From Aesop at Raconteur Report, Medical Tip: Tourniquets Work reminds you to get tourniquet training if you don’t have it already.
One of the local constabularies recently encountered Nameless Crazy Person with butcher knife in hand, agitated and in a stabby mood. Despite repeated commands, NCP refused to drop knife, and/or broke the containment bubble, whereupon officer plugged NCP. Unknown number of rounds fired, but two connected.
One to each arm. (-25 points for lousy marksmanship at knifefighting – which is knifefight dying – distance. Bonus points for unintended humanitarian efforts.)
One nicked the right outer bicep. Literally, a flesh wound. Rub some dirt on it (or, in this case, a wad of 4x4s) and walk it off. No harm, no foul.
Other round: in the stabby knife-wielding arm, 9mm or 40SW pellet entered the upraised left arm proximal to the inner elbow, and travelled along the near-horizontal upper arm, and exited just below the left armpit (axilla for medical types).
Neither round close to anything obviously vital, except…
Round #2, during its journey through the meaty bicep area, must obviously have punctured/torn/lacerated the L brachial artery, i.e. the one what all the blood from Mr. Heart travels in to arrive in the rest of Mr. Arm.
Result: a steady blurp-blurp-blurp of bright red blood, all over the ground.
To his everlasting credit, Constable quickly applied first an Israeli Battle Dressing to the arm of the now knifeless suspect, to whom the application of lead had reduced his crazy efforts noticeably. Which IBD application slowed the blurp-blurp nary a whit.
So, reverting to academy-standard (nowadays) training, he whipped out his CAT Tourniquet, and lashed that sucker down just like in training videos, and turned off the blurp-blurp in about 6 twists of the windlass, despite the pained response from NCP.
Medics brought NCP to our world, where our trauma nurse and trauma doc were certain that applying a TQ was waaaaaay overkill, but “Bless their hearts for doing too much instead of too little”. So, they untwisted that TQ, and were immediately rewarded with blurp-blurp-blurp of bright red arterial blood, again.
I twisted the TQ back on and tightened it, and we sent NCP directly to trauma surgery for vascular repair, so that he could continue to be crazy with two functioning arms.
And I told the paramedics and the PD officer responsible for the TQ that they’d saved an actual life with that thing, because NCP would have died at the scene in about two minutes if they hadn’t tourniquetted off the flow of arterial blood from a “mere” arm wound. Which not only saved his life, it prevented about two trees-worth of resultant officer-involved homicide paperwork.
TL;DR:
Put the effing TQ on if the bleeding doesn’t stop with pressure, and make it holy by cranking the hell out of it.
You needn’t carry four TQs on your body, but you have four limbs, so if you like them, and you enjoy living, you’d be well-advised to have four TQs somewhere close by, like kit/pack/bag, etc.
Not at home in your medicine cabinet 20 miles away.
When you need one (or, God forbid, more than one) it will be Right Effing NOW, and not “in twenty minutes or so”.
If you’d rather ignore that advice: Suture self.
FTR, trauma literature based on medical trauma data from Sandbox I and Sandbox II have documented applications of as long as 4 hours before removal in surgery with no residual harm of any kind to extremities as a result of the TQ application, in young, otherwise-healthy, military-aged troops. YMMV, but they are not in any way “sacrificing a limb to save a life”, anytime in the last 20 years. If you’re within that time span for arrival at definitive medical care, and it’s medically justified, it’s better to slap one on than watch your patient exsanguinate and die.
And now, refresher training for those who wish it:
Eugene Nielsen at Spotter Up has a pretty comprehensive article on The EDC Tourniquet.
According to published research, reported in the October 2017 issue of the Journal of the American Medical Association (JAMA)), the average response time in the US from the time of a 911 call to arrival of EMS on scene was seven minutes. This increased to more than 14 minutes in rural settings. A person can bleed out from a severed femoral artery in less than five minutes. You do the math.
By the time EMS arrives it may be too late. You need to be your own first responder.. Photo: Public Domain.
