US Mil Medics Use Old & New Techniques

Fascinating article in today's Washington Post about how instructive, and even transformative, the Iraq and Afghanistan wars and the Somali debacle of '93 have been in the trauma care protocols of U.S. military medics. The article focus is on treating blood loss. They have actually gone back to some WW I and II strategies as well as implementing new technology.


http://www.washingtonpost.com/wp-dyn/content/article/2010/11/01/AR2010110104802.html?hpid=sec-health

The single most important change was the endorsement of tourniquets, ancient devices that for the second half of the 20th century were considered too dangerous to use because extended use can cause tissue damage. The new ones optimize the force distributed across the strap and can be tightened and locked with one hand. Every soldier carries one, and medics carry a half-dozen.

A new generation of bandage, called Combat Gauze....

Medics are now taught not to worry if a person's blood pressure is as low as 85/40 (normal is 120/80) as long as the patient is alert.


Content of a military medics' bag:

http://www.washingtonpost.com/wp-srv/spe...ST2010110104926

Very interesting. Any links to pics or info on the new tuirniquets? The NYT photo was too small and didn't disply it well.

billvann... look up Special Operations Forces Tactical Tourniquet
SOFTT

Interesting article. I do remember always reading that tourniquets were a tool of absolute last resort.

Can anyone explain this sentence to me?

"Data presented at a conference in August revealed that 8.8 percent of the U.S. combat casualties in Iraq and Afghanistan died, either on the battlefield or later of wounds."

So either they died immediately or later?

"80% of the time it works every time."

Ajax, probably just bad grammer. I think that's talking about the rate of combat injury death. But I agree, poorly worded.

This topic has been discussed before (not with this article though). When I did my combat medicine course in April, tourniquets were big. The big push was try for a few minutes with gauze, if not working, tourniquet 'em and transport 'em.

The other big news is "who cares about BP if the brain is perfusing." It helps decrease the weight of IV bags. Plus, too much IV fluids can decrease clotting, worsen bleeding, and "push out" the blood (there's only so much room for fluid in the blood vessels).

As a non-native English speaker with English as my secondary professional language, this is a challenge I can't resist



They died. Some died immediately, some died later.



Translates to: 80% of the time it works. Plain and simple. The "every time" is superfluous and does not add anything but confusion.

Yes, the KISS principle absolutely applies to writing as well.

It's amazing how much more effective regular fresh blood is vice components or IVs.

Only man would try to improve on a machine as ingenious as man.

In Wilderness First Aid last summer they were also more supportive of tourniquets than they had been 2-3 years before. Still only to be applied if you can't stop bleeding any other way, pressure will work 95% of the time, and only worthwhile if you have a ready made TQ and not just a length of paracord. In other words, don't leap to a later option if others are still available to you and work, and don't be stupid with your choice of TQ material.

FWIW I have a CAT style tourniquet on what I call my Bloodstopper 2000 kit, which rides in the trunk of my car and is outfitted solely for stopping profuse bleeding at car accidents and the like, until professional help arrives (pronto). The CAT is on the outside of the kit and available, but the kit also contains kerlix (roll gauze) and 4x4s which have actually seen duty after accidents. Happy to say I still have never encountered a medical scene requiring a TQ.

I appreciate the effort but my question was mostly rhetorical. Of course combat deaths occurred either on the battlefield or later, where else could they happen?

I remember the old combat bandages. I always carried two, on the idea that bullets can make two holes, one in, one out. My small signal mirror rode between the two bandages, which cushioned and protected the mirror. I also carried some bandaids in the same small pouch, as it was easier to treat small booboos than find the medic. And as with most grunts, I always had a bottle of Tylenol or Motrin in my ruck.

It's nice to see that the new IFAK have some real stuff in them. The medics can't be everywhere.

With any luck you may never encounter such a scene. Remember the original article was discussing a combat situation, with blast injuries from IEDs as a prominent part of the picture.

Civilian settings are a little different. I have seen a lot of fractures, mostly from falls, and precious few, if any, blast injuries. I've never had to use a tourniquet, although my training has always included them as a potential tool in extreme situations. Most of my experience has been in backwoods conditions. I suppose injuries in vehicle accidents might be a little closer to the combat spectrum.

Agreed, and even if the injury is more severe I wouldn't be treating any injuries under combat conditions. Stick to the basics: call 911, evaluate scene, approach safely, consent to treat victims, c-spine immobilization, stop bleeding, treat for shock, wait for the cavalry, which will be arriving directly.

