Embracing the Use of Tourniquets to Save Lives

Embracing the Use of Tourniquets to Save Lives:

By Ron Mason EMT-P 

(29 April 2016)

The use of tourniquets by professionals and lay persons alike are no longer considered as dangerous as they were thought to be in the past. Using tourniquets in the combat field pre-hospital setting by combat medics and Corpsmen has proven highly effective in saving lives.  However, because of the stigma attached to them as being dangerous, the adoption of the tourniquets use in the United States on the street in the pre-hospital setting by trained Emergency Medical Technicians (EMT’s) and the lay persons is close to non-existent in its use as a tool to save lives. After reviewing all of the supported evidence from the field of battle, one can determine that it is imperative that the use of tourniquets needs to become an accepted form of bleeding control.

For centuries, tourniquets have been used in clinical settings to stop blood loss for minor and major surgeries alike. This is the go-to equipment and solution for doctors. It is a trusted treatment and remains uncontested in its ability to save lives. Shortly after World War II (DeGregory, 2007), tourniquets fell out of favor in both, street medicine and the combat setting. Using a tourniquet was commonly believed to cause limb loss and tissue damage beyond repair. The major oversight in this conclusion was simply this; stopping large amount of blood from leaving the body as quickly as possible saves lives and increases long-term patient prognosis. Somewhere along the way, the old adage “life over limb” was misplaced in hasty need to not have the person bleeding profusely from a bullet wound, traumatic amputation or other puncture wound. There is an aphorism in the medical world that states, “Eventually all bleeding stops” (Benjamin, 2016).

According to an article by BoundTree University (2011), tourniquets swiftly disappeared from the history books until the eighteenth century where the instrument resembling today’s devices, appeared. In “1718, Louis Petit, a French surgeon, developed the screw device derived from the French verb "tourner" (to turn), he named the device "tourniquet" (McEwin, n.d) as it is commonly known today. Subsequently, throughout modern times, the device has gone in and out of favor as professionals debate over the risks they pose to the victim. According to DeGregory’s (2007) article, “they had been shunned by the military since the end of World War II” (p. 16, 2007).

Shortly after a battle in Somalia, the military looked into reevaluating the use of tourniquets (Efficacy of Prehospital Application of Tourniquets, 2008). As depicted in the movie, “BlackHawk Down” (Sony, 2001), without the means of an extraction, several soldiers, died in combat that day from bleeding to death. When the fighting ended, the military commissioned an investigation and looked at what they could do to resolve treatable combat battle field deaths. The two major items they purposed were; a new tactical care doctrine and the use of tourniquets on the battle field. Shortly afterwards, the military adopted the civilian version of Pre-hospital Trauma Life Support (PHTLS) and adjusted it to a more combat friendly version called Tactical Combat Casualty Care (Journal of Emergency Medicine, 2013), (Efficacy of Prehospital Application of Tourniquets, 2008).

While the military was instrumental in the fallout of tourniquet usage, they now lead the charge of reviving the use of tourniquets, in the United States. However they have been met with resistance and have been slow to catch on with pre-hospital workers, and even slower with law enforcement and firefighters. That is currently changing but at a slower rate than it should be.

Additionally, tourniquets are still not endorsed or instructed to the civilian population on a wide scale; civilians continue to be taught with literature that is a decade behind. In an article by Barret, he quotes [Dr.] Pons, "It's kind of a radical change in thinking, because for years we have been teaching that tourniquets should be the absolute last resort,” (WSJ, 2013). Quite the opposite is true: placing the tourniquet on as soon as possible has shown amazing results in both combat operations and traumatic exsanguination (massive or complete blood loss) here in the United States. The average adult can fully exsanguinate in less than five minutes and irreversible damage happens in less than three minutes (WSJ, 2013) with 30% blood loss and at this time, the United States military medical community, based on the recent wars and data shown in this paper, has more experience and data on the effects and positives outcomes of the tourniquet than any fighting force in history. No service person is shipped off to war without proper training, an individual first aid kit and a tourniquet.

Traumatic death is the number one killer of all Americans in the age range of birth to 46 years of age and is the number three killer of people of all ages in the United States. (National Trauma Institute, 2014).  Each year trauma counts for over 190,000 people dying and takes 30% of all life years lost (National Trauma Institute, 2014). Roughly 3% or 5700 of these deaths are from traumatic amputation (NHTSA, 2014), 13,286 are from gunshot deaths in 2015 (BBC, 2015), and 475 died from mass shootings (BBC, 2015). Obviously, proficiency with a device to stop bleeding immediately and allow medical personnel to get patients to the hospital is in great need on the streets of America. Why do we have such resistance from the civilian medical world and first responders in implementing the use of the tourniquet to civilians in our country?

The number one concern is that tourniquets cause the loss of limbs or nerve damage to those who have had a tourniquet applied to a limb that suffered damage. In a 2007 study conducted by a combat support hospital in Iraq by the military, 499 patients received 862 tourniquets in the field on 651 limbs (Journal of Emergency Medicine, 2011). Survival rate of 87% was documented for those who had the tourniquet applied. If the tourniquet was applied prior to onset of shock, the survival rate was 96% (Journal of Emergency Medicine, 2011). Only .4% had limb shortening, four patients total had transient nerve issues at the application site of the tourniquet, and zero amputations resulted solely from using the tourniquet (Annals of Surgery, 2009). The study concluded lifesaving benefits and low risk, while stopping the bleeding and preventing the patient from going into shock (Journal of Emergency Medicine, 2011).