In an active shooter or terrorist incident, emergency personnel won’t reach victims until the threat has been neutralized. During the Paris attacks on 13 November 2015, it was over 160 minutes from the time the terrorists fired the first shots in the Bataclan theater until the responding emergency personnel were able to reach those inside the venue.
The reality is that you’re going to be your own first responder. Bystanders will always be first on the scene, whether it be terrorism or other criminal act or an accident. In the Boston Marathon bombing on 15 April 2013, bystanders employed improvised tourniquets to save lives. Time consuming and inefficient, but it was all that they had. Don’t plan to improvise if the need arises. Always have a real tourniquet.
Data from the Boston Marathon Bombing found that six of the rubber and improvised type tourniquets had to be subsequently replaced with C-A-T® tourniquets. Additionally, the most common EMS tourniquet on scene consisted of rubber tubing and a Kelly clamp.
Roughly 80% of combat deaths and 50% of civilian trauma deaths are attributable to hemorrhage. It’s the most preventable cause of death in compressible injuries. The proper use of tourniquets saves lives.
Hypovolemic Shock
Time is of the essence. Hypovolemic shock occurs where there is an acute fluid or blood loss in the body. It’s a life-threatening emergency. Hypovolemic shock is most often secondary to rapid blood loss (hemorrhagic shock). It causes inability of the heart to pump the essential blood needed to the body, resulting in multiple organ failure due to inadequate cellular oxygenation. There are four stages of hypovolemic shock.
No, it’s not an ancient torture device, although Roman soldiers may have begged to differ. It’s a Roman thigh tourniquet circa199 BCE to 500 CE. It’s made from bronze. Photo: Welcome Collection. Licensed under the Creative Commons Attribution 4.0 License.
Stopping the blood loss before patient goes into Stage II shock, ie., blood volume loss up to 15% (~750 mL), keeps survivability at around 94%. If blood loss continues and the patient is in Stage II (30% or ~1500 ml) or greater, the survivability goes down to 14%, without any blood being administered. These figures are based on a US Army Institute of Surgical Research (USAISR) study conducted in 2006 and 2007.
Tourniquets
While I recommend that everyone carry a trauma kit, a tourniquet (and gloves) needs to become part of your everyday carry (EDC) at the at the very minimum. Tourniquets have emerged as the standard of care in the tactical environment due to their ease of use, rapid application, and complete stoppage of blood loss. Current protocol considers the tourniquet an initial lifesaving intervention to control massive hemorrhage from an extremity.
The old dogma of “save a life, lose a limb” has been proven to be false. A tourniquet can safely remain in place for up to two hours. Thousands of combat veterans are walking around today with all their limbs because their lives were saved by tourniquet use.
The use of tourniquets on the battlefield isn’t new. As far back as Alexander the Great’s military campaigns in the fourth century BC, tourniquets were used to staunch the bleeding of wounded soldiers. The term “tourniquet” dates from the 17th century and originated from the French “tourner” meaning “to turn”. .
Tourniquets have emerged as the standard of care in the tactical environment. Combat Application Tourniquet (C-A-T) is recommended by CoTCCC and standard issue to the US military. First responders and others are most likely to have trained with the C-A-T. Photo: North American Rescue.
Tourniquets lost popularity after the US Civil War, having been blamed for complications that resulted in amputation. This misunderstanding has unfortunately persisted, especially as it pertains to tourniquet use in civilian settings.
Although there have been several studies in the past that have looked at tourniquet use in civilian settings, the survival benefit for patients has been unclear. However, new research shows that for civilian patients with peripheral vascular injury, prehospital tourniquet use is associated with dramatically improved odds of survival.
The study, titled “Civilian Prehospital Tourniquet Use Is Associated with Improved Survival in Patients with Peripheral Vascular Injury,” was published 29 March 2018 and reported in the May 2018 issue of the Journal of the American College of Surgeons (JACS). This study was a multi-institutional retrospective review of all patients sustaining peripheral vascular injuries admitted to all 11 urban Level I trauma centers in the state of Texas from January 2011 to December 2016.