Deaths are generally classified in 3 sometimes 4 groups when it comes to TCCC (Tactical Combat Casualty Care):

1-Non-preventable death on the battlefield, meaning that no matter what medical interventions were made immediately after injury the patient would have died. Examples: complete transection of the thorax, decapition or massive open head wounds.

2-Preventable deaths on the battlefield, meaning that the patient/soldier/etc could have reasonably been saved with combat level interventions applied appropriately immediately after injury. Examples: arterial bleeding stopped by a tourniquet, occluded airway fixed by either positioning, nasal airway, tracheal airway (ET tube, King airway, or other), or surgical cric, decompression or a tension pneumothorax. Those three are the leading causes of preventable death on the battlefield at this time.

3-Non-preventable deaths due to injuries incurred on the battlefield, meaning injuries that were so severe that even with extensive capabilities being available or applied either at battalion aid stations or forward surgical teams they still die, just not on the battlefield. Examples: severe head injuries, massive internal injuries to essential organs (heart, lungs, liver being the leaders).

4-Preventable deaths due to injuries incurred on the battlefield, meaning that the patient/soldier could have lived had steps been taken throughout the spectrum of care after the care under fire phase. Examples being antibiotic therapy, surgical procedures, etc.

On a separate note:

Tourniquets should not be a tool of last resort. Assigning it that title means that you will use other steps first even when you know that a tourniquet is appropriate. Tourniquets are tools just like any other item in medicine and just as I wouldnt use a tongue depressor to splint a broken leg, it is misguided to recommend against using a tourniquet as a first line intervention in an obvious arterial bleed in an extremity. Being realistic in your training and understanding when and when NOT to use a tourniquet will keep you on the right path. If the bleed is squirting and not just dripping or oozing you can try with a single pad/gauze/etc and pressure to stop it, should that fail you need to go immediately to a TQ. Particularly in a remote environment where literally every drop of blood is priceless and it will be a good bit of time before you can replace it.

As a combat medic for a security team in Iraq I used tourniquets for any extremity squirters. As a civilian Paramedic in the states my protocol is to apply pressure with a gauze pad and failing that transition to a tourniquet. Many people have died relearning these lessons and I hope we dont soon forget them again.


Some pointers on TQ use:

-Use a premanufactured device, I recommend the SOFT-T, SWAT TQ, and TK4/TK4L based on my experience and testing. Belts dont work as well as you would think. I literally just ran a gun shot wound call where a guy had shot himself in the leg and tried to use a belt as a tourniquet. For one, he didnt need a tourniquet and for two, it was completely ineffective at applying pressure. The TK4 costs less than $10 and weighs less than 2oz.
-Know how to use it, that means get a couple and dedicate one to training and practice applying it with your strong hand and weak hand on all extremities.
-Dedicate one to training, many after action reports (AARs) from the military revealed early failures of TQs and it was found that this was due to people repeatedly using them in training and then putting them on their gear for operational use. They were not designed for this as they are single operational use items. So dont set yourself up for failure.
-Get training on when and when NOT to use it. As good as online forums are they are no replacement for hands on, structured training from a professional.

I know that was kind of long winded but hopefully that will answer some questions.

Mike

Good info, MikeG. It matches up with what TCCC was teaching a few months back.

IMO, given that most here aren't going to be messing around with IV fluids and making decisions on blood transfusions the effective take-away, the lesson that can be put to practical use, is to apply tourniquet/s early. If the bleeding from a wound isn't obviously insignificant you skip the direct-pressure and pressure point steps taught thirty years ago and apply a tourniquet. When things slow down you come back and reevaluate.

It is simple enough, but often quite painful, to remove a tourniquet that was installed where it wasn't needed. Putting blood lost back in is a much harder trick.

The turnaround on tourniquets is so complete that they are included in NREMT test sheets for hemorrhage.

Some still recoil at the thought of using a tourniquet for any reason. Want to know how a surgeon works on a pt's hand or foot? They apply a pneumatic tourniquet, stop all blood flow to the extremity for 2 to 4 hours, do their work, then remove the tourniquet. Happens every day in hospitals all over the country.

Two additional things to keep in mind:

-Although it's common practice to place the tourniquet just above the source of bleeding, it isn't always effective due to the fact that there are two bones located between the wrist and the elbow, potentially preventing sufficient pressure on the artery to stop the bleeding (the same is obviously true with the lower legs). In these cases it is often necessary to place the TQ higher up the extremity where it can compress against a single bone and stop the arterial bleeding.

