Tourniquets

[Eamonn]

As you might imagine in a correctional setting it's important that all of our contact staff are trained in First Aid and CPR/AED.

For my many sins, I'm one of the instructors in the jail where I work.

The Department of Corrections uses the courses set by American Safety and Health Institute.

Have to admit that prior to starting to work for the DOC, I'd never really heard of ASHI. Reading a little about them they seem in some ways to be affiliated with Saint John's, who were and maybe still are very big in providing First Aid training and courses back home in the UK.

The course material was updated just recently. In fact it changed a lot, changing from one course to two. CPR/AED is now a course by itself, with Basic First Aid being its own course.

I was a little surprised to see that tourniquets are back.

Last year they were a big No, No. But now can be used to control severe bleeding in emergency situations when direct pressure isn't working.

I don't teach or use any of the courses from other organizations, such as The American Res Cross.

I was wondering if like ASHI they have also brought back tourniquets?

Ea.

[Eagle92]

Eamon,

 

Yes tourniquets are back.

 

This is what I know and have been told in regards to the entire CPR/AED and First Aid thing.

 

I know every 5 years, American Heart Association has a big conference where they announce the latest research on CPR. The results get published, and the new methods of CPR and advance CPR come out within a year. ARC and others will use AHA's standards in teaching CPR.

 

Now I've been told the same thing happens on the first aid side of things, except it's ARC that is responsible and everyone else follows.

 

Also I've been told a lot of the changes are a result of emergency medicine on the battlefield.

[qwazse]

Also I've been told a lot of the changes are a result of emergency medicine on the battlefield.

 

... and campus shootings ...

 

 

[KC9DDI]

Yup, tourniquets are back for severe, uncontrollable arterial bleeding. Evidence has shown they do much more good than harm, so please don't be afraid to teach their use.

 

Starting a couple years ago, civilian ambulances started being issued the same tourniquets used by military medics

[Gunny2862]

Bottom line, issue is that when taught they need to be last or next to last (Cauterization) and for actual settings where they are appropriate.

 

I had folks even in the military who didn't think about pressure points, direct pressure, bandage, Quik clot, dressing, or using them in conjunction with each other, who went straight to the tourniquet when given "realistic moulage" scenarios. Stress somebody and they tend to go for the big dog rather than just going thru the procedures in order..., ongoing frequent training is key, which is why teaching lay responders advanced procedures is problematic.

 

It's as though doing those last ditch scenarios, the spectacular, or don't do this unless everything else fails(and you'd rather go to court than watch your buddy die while doing nothing) stuff tends to stick in the students heads, but the basics go away.

 

I think tourniquets belong in the First Aid bag, but they need to be on the bottom of it...

[KC9DDI]

Gunny - There are times when a tourniquet should be the "first line" intervention - like when bleeding is so profuse that the patient will bleed out while you're playing around with pressure points and elevation. Again, actual evidence shows that tourniquets do much more good than harm in these cases, even if you "err" on the side of applying a tourniquet.

 

Yes, there absolutely is a training element that is required to identify the types of injuries where a tourniquet should be applied early. But it is not correct to teach that a tourniquet should ALWAYS be a last resort.

[John-in-KC]

IMO, BSA needs to be careful about teaching tourniquets in due course youth first aid (T-2-1 and FA MB).

 

Let's let the dust settle and get the citations straight. An EMT who can make a field judgment is one thing; a 12 year old another.

[Stosh]

I ran with an ambulance crew for 15 years and the whole time the use of "tourniquets" was an option. It never "went away".

 

Controlled use of tourniquets and tourniquet devices has always been played out in modern medicine. Air splints over open wounds, blood pressure cuffs applied just enough to slow if not stop circulation to the limb as necessary, etc. have always been in use. Triage: if it's a choice between losing the limb or losing the life, go with the limb.

 

Stosh

[Gunny2862]

KC9DDI, I'm not saying it's even a last resort nor that it shouldn't be an option. It's not that you have to do them in order, but you should think of them and pick the appropriate tool, too often lay folk go for the sledgehammer when a roofing hammer might have been appropriate.

 

What I'm saying is that for too many people it's always the first resort when you place them under the real stress of a real situation (and then some still can't do it right) or even when they know it's not a the real deal but a stress training scenario.

 

Concur with John-in-KC and jblake47.(This message has been edited by Gunny2862)

[Eamonn]

To be very honest in a jail setting the wait time for professional qualified medical help is normally very short.

Many of the Correction Officers, especially the younger guys are not long out from serving in the military. My fear is that some of these guys will jump to using tourniquets, when there really isn't a need.

Also, the course material doesn't do a very good job of covering the use of them.

Ea.

[KC9DDI]

Again, actual evidence from actual cases where tourniquets have been applied (many of which were in combat situations) show that the benefits of tourniquets FAR OUTWEIGH the risks. This strong evidence is probably why more and more organizations are training for it.

 

Like anything else in first aid (or anything else in Scouting), it's a skill that must be learned and practiced to be done correctly. That's not a reason to not teach tourniquet use - instead, it's a reason to teach it correctly.

 

 

[Reasonable Rascal]

From a long-time Paramedic: you will know very quickly whether direct pressure is going to work or not. Very quickly.

 

Even more to the point if a limb is semi- or completely amputated a tourniquet is ALWAYS appropriate. For a stab would you should have time to figure it out, or note that the wound is in a location for which a tourniquet is totally impractical (torso, etc).

 

I recall a situation in the mid-80's that involved a broken beer bottle applied to the upper arm (family dispute). Brachial artery et al severed and blood literally puddling in the guys lap. Tourniquet applied as a first line measure. He lived and the arm was saved after some fancy micro-surgery to rejoin the artery.