The study found that “Although still underused, civilian prehospital tourniquet application was independently associated with a 6-fold mortality reduction in patients with peripheral vascular injuries. More aggressive prehospital application of extremity tourniquets in civilian trauma patients with extremity hemorrhage and traumatic amputation is warranted.” Simply put, tourniquets save lives.
Popular commercial tourniquets include the Combat Application Tourniquet® (C-A-T®), SOF® Tourniquet, RevMedx® TX® Series Ratcheting Medical Tourniquet -Tactical™ (RMT-T™), SAM Extremity Tourniquet (SAM-XT™), Tactical Mechanical Tourniquet™ (TMT™), SWAT-T® and Rapid Application Tourniquet System®® (R.A.T.S.®) / Rapid Tourniquet. Each has its pros and cons. All are capable of occluding blood flow when properly applied.
No longer a last resort, a tourniquet is now considered an initial lifesaving intervention to control massive hemorrhage from an extremity. SWAT-T is a versatile tourniquet that has proven effective in studies and has been successfully fielded in combat. Photo: H&H Medical.
As of this writing, the C-A-T, RMT-T, SAM-XT, SOF Tourniquet (SOFTT-W), TMT and TX Series (TX2 and TX3) are the only US military Committee on Tactical Combat Casualty Care (CoTCCC) recommended non-pneumatic limb tourniquets. It’s important to keep in mind that the CoTCCC, a division of the DoD Joint Trauma System, is looking at tourniquets for use on adults in combat by trained military personnel. not for use by civilians with limited training or for use on children.
The C-A-T, RMT-T, SAM-XT, SOF Tourniquet, TMT and TX Series are windless/ratcheting tourniquets. The SWAT-T (Stretch, Wrap and Tuck Tourniquet®) and R.A.T.S. are elastic wrap tourniquets.
A plus to elastic wrap tourniquets is that they pack down into a significantly smaller size, making them easier to carry. They’re also considerably less expensive than windless/ratcheting tourniquets. On the downside, elastic wrap tourniquets require a wider range of motion to apply. The latter can make self-application more difficult.
The SWAT-T and R.A.T.S. can be be employed for higher axillary and groin applications than windless tourniquets. They may also be employed for pediatric and K-9 applications, where standard windlass tourniquets cannot. A study of commercial tourniquets conducted in Israel, and reported in a paper submitted to the 2018 NAEMSP Scientific Assembly, found that the SWAT-T and R.A.T.S. were the best tourniquets for use on children.
It should be noted that North American Rescue states that the C-A-T has been shown to be effective on limbs as small as five inches in circumference. It should also be noted that the TX Series ratcheting tourniquet is available in a pediatric model designed specifically for children.
The SWAT-T is a versatile medical multi-tool that may be employed not only as a tourniquet, but also as pressure dressing, occlusive device, elastic bandage, sling and swathe, used to secure a splint, and more. If the SWAT-T is employed as a pressure bandage or dressing, it’s important to check for a distal pulse after application. Although not a CoTCCC-recommended tourniquet, the SWAT-T has been the subject of several studies which demonstrated it’s efficacy.
PHLster Flatpack is a great way to EDC a windlass tourniquet. Flatpack is shown with SOF Tourniquet (SOFTT-W). Photo: PHLster Holsters.
PHLster Flatpack Tourniquet Carrier
No tourniquet does you any good if you don’t have it with you when you need it. I have found the PHLster Flatpack® Tourniquet Carrier from PHLster Holsters to be a great, low-profile way to EDC a windlass tourniquet for easy, one-hand deployment. Designed for versatility, it allows you to carry a folded and staged windlass tourniquet on your belt, in a pocket or with MALICE CLIPS® for MOLLE/PALS mounting..
