Stop the Bleed: The Value of Tourniquets

Beside the sheer horrific nature and senselessness of the acts, the Sandy Hook shooting, the Boston Marathon bombing, the Orlando nightclub massacre share a critical commonality. In all of these cases many of the fatalities were caused not by the immediate blast or bullet, but by rapid and catastrophic bleeding. Unfortunately, this appears to be an increasing phenomenon,  but it is one that can be prevented. In June 2016 the American Medical Association recommended that all law enforcement, firefighters and the general public be trained to use a tried-and-true method for emergency response to traumatic bleeding; the appropriate use and application of a tourniquet. 

According to the CDC, uncontrolled post-traumatic bleeding is the leading cause of potentially preventable death among trauma patients.  A new program: "Stop the Bleed", through the Department of Homeland Security has been developed and initiated.  Doctors and nurses have taken to the streets to train individuals on how to use a new accessory in the public arena: a "severe bleeding kit." It's part of a national movement, encouraged by the White House, to make tourniquets commonplace in schools, stadiums, airports, malls and other places to reduce casualties from mass attacks and bombings.

Yes, you have had training in this, hopefully multiple trainings with hands-on practice; but how much to you remember, and how competent do you feel with your skills?  Your answer could be a matter of life or death.  This is presented as a basic review. If you need a refresher course, your peers probably do too.  Insist on additional training from your department, and review related material.

To Tourniquet or Not to Tourniquet

Penetrating wounds to the head, neck, or torso, are considered “load-and-go" situations.  Time is of the essence and medical care should be administered while in route to the appropriate level trauma hospital. Pressure dressings may be helpful, but immediate life saving surgery is invariably required in these cases.

However, these same wounds to an arm or leg are almost always survivable if a tourniquet is used immediately and appropriately. Once the bleeding is stopped, the immediate threat is not necessarily an emergency, the victim can remain behind cover until an appropriate extraction route can be tactically executed. The tourniquet can be left in place until the victim(s) is transferred to the emergency room.

When to Use a Tourniquet

• When dealing with an uncontrollable hemorrhage from a limb sustained after some form of penetrating wound; gunshot or stab wound, blast injury, as well as a partial or complete amputation.
• When dealing with multiple wounds on the same victim; preventing exsanguination (bleeding out) takes priority. Quickly applying a tourniquet and stopping the bleed will allow you to address other potential issues like a compromised airway.
• When dealing with multiple victims in a mass casualty event such as a terror attack.  In this scenario you can apply a tourniquet to someone who has a severe bleed, put them in a recovery position, and then you move to the next person.
• When you are in doubt (for example, you can see a large amount of blood pooling on the ground, saturating the victim’s clothes) go ahead and quickly apply a tourniquet.  Initiate an EMS response; tourniquets can and will be removed if they aren’t required.

Stop the Bleed Pressure/Tourniquet Sites

Generally speaking, a tourniquet will more likely be required for arterial bleeding rather than for venous bleeding. Arterial blood is oxygenated blood being pumped from the heart and is characterized by bright red blood spurting from the wound. Venous blood is deoxygenated blood that is returning to the heart and is characterized by a steady flow of dark red blood from the wound. 

Important Facts:

• Adults have 10-12 pints of blood.
• When you donate a pint of blood, your body generates replacement blood in 1-2 days.
• A loss of 2-3 pints results in a 20-30% decrease in blood pressure.
• A 40% loss of blood (4 pints) will usually result in death
• A person can bleed to death from a complete femoral artery and vein disruption in 2-4 minutes.

Fifteen Pointers:

1. Apply a tourniquet immediately for life-threatening bleeding. Note the time, and mark it (on the forehead) if possible.
2. Use your knife to expose the wound if at all possible; examine the situation and the extent of the wound. You never want to apply a tourniquet over an individual’s clothes as this can create a situation where the tourniquet slips down on a wound or off an amputation, rendering it useless.
3. Apply the tourniquet 2-3 inches above the bleeding site.
4. Start turning the tourniquet, this will apply pressure to the limb while squeezing the muscles, thus slowing and then preventing the blood flow. Tighten the tourniquet until the bleeding stops. A quick check of the radial pulse (wrist) or dorsal pedal pulse (top of foot or behind the inside ankle bone) also allows for this assurance.
5. Tourniquets may be left in place for 2-4 hours (or longer in some cases) without difficulty in a worst case scenario.
6. A properly applied tourniquet is extremely painful. In fact, it will often be more painful than the actual gunshot or knife wound itself.           
7. Periodically check to ensure bleeding has not resumed, tighten or reposition the tourniquet as indicated. A second tourniquet may be required.
8. Although it is a difficult decision, it is always better to sacrifice a limb than to lose a life to excessive bleeding.
9. If at all possible, tourniquet removal should be left to experienced medical personnel in a medical facility.  For protracted transport times consult with EMS staff on removing or loosening the tourniquet.
10. Training in the proper use of a tourniquet is crucial. So is practice and proficiency. You need to be able to apply a tourniquet confidently to your own arm or leg within 30 seconds.  Practice using your non-dominant hand as well.  Practice on your partners. Practice on your K-9 partner. Your tourniquet can save animals as well as people.  Know the processes backwards and forwards.  Watch videos online, re-read the information, talk to the training officers about receiving more in-service trainings.
11. Always carry a tourniquet with you, in a holster, on your duty belt. It does no good if you keep it in the first aid kit in the trunk of your car or zipped into your vest under your uniform when time is of the essence. 
12. Tourniquet packages can be difficult to open, especially with using only one hand, it is suggested to open the package, prepare the tourniquet and repackage it and carry it with you.
13. Know what type of tourniquet your partners are carrying, and where they keep it.
14. If your department has not yet provided you with a tourniquet, purchase one for yourself NOW! The advantage of the professional grade tourniquet is the ease of use on treating both you and someone else.  Good tourniquets can cost as little as $10-$50, it is money well spent. Although rather pricey, integrated tourniquet systems (I.T.S.) which are built into your uniform do exist. 
15. Remember, although a packaged EMS/tactical tourniquet is recommended, you can always make a tourniquet out of many materials if needed:  a bandana, a sock, a shirt, a belt, a carabiner, a stick, flashlight, tactical pen. There are plenty of diagrams on the Internet if you need a scouting refresher.

Trauma is the leading cause of death for Americans 45 and younger, killing nearly 148,000 people in 2014, and costing an estimated $670 billion in medical expenses and lost productivity.  Fundamentally, the recommended means to control uncontrollable extremity bleeding in any tactical environment, while under fire, is a rapidly and properly applied tourniquet. Considering the daily threats faced by law enforcement, it is no longer acceptable to report for duty only having attended a basic first aid class.  Officers must not only be prepared and equipped to deal with a life threatening injury to themselves and/or their partners; they must also be prepared to accept the responsibility of sustaining that emergency medical treatment until the casualty can be transferred to a more definitive medical provider.  Stay safe out there.

Links:

Basic Self Aid http://rp.tpcaf.org/index.php?_m=downloads&_a=downloadfile&downloaditemid=537

Stop the Bleed Training for Law Enforcement http://www.naemt.org/education/B-Con.aspx

Tourniquet First http://www.jems.com/articles/2010/05/tourniquet-first.html