WSJ 12/21/20

Many civilian lives could be saved by using tourniquets.

Robyn Gardner lay bleeding by a river near Sacramento, Calif., her thigh ripped open by a boat’s propeller. A former Army medic happened to be nearby. He applied a tourniquet, which immediately stopped the bleeding and stabilized Gardner. But when the ambulance arrived, the crew removed the tourniquet, because tourniquets weren’t an approved trauma intervention in the jurisdiction. EMTs tried other techniques to control the bleeding, but Gardner died at 38 in 2003.

Tourniquets save lives, but an exaggerated fear of tissue damage led medical authorities to ban them from use on both military and civilian trauma patients. Some 3,400 American lives were lost in Vietnam from failure to use these simple devices.

That realization prompted a four-year review of battlefield trauma care, which led to the development of Tactical Combat Casualty Care, first described in 1996. TCCC recommends tourniquets for life-threatening extremity bleeding until the casualty reaches a surgeon. But most U.S. military units ignored the advice at first and didn’t carry tourniquets into Afghanistan and Iraq.

That changed as casualties mounted. In 2005 the U.S. Special Operations Command and the U.S. Central Command both mandated tourniquet use. Studies since have found hundreds of American lives have been saved on the battlefield with tourniquets and little danger of tissue damage.

Civilian trauma care has always benefited from military wartime experience, but the process can be slow. By 2010 tourniquets were routine in the military but rare outside it. Civilian tourniquet use increased significantly after 2013, when Hartford, Conn., trauma surgeon Lenworth Jacobs convened a group of experts to study ways of saving lives in civilian mass casualty incidents such as the Sandy Hook school shooting. The Hartford Consensus led the American College of Surgeons and the American College of Emergency Physicians to endorse tourniquet use by professional first responders.

Yet scores, perhaps hundreds, of first-responder organizations still don’t use tourniquets. EMS systems, fire departments and other such agencies are local and autonomous, making it hard to hold them to national standards.

Civilian studies show that deaths related to extremity hemorrhage increase 600% when prehospital trauma systems don’t use tourniquets. By using recently published, high quality regional data, we estimate that up to 5,300 deaths a year could be prevented throughout the country through the use of these simple devices. Money isn’t an issue: A tourniquet costs less than $30.

Too many Americans bleed to death every year from severe extremity hemorrhage. Every professional first responder needs to have a tourniquet in his medical kit. Nobody should face Robyn Gardner’s fate because first-responder organizations fail to keep up with evolving standards in trauma care.

Dr. Butler, a retired U.S. Navy SEAL captain, is a former command surgeon for U.S. Special Operations Command. Dr. Holcomb, a retired U.S. Army colonel, is a former commander of the U.S. Army Institute of Surgical Research.

https://www.wsj.com/articles/the-military-learned-to-stop-the-bleeding-11608499774 [Paywall]

The need for tourniquets is rare. At least outside of a war zone (or Chicago). When I was an ambulance paramedic, we could use tourniquets if we wanted, but I never had to. I never even considered using one. I was able to stop my patient's bleeding by other methods.

But if you need one, you need one. Doesn't matter if that scenario is rare - you need what you need when you need it.

I carry a tourniquet in my day bag, along with other first aid gear. I do not really expect to ever have to use it, but it's there just in case.

My experience is similar to Haertig's. Long time volunteer in Mountain Search and Rescue (470+ ops) and career NPS. Never had to use a tourniquet. Bleeding always stopped w/ direct pressure - I don't even specifically recall using a pressure point..

Most of our trauma involved fractures, etc. as the result of falls, also the leading cause of fatalities (often booze was a factor). There were occasions where victims perished before we , or anybody else, could reach them. Exsanguination may have been a cause or contributing factor.

I suspect that battlefield wounds are more likely to require T use, compared to typical civilian environments.

I have added T's to my FAK. At worst, it is yet another bandage. To be most effective, a T should be applied properly and promptly. Either the injured individual or companions is likely to be more helpful than the late arriving rescuer.

It seems a TQ is a lot like a parachute; you very rarely need one but when you do nothing else will suffice.

I am not a medical professional, but I am a professional firearms instructor. I've been very fortunate to train with some truly knowledgeable and excellent instructors, including medical instructors. Two I have trained with had an Army medical background followed by a large city fire department paramedic background.

As I learned from them and others, the TCCC guidelines are evidence-based and are the gold standard for traumatic wound care, such as one might find on the range during a class or practice.

Learn how to use one, and please carry a TCCC approved tourniquet.

Stop The Bleed is the American College of Surgeons sponsored course:
https://www.stopthebleed.org/

The website includes links to available training options across the US and elsewhere.

Courses last about 90 min., and are usually free.

If no local training is available, contact your local EMS council, Fire Dept., or hospital to ask about bringing in a course.

Many of the folks on ETS would qualify to attend the 2-3 hour or so training course to become instructors: see the above link for details.

