimal resources to train participants in tourniquet application. Trainees learn through two phases; a low-fidelity skills station combined with a higher-fidelity “bleeding arm model” simulation.

Target Learners

This simulation model was designed for all levels of health-care workers. Our targeted audience included sixty nurses and clinical officers in a resource-limited setting in rural Uganda. However, our model can be used to train healthcare providers, first responders, or even lay-persons throughout the world.

General Group Size

Ideal group size includes 4-6 learners. Following a discussion of indications for application, safety, and technique, the group practices skills through low-fidelity simulation on foam pipe insulation. Then, each participant rotates individually through a high-fidelity simulation using the “bleeding arm model.”

Required Materials

The windlass tourniquet requires:

  • A strip of cloth
  • A pen/marker/stick

The simulated “bleeding extremity” requires:

  • Skeleton arm (e.g from a Halloween store). A PVC pipe or broom handle can alternatively be used.
  • Foam pipe insulation (approximately 2-3” in diameter)
  • Tubing from a nasal cannula
  • Penrose drain
  • A plastic water bottle with its associated cap
  • Duct Tape

The Technique

Create a “bleeding arm” model

  1. Poke a hole in the cap of a plastic water bottle. The hole should be slightly smaller than the diameter of the nasal cannula tubing.
  2. Cut one end of the nasal cannula tubing at the point just before it widens to become the nasal prongs. Slide tubing through the water bottle cap until the larger end that typically connects to oxygen source catches. Seal the tubing to the cap in place with duct tape.
  3. Slide penrose drain over nasal cannula tubing and tape it well with duct tape to connect the two with a strong seal.
  4. Loosely tape the penrose drain to the simulated “arm.” For our model, we taped penrose to the humerus of a plastic arm from a Halloween skeleton. Alternatively, you can use a PVC pipe or broom handle.
  5. Secure foam pipe insulation around the arm and penrose drain with a rubber band.
  6. Tint water with food coloring or powdered drink mix, fill bottle with water and screw cap onto bottle.
  7. Hold the water bottle upside down above the level of the arm such that gravity causes it to pass through tubing and out of the end of the tubing, simulating hemorrhage.

Figure 1: Steps to creating the Bleeding Arm model

Tourniquet Skills Station

At the skills station, participants create a windlass tourniquet using a piece of cloth and a marker, and then apply the tourniquet to a piece of foam pipe insulation. If needed, a pen or stick can be used in place of a marker. Participants then complete the following steps:

  1. Tie a strip of cloth around the foam pipe insulation.
  2. Tie a second knot. Prior to tightening the knot, place a pen/marker (or stick) through the loop.
  3. Once in place, secure the knot over the marker such that the marker is in the middle of the knot.
  4. Lastly, twist the marker clockwise. Demonstrate on the foam pipe how this clockwise turning creates compression of the foam pipe.

Figure 2: Low-fidelity windlass tourniquet skills technique

Bleeding Arm Model Simulation

Following the skills station, participants complete the “bleeding arm model” simulation during which they are presented with a clinical scenario that involves a patient hemorrhaging following a traumatic injury. The person running the simulation elevates the upside-down water bottle such that water (“blood”) flows from the model. Ideally, perform this portion outdoors and/or over a trash can to avoid spilling “blood” all over the floor. Participants are required to use the knowledge learned in the skill station to appropriately apply a windlass tourniquet to the model. Due to the thickness of the foam layer, the penrose is difficult to compress simply by tying a knot in the tourniquet and a windlass technique is required to successfully compress the model enough to stop the “bleed.”

Figure 3: The Bleeding Arm high-fidelity simulation scenario in action

Lessons Learned

  • Participants learned the skill well from the low-fidelity skill station, but appeared more enthusiastic and engaged during the high-fidelity “bleeding arm model” component of the training.
  • Hands-on simulation seemed to be especially beneficial for improving comprehension for those with less English fluency as compared to oral presentations.
  • Performing the activity outside or having a trash can handy to catch the water will help reduce mess.

Educational Theory

Simulation is a commonly used teaching strategy in medical education. Although access to simulation in low- and middle-income countries is limited, often due to cost, evidence suggests that it improves knowledge, skills, and patient outcomes [5-8]. Both low- and high-fidelity simulation models have unique benefits. High-fidelity models offer healthcare workers realistic simulation environments, whereas low-fidelity models are often easier and less expensive to create. Tourniquet application saves lives. By combining low- and high-fidelity simulation techniques and incorporating low-cost materials, this “bleeding arm model” can teach individuals how to prevent unnecessary morbidity and mortality in trauma patients.


Want more clever educational didactics? Check out the IDEA series. 

  1.   World Health Organization. Resolution WHA 72.16: Emergency care systems for universal health coverage: ensuring timely care for the acutely ill and injured. Accessed February 12, 2020.
  2.   Mock C N et al. Trauma mortality patterns in three nations at different economic levels: implications for global trauma system development. J Trauma 1998;44(5)804–814. PMID: 9603081
  3.   Pons P T, Jacobs L, SAVE A LIFE: What Everyone Should Know to Stop Bleeding After an Injury © 2017 American College of Surgeons. Accessed February 12, 2020.
  4.   Dennis A et al. Missing expectations: Windlass tourniquet use without formal training yields poor results. J Trauma Acute Care Surg. 2019;87(5):1096-1103. PMID: 31274827
  5.   Puri L et al. Enhancing quality of medical care in low income and middle income countries through simulation-based initiatives: recommendations of the Simnovate Global Health Domain Group. BMJ Simulation and Technology Enhanced Learning 2017;3:S15-S22. DOI: 10.1136/bmjstel-2016-000180
  6.   Mduma E et al. Frequent brief on-site simulation training and reduction in 24-h neonatal mortality—an educational intervention study. Resuscitation. 2015;93:1-7. PMID: 25957942
  7.   Walker D et al. Team training in obstetric and neonatal emergencies using highly realistic simulation in Mexico: impact on process indicators. BMC Pregnancy Childbirth 2014;14:367. PMID: 25409895
  8. Mikrogianakis A et al. Telesimulation: an innovative and effective tool for teaching novel intraosseous insertion techniques in developing countries. Acad Emerg Med 2011;18:420–7. PMID: 21496146




Lacey MenkinSmith, MD CTropMed

Lacey MenkinSmith, MD CTropMed

Assistant Professor of Emergency Medicine
Global Emergency Medicine Fellowship Director
Medical University of South Carolina
Lacey MenkinSmith, MD CTropMed

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Richard Tsen, MBBS

Richard Tsen, MBBS

Global Emergency Medicine Fellow
Medical University of South Carolina
Richard Tsen, MBBS

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Logan Wolford, MD

Logan Wolford, MD

Resident Physician of Emergency Medicine
Medical University of South Carolina
Logan Wolford, MD

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