I base my opinion on their description of the model (emphasis mine):
These pigs are very sick; not exactly a classic EMS patient. I am intimately aware and understanding of the limitations of animal models (I work with a mouse model of inhalation injury/ARDS - no models are perfect) but these pigs are in rough shape.
Even in the setting of acute coagulopathy in the field, the benefit of hemostatic vs. regular gauze is relatively minor. Very sick patients have much bigger problems; IV access, time to ED/OR, IV fluid resuscitation, etc will be greater determinants of outcome. Sure, you can use it and it may be superior to standard gauze, but it won't save your ass.
Anecdotally, the coagulated patient I had with a big forehead bump/lac didn't respond at all to hemostatic dressing, even after I threw a figure 8 on a small arterial bleeder and put in a couple of deeps to bring the subQ tissue together. Had to apply pressure on his head for 45 minutes, during which he vasovagal'd on me and I thought he died, lol. Got to hit the code button.
Uh, it's actually not quite as black and white as you think. Also part of my objection to the article.
Here is how the authors defined their endpoint for hemostasis:
So, they apply dressing and pressure for 2 minutes, remove for 5 minutes, observe for bleeding. If bleeding, do this again. If it bleeds again, failure.
I don't know about you, but I cannot envision a pre-hospital scenario in which pressure is applied at such intervals, nor do I think a study designed in this fashion really tells me very much at all.
See above; even if it was a junctional bleed, I don't think the article you linked really tells me anything about how useful hemostatic gauze is vs. standard gauze.
re: confounders; they can easily expand into other groups: TQ + standard gauze (SG); TQ + hemostatic gauze (HG); SG only; HG only; negative control. Costs more, sure, but it's not at all a ridiculous suggestion.
...The PDF I linked are the most recent (I believe) recs from the American College of Surgeons Committee on Trauma (ASCOT). Frank Butler (Chair of the CoTCCC) is an author. Their positions are not inconsistent. In fact, that text of PDF is basically identical to guidelines by the
NHTSA, who had similar complaints about the available data (but also endorse their use anyway):
A total of 15 articles were reviewed to establish their position (p169) on hemostatic agents (participant n = ~2000); more than a few, on par with the
# used by TCCC to establish their (similar) guidelines (pS42).
TLDR: hemostatic gauze may be better then standard gauze but the evidence for this conclusion is weak, and the benefit likely to be incremental vs. standard gauze. I think there are other new-ish technologies that are a lot more impactful for professionals (like the EZ-IO, use of ketamine for prehospital sedation/chemical restraint); similarly, for the non-professional first responder, the incremental advantage of hemostatic gauze will be less significant than solid first aid/CPR fundamentals and getting them to a hospital ASAP.