Some of the local folks were gearing up to teach the local university administration and school district teachers/administration/students the Stop The Bleed course and advocate for getting Stop the Bleed trauma wall mount kits placed near every defibrillator in publicly accessible buildings when COVID hit. Plans are hold.

The biggest hospital systems in western Pennsylvania have funded the training of the public school teachers/administration and funded placement of Stop the Bleed Kits in each of the public school buildings to the tune of several million dollars:
https://www.firerescue1.com/community/ar...r9UbJDE9S6xRUj/

I've added a CAT to each of my car kits.

A ounce of prevention is worth a pound of cure. MTC

Stop the bleed is even given in The Netherlands. Did the course 2 years ago. Did cost €100, but honestly the best instructor I had for any first aid course. Didn't do a refresher yet due to Covid. (Did refresh my regular first aid).

My outdoors stuff is basically using a chainsaw in my woods. I carry an Israeli bandage in my side by side, and think I may add a tourniquet.

Probably a good idea. Do you use chainsaw chaps?

Sweet, there are classes near(ish) me!
Thank you for sharing this organization.
-Blast

I think I have calmed down now, the first story had my blood boiling. That was border criminal negligence . I don’t care about the politics.

As I understand it, DaveL, medical first responders in the USA are required by law to follow the medical orders and standards of care set by the EMS systems they are associated with. What happened to Ms. Gardner was a tragedy, but it was one of bad policy and law.

It’s worth saying out loud that you didn’t say otherwise.

In reply to...do I use chainsaw chaps?

Yes, after my niece, who is a forester, chewed me out. I got a small scar on a knee from starting a saw up off the ground, and it dipped a bit. Learned my lesson before anything serious happened.

Follow up to the original WSJ Opinion story -

Letter to the Editor of the WSJ by Gerald Holmquist, 12/28/20 -

Regarding Frank K. Butler and John B. Holcomb’s advocacy for the tourniquet (“The Military Learned to Stop the Bleeding,” op-ed, Dec. 21): My fraternity at the University of Chicago, Phi Delta Theta, was geared toward physics, not parties. Fiscally constrained, we took in the occasional boarder. Rick Ames was one. We soon recognized him as a seldom-bathed alcoholic and searched for an excuse to kick him out.

One night in 1962 we found it—and then some. Rick severed an artery by jabbing his forearm through one of the house’s glass windows. A serpentine trail led me and a friend to a pool of blood.

Equally intense emotions of disgust and sympathy pulled me in opposite directions, but my Boy Scout training took over. I squeezed a pressure point to stop the bleeding and tourniqueted Rick’s arm, noting the time in huge magic-marker letters on his forehead.

Rick was wrapped in plastic garbage bags, carried over the rugs of the foyer and driven to the emergency room in some reluctant brother’s automobile. The next day our boarder’s bags were gone, his key was returned and he was forgotten.

It turns out Rick’s father was a CIA agent who eventually got Rick into the agency. From there Aldrich “Rick” Ames became the most notorious mole in CIA history, betraying at least 12 of America’s best secret agents in the Soviet bloc. Many of them were executed. Alas, I was a few pints of blood away from saving these fellows, but my Boy Scout training doomed them. The tourniquet works.

https://www.wsj.com/articles/sometimes-the-tourniquet-works-all-too-well-11609097138 [Pay wall]

Yet another tourniquet story -

After an elderly woman named Tokiko Ahuso was bitten by a deadly viper on Nov. 6 in Kin, a town in the Okinawa Prefecture of Japan, U.S. Marine Sgt. John James sprung into action and rendered first aid. Thanks to his efforts she survived, and on Dec. 23, Ahuso attended an award ceremony for James at Camp Hansen, Okinawa.

- - - -

. . . Ahuso was bitten by a habu viper. Okinawa is home to 24 snakes, eight of which are venomous, and of those, four are habu, and each one poses a real danger to people.

- - - -

. . . James and some friends were outside grilling burgers and hot dogs when they heard a sudden commotion as Ahuso yelled out "habu, habu!" After a call was placed to emergency services, James used a friend’s belt to tie a tourniquet two inches above the snake’s bite marks -- he credits his quick thinking to the training he received as an embassy guard.

"We did medical training once every week for three years for embassy attack training, and a lot of the training goes into how to apply a tourniquet or do CPR," he said.

After emergency services arrived they were able to find the snake, and in doing so, identified the correct anti-venom to treat Ahuso’s wound.

[Full article at link]

https://www.military.com/daily-news/2020...RC=eb_201229.nl

As a Vascular Surgeon dealing with trauma for 33 years I agree that although not ususally necessary, a tourniquet is very useful and almost never harmful if removed within a couple of hours (or more). Direct pressure almost always works but often people put a bunch of gauze on a wound and apply pressure with their palm which usually allows a person to bleed to death without squirting on you. Even one or two fingers deep in a wound on the vessel itself stops most bleeding (for extremities). Tourniquets do cause severe ischemic pain to limbs- but don't take them off until ready for the operating room (in most cases) unless another means of control is available.

The CoTCCC protocol I have been taught is that once a TK goes on, only someone like you should take it off.