-Once you install a TQ, do not remove it for any reason. Although anyone can install a TQ, only a trained medical professional should remove it. High concentrations of lactate and hypoxanthine build up in the tissue below the TQ, which if quickly released into the bloodstream upon TQ removal could cause serious medical complications, including shock.

Jim

This article addresses Preventable Deaths. In general terms 80 % of combat casualties die on the battlefield. The remaining 20% can be termed Preventable Deaths if the militaries version of the ABC’s are initiated in time. Combat Lifesavers are taught to aggressively treat hemorrhage on extremities using tourniquets, Combat Gauze, and Israeli pressure bandages. They are also taught how to manage the airway, using a nasopharyngeal airway (NPA), and treating penetrating chest injuries using occlusive dressings, wrapper from combat dressing and tape, along with relieving tension pneumothoraxs by inserting a 14Ga catheter in the second intercostals space on the injures side. It is not practical to perform CPR on the under fire. The Army IFAK contains all the materials necessary to treat the above listed injuries.

Cheers,
W-W

It's interesting how the tone of the discussion here on ETS around things like tourniquet use has changed. The last time we discussed this same topic of advances in military medicine--maybe a couple years ago--was rather more cautious in tone about turniquet use, from what I remember, particularly about applying them in the civillian setting.

Was it Polak187 who was mentioning that many former medics who went into EMS after getting out were often too quick to jump to the tourniquet when direct pressure would have been sufficient?

Just like advancements in auto racing often filter down to passenger cars, so too can advancements in military medicine, but they're not the same situations, so it's going to take time to figure out what to keep and what to discard from all the recent combat experience.

I'm glad medical treatment and training now incorporates tourniquets, but for most of us this isn't a huge change - unless we are battlefield medics or active EMS, we just don't see many arterial bleeds. We still see 95% bleeding that can and should be treated by pressure. But if I see uninterrupted arterial bleeding, I'll reach for my Bloodstopper 2000 kit with the TQ and apply that. Its always good to have other options.

There is the possibility of a pendulum shift, that with broader acceptance of TQ use some wahoos out there may apply unnecessary or unsafe tourniquets. That can only come from folks who aren't trained or experienced.

Isn't that the situation that led to a conservative attitude with respect to tourniquets in the first place? I think you are right about the pendulum...

I am actually attending a combat medical course next weekend in CT, as a guest. The instructors are current & ex mil and LE. I was on another forum, discussing TQs, and recent experiences a buddy related to me regarding the types of TQs they use in SF. The person PMed me & invited me to the course. Specifically, he is one of the people who helped develop the current SOF-T tourniquet, and they are working on other developments. I am excited to participate in this, and plan on doing a write-up post-course, provided I am allowed to by the guy who invited me.
But, yes, the military has moved back to the TQ being the primary way to treat blood loss on the extremeties during the "care under fire" phase. So much so, that a lot of soldiers actually wear a TQ on each appendage, so that they can quickly stop blood flow themselves, if needed. I believe that the studies indicate that, when a TQ is applied properly, they can be left in place as long as 6 hours, and the limb is still recoverable. Now, the key word is PROPERLY. One that is cranked down WILL cause a lot of damage. But applying one properly, tightening it until blood flow stops, then securing it, will not cause permanent damage if its on there only an hour or so.

One thing that's encouraging this time around is the ready availability of a good tourniquet supply - SOF-T, CAT and some other types are out there, being tested in real life conditions. They're relatively cheap, $15-30. And good TQ designs are winning on predictable grounds - patient survival, and viability of limbs after applying the TQ. Folks have come to understand there are limits to TQ, as old soldier says approx 6 hours, properly applied. Not that I was actively looking, but before the Iraq War I couldn't find real TQs, which meant you could be tempted to use anything from a belt (Rambo) to surgical tubing. I recall one dark, hushed conversation in an old WFA class where we talked about using webbing in a real pinch, in hopes of stopping the bleed, but at the sure cost of the limb. If folks can stay within their training and not improvise and choose poor TQ materials, mostly we'll be okay.

Medicine and medical care advances, the pendulum swings are almost always for the better. I grew up next door to a vascular surgeon who made his bones in the Viet Nam war, pioneering new surgical techniques in battlefield conditions, saving arms, legs, hands and and feet that once would have been amputated. He passed away some years back, years later I stayed in a hotel in Dublin where they were having a medical conference in vascular surgery, I mentioned his name, he was thought of as a God. As it should be.

Which reminds me, god bless all you veterans out there, I'm thinking of you today.