Training
Having the necessary tools is only part of the equation. Equipment is only as good as your training. Basic emergency medical training should cover the entire spectrum of lifesaving skills. And like shooting, they’re perishable skills.
Emergency medical training should be part of the basic skill sets of every firearms owner. In fact, it should be part of the basic skill sets of everyone. The time to learn isn’t when someone is bleeding out.
Kerry Davis of Dark Angel Medical discussing hemorrhagic injury management and tourniquet placement with two students in Direct Action Response Training (D.A.R.T.) course. Hemorrhage is the most preventable cause of death in compressible injuries. It accounts for approximately 80% of battlefield deaths and 50% of civilian trauma deaths.
Dark Angel Medical also offers an outstanding two-day Direct Action Response Training (D.A.R.T.) course at various locations around the country. All participants receive BCON (Bleeding Control) certification from the American College of Surgeons. It also provides 16 hours of CEU’s, per CECBEMS, to NREMT EMT-Basics/Advanced and Paramedics. I have taken the D.A.R.T. course and highly recommend it. Dark Angel Medical is also a great source for trauma kits and components. I have taken the course and highly recommend it. Idid an article on the D.A.R.T. course recently for Spotter Up.
The online learning platform Deployed Medicine is also valuable resource. It’s used by the Defense Health Agency (DHA) “to trial new innovative learning models aimed at improving readiness and performance of deployed military medical personnel.” Learning assets include the standardized Tactical Combat Casualty Care All Service Members (TCCC ASM) Course curriculum developed by the Joint Trauma System, which is part of the DHA. You don’t have to be a member of the military to take advantage of its resources.
Some Final Thoughts
Preparedness requires the proper mindset, training, and tools. It doesn’t just happen. It’s a way of life and takes some effort. And it’s about preparing for possibilities, not just probabilities.
Carry a proven tourniquet. Not all tourniquets are created equal. I recommend carrying at least two tourniquets. This will leverage your capability. I carry a C-A-T as my primary EDC tourniquet and a SWAT-T as my secondary/backup tourniquet
Buy from a reputable source. If you try to save a few bucks you may wind up with poorly made counterfeit. Counterfeit tourniquets are a growing problem. They can cost lives. The life you save may be your own or that of a loved one.
Practice with the tourniquet in situations that are similar you may encounter. Get a spare/training tourniquet for this purpose. Don’t use the actual tourniquet that you will be counting on in an emergency. Practice both strong and support side applications.
This article from Wilderness Doc discusses a key difference in civilian vs military shooting injuries and how, because of the difference, the first aid focus for civilians may be better served with blod clotting bandages than tourniquets — Pre-Hospital Care in Mass Casualty Shootings.
You will likely recognize the above picture as a CAT tourniquet. As programs such as Stop The Bleed and others have focused on the use of tourniquets in the field, these have become a popular item for most to carry in our kits. This is for good reason too. Studies and data coming from military experience in Afghanistan and Iraq have shown, these devices are no longer to be considered the “last ditch” efforts we once thought. That being said, what does the data show about efficacy or applicability of this data in civilian shootings as we have recently seen in El Paso and Dayton?
This very question was addressed in the May/June 2019 edition of the Air Medical Journal. Three studies by Smith, Butler and de Jager were used to discuss differences between the battlefield and civilian injuries. Interestingly, military injuries tend to be to extremities. This is due to several reasons. First, many soldiers are injured by high explosive devices and the fragments coming off of them. Secondly, the battlefield and the highly armed nature of the two sides on the battlefield, tends to separate the combatants much further than what is seen in the civil setting. This separation makes shots to vital areas such as the torso, head and neck less likely. Finally, soldiers tend to wear body armor that covers vital areas. While not fool proof, especially against higher caliber and more powerful rounds, it can protect against many rounds, especially if shot from a distance.