 

Back about "72 a kid in my troop saved his younger brother after the boy severed his ulner artery (forearm) after he ran it through a glass storm door. The Dr. certified that the kid's life would indeed have been lost if the proper intervention was not applied (belt and stick), and the Scout received a Certificate of Merit in front of the entire Jr. HS assembly. The Dr. was a surgeon and did the repair work - he knew his stuff. I worked with him for 3 years later on after I graduated and started my EMS career.

 

5 years later almost to the day he 9the hero Scout) did the same thing again at the beginning of his freshman year at UNI. Virtually identical scenario and injury and treatment. But by then no longer a registered Scout so there was no second recognition.

 

Basically a 13 y.o. was able to properly identify the need. It is not difficult to teach them how to properly recognize when it is needed.

 

RR

[Beavah]

Yah, KC9DDI, do yeh have a few references on that "evidence" that yeh can point us to?

 

I remember the days when we had every Tom, Dick, and Harry civilian responder slapping a tourniquet on their kid for ordinary cuts. Gunny is right, da average inexperienced civilian responder sees what looks like "a lot of blood" and goes immediately for the big dog. There were good reasons for the instructional policy change to strongly discourage their use in civilian responder courses. As others have pointed out, they never "went away" for professional responders or military medics.

 

I reckon there's also a difference between in-town/frontcountry use where transit times are short, and wilderness/backcountry/sidecountry use where transit times are longer and tissue necrosis is a bigger concern. I don't believe the Wilderness Medical Society, for example, has changed their Practice Guidelines. And if yeh do use 'em yeh should be familiar with the protocols for periodically releasing tourniquet pressure.

 

When considering policy changes, yeh have to look at unintended consequences as much or more than your hoped-for intended consequences. So often while tryin' to do something helpful yeh do far more harm. I'd be awfully slow about teaching tourniquet use at any level below MFR/WFR.

 

Beavah

 

[KC9DDI]

Sure Beav, here's one good one. I don't know if the full version is freely available, but the abstract offers some pretty compelling information: http://journals.lww.com/jtrauma/pages/articleviewer.aspx?year=2008&issue=02001&article=00008&type=abstract

 

There were good reasons for the instructional policy change to strongly discourage their use in civilian responder courses.

 

What exactly were those reasons?

 

I reckon there's also a difference between in-town/frontcountry use where transit times are short, and wilderness/backcountry/sidecountry use where transit times are longer and tissue necrosis is a bigger concern

 

Yup, big differences. You need to balance concern for tissue necrosis with concern for blood loss during the long transport. Training & practice, training & practice. Of course, the evidence is showing that tissue necrosis and nerve damage is less of a concern than we previously believed.

 

When considering policy changes, yeh have to look at unintended consequences as much or more than your hoped-for intended consequences.

 

Sure, but you also need to look at real, measurable, evidence-based results, statistics and practices. You need to balance that with fear, uncertainty and speculation about unintended consequences. Look at CPR, for example. There's risks involved with CPR (broken ribs, organ damage). But we still do CPR (and teach "civilian responders" to do CPR) because we've learned that the benefits far outweigh the risks. And part of our training includes learning to recognize indications and contraindications for the procedure, and how to minimize "unintended consequences." Tourniquets are no different. There's risks, the procedure can be done incorrectly, and can be done unnecessarily. But the benefits outweigh the risks, and the risks can be managed with good training and practice.

 

This discussion is nothing new - it comes up any time evidence supports changing the "conventional wisdom" way of providing first aid or prehospital medical care. Heck, the same conversations ensued when the recommendation came to move away from tourniquets. The same thing happened with the recent changes to CPR. And, in the industry, the same conversations are going on now about spinal immobilization and ACLS drugs.

 

As we learn more and more about the effectiveness of various procedures and interventions, the recommendation on how to train both professional and lay responders will change. And people will resist these changes on the basis of vague speculation about "unintended consequences." It's always been like that. Eventually it will catch on :-)

[Beavah]

Yah, hmmm...

 

That journal that yeh reference seems to be a third-tier journal (so far down the journal hierarchy that da nearby top-tier medical school doesn't even subscribe), and da article itself is comin' at it from the perspective of trained military medics and combat-type casualties.

 

The results seem interestin' and informative, sure enough, though that's still pretty weak evidence, and still pretty remote from civilian and wilderness first response, eh?

 

In combat casualties, severe trauma is very likely. That's da sort of thing that weaponry is designed to do. Incident rates are goin' to be much different in the civilian world, and the injury patterns for civilian trauma (automobiles, falls, power tools) are goin' to be very different from the type and pattern of injuries when you're takin' heavy weapons fire. What's appropriate for limbs torn off by explosions might be completely inappropriate for limbs severed by a boat prop or other mechanism where reattachment is still possible. MCI triage is goin' to be much more in play in combat casualties, and training and equipment is goin' to be different.

 

Do yeh have any other references from more respected journals or closer to home?

 

Lots of times people take one study in special circumstances and jump on a bandwagon before enough research and development really has been done to justify a change. In fact, I'll wager that happens at least as often as folks holdin' on to tried and true longer than they should.

 

Don't get me wrong, I'm a big proponent of greater scope of civilian first responder training and practice, particularly for those of us who are out in the backcountry. There are indeed a few times when tourniquets or similar techniques are indicated, and always have been at the professional responder level. I'd just be more cautious about this one and let it work its way through broader review and protocol revisions before goin' all-in. A combat medic's lived experience with what constitutes "severe bleeding" is likely to be quite different from a civilian first aider's.

 

Beavah

(This message has been edited by Beavah)