What does this difference mean for civilian first responders in such scenarios? It means that chest, back and head shots are much more likely. These areas are, obviously, not amenable to tourniquet placement. So, while still important, we need to adjust training and prepare our first responders for what they are more likely to see. In particular, the authors advise focusing on chest wounds. While there are many who have survived head shots, the chest can be far more survivable. Focusing on pressure and hemostatic impregnated gauze as well as chest seals and decompression may be the next line in pre-Hospital treatment. Also, ensuring such first responders are well versed in all forms of artificial airways can be lifesaving…
Tourniquets get a lot of digital bandwidth in tactical and preparedness virtual circles. Rightfully so, since they’ve demonstrably saved a …ton of lives over the last two decades of combat. Unfortunately though, in the process of bludgeoning a deceased equine, in order to overcome decades of medical institutional inertia about the supposed hazards of tourniquet use, many people—myself included, unfortunately—have neglected to make it a point to discuss the surrounding issues.
Let’s start with this, just to get it out of the way:
If you carry a gun, and you’re not carrying a tourniquet or two, you’re either LARPing, or you’re a… idiot. The fact is, a “gunfight” implies bilateral ballistics, and the enemy gets a vote. If you assume your one box of ammo a month “practice” regimen means you’re automatically a far better marksman than the bad guy you are going to end up in a gunfight with, well, I’ve got an 8 ounce jar of fairy dust I’ll sell you cheap, and it’s guaranteed to make you stronger, faster, higher flying, and generally more attractive to members of your preferred sex.
Sure, you COULD try using your belt or handkerchief or what-the-…-ever to improvise a tourniquet, but experiential research and laboratory study both pretty clearly demonstrate they are a piss-poor substitute, and don’t work particularly well (which is not the same thing as saying they DON’T work, AT ALL. I know people who have saved lives with improvised tourniquets, and you may too. Both they, and their patients, probably would have appreciated a manufactured, quality, tourniquet).
That having been said, we’ve got to look at the circumstances surrounding battlefield wounds, versus our likely circumstances, to see if tourniquets are even MOST of the answer, let alone all of the answer.
Tourniquets to control bleeding has been in use for centuries, sometimes praised and sometimes reviled as a tool of the devil. Painful lessons learned in Iraq and Afghanistan, however, lead us to believe that they save lives that would otherwise be lost to hemorrhage. In civilian life, the rapid and effective use of a tourniquet by those at the scene gives valuable time for emergency medical personnel to arrive. In survival settings, it doesn’t take a rocket scientist to know having tourniquets in your medical kit is not a bad idea.
For years, the Committee on Tactical Combat Casualty Care (CoTCCC) has approved a small number of commercially available tourniquets, which I’m sure many of you have in your medical kits: They include the combat application tourniquet or CAT and the special operation forces tourniquet SOF-T.
Both Gen 6 and Gen 7 CAT Tourniquets are acceptable
These are the tourniquets you’ll find in our medical kits. We also add the non-TCCC SWAT tourniquet as a secondary tourniquet in many of them, mostly due to its versatility to also function as a pressure dressing and splint stabilizer.
Now, the TCCC committee has widened the range of options acceptable for the effective control of bleeding. One of their additions is the SAM-XT (pictured at top of page), produced by the venerable Dr. Sam Scheinberg of SAM medical. SAM is well-known for producing malleable splints useful for a number of orthopedic injuries, and now their tourniquet is considered acceptable for even military use…
The top cause of preventable death in trauma is bleeding. 20% of people who have died from traumatic injuries could have survived with quick bleeding control.
May is National Stop the Bleed Month, bringing Bleeding Control (B-CON) Instructors and students together for a month of training – free of charge in many places. Go to bleedingcontrol.org to find a class.
On Saturday May 11th, Dr. Jacobo Rivero will be teaching a free stop the bleed class in Prosser from 9:00 am to 11:00 am. The class will also be taught on June 8th and July 13th at the same location and hour.
Call 786-6601 to RSVP for Dr. Rivero’s classes. Space is limited.
Location: PMH Vineyard Conference Room
723 Memorial St, Prosser, WA
Lower Valley Assembly 