There are many statistics and studies showing that tourniquets are not the hindrance in providing life and limb saving medical care and are considered the norm as detailed throughout this paper. Why is there still push back on using this life saving device? In all probability, it stems from a lack of information communicated to EMS providers, doctors who are not current in available information and governing agencies who place protocols for Emergency Medical Technicians to practice. Another reason it is often overlooked stems from the pre-Iraq war days.

Tourniquets used in the field were not consistent across the board; training was negligible, tourniquets were too thin and inadequate to sufficiently stop bleeding and inflicted massive tissue damage. Today, new materials and advancing technology have enabled the average person to be swift and proficient in applying the modern commercially available devices. Additionally, training and education is available via the internet.  One can find expert advice, information, and training videos.

         In an Army Times article by Kime (2014), he quotes Dr. Hunt, an Army veteran and doctor who worked on victims of the Boston Marathon bombing: "Bystanders have played critical roles in emerged threats, things we already face, bombings, active shooters. ... The purpose of our group is to identify actions and tools the general public at large can use to save lives," (p. 8, 2014). Dwyer (2016) quotes [Dr.] “Gupta , “is that there is good training for who needs one, how to apply one, and then making them available and they can really save lives” (p.23, 2016).

Hunt said the White House-led group is working to develop a public service campaign that will have the sticking power of successful initiatives such as "Stop, Drop and Roll" or "See Something, Say Something." (p.16, 2014). "We need to get it right. We have a real opportunity to prevent deaths," Hunt said. (p. 18, 2014). Even after the Boston Marathon bombing, the Red Cross’ position was “Only trained people should use them and only as a last resort” (Lloyd, 2013). As of October 2015, the American Heart Association after all its push back has finally conceded that tourniquets can and should be used after initially trying to stop bleeding with direct pressure. (Red Cross and Heart Association Announce Updated Guidelines, 2014).

The need to give first responders the ability to save lives in the field is crucial. Why is there still continued push back on using this life saving device? Change is needed and there must be willingness for the public and doctors in the trauma centers to accept and learn the lessons of the past. The general public is extremely capable of using these simple devices, and the distance to the hospitals is more than adequate within the studied time constraints to help rather than hurt individuals who have the need to have a tourniquet applied.

References

Barret, D. Tourniquets Gain New Respect Recent Tragedies Prompt Rethinking of Ancient Technique. The Wall Street Journal. Retrieved from http://www.wsj.com/articles/SB10001424052702303672404579151982256689914

Benjamin, A. (2013, April 16). Events force BAA to alter course at Marathon. Boston Globe. Retrieved from http://www.bostonglobe.com/sports/2013/04/15/baa-alters-boston-marathon-after-blasts/KNAF53rH44yECYwrGpD25L/story.html

Burke, P., Kalish, J., Feldman, J., Agawal, S., Glantz, A., Serino, R., & Herish, E. (2008, July 31). The Return of Tourniquets: Original research evaluates the effectiveness of prehospital tourniquets for civilian penetrating extremity injuries. Journal of Emergency Medicine. http://www.jems.com/articles/print/volume-33/issue-8/patient-care/return-tourniquets-original-re.html

Center Disease Control. (2014, February). Trauma Statistics . In National Trauma Institute . Retrieved April 20, 2016, from http://www.nationaltraumainstitute.org/home/trauma_statistics.html

Dwyer, D. (2016, January 9). Tourniquets, now carried by Boston police, weren’t always standard. Boston.com. Retrieved from http://www.boston.com/news/untagged/2016/01/09/tourniquets-now-carried-by-boston-police-werent-always-standard

Guns in the US: The statistics behind the violence. [Online Exclusive] (2016, January 5). BBC.com. Retrieved from http://www.bbc.com/news/world-us-canada-34996604

Kime, P. (2014, August 20). Army doctor promotes use of tourniquets. Army Times. Retrieved from http://www.militarytimes.com/story/military/2014/08/20/army-doctor-promotes-use-of-tourniquets/14333319/

Kragh, J., Littrel, M., Jones, J., Walters, T., Baer, D., Wade, C., & Holcumb, J. (2011, December). Battle Casualty Survival with Emergency Tourniquet Use to Stop Limb Bleeding. Journal of Emergency Medicine, 590-597. http://www.jem-journal.com/article/S0736-4679(09)00638-6/fulltext

Kragh, J., Walters, T., Baer, D., Fox, C., Salinas, J., & Holcumb, J. (2009, January). Survival with emergency tourniquet use to stop bleeding in major limb trauma. Annals of Surgery. http://www.ncbi.nlm.nih.gov/pubmed/19106667

Kragh, J., Walters, T. J., Westmorland, T., Miller, R. M., Marby, R. L., Kotwal, R., & Ritter, B. A. (n.d.). Tragedy Into Drama: An American History of Tourniquet Use in the Current War (3rd ed., Vol. 13). N.p.: Journal of Special Operations Medicine. (Original work published 2013) http://www.ncbi.nlm.nih.gov/pubmed/24048983

Lloyd, J. (20113, April 18). Emergency tourniquets, war lessons saved lives in Boston. USA Today. Retrieved from http://www.usatoday.com/story/news/nation/2013/04/17/tourniquets-emergency-boston/2091079/

McEwin, J. (n.d.). Tourniquet overview. In Tourniquet.org. Retrieved April 7, 2016, from http://www.tourniquets.org/tourniquet_overview.php

Red Cross and Heart Association Announce Updated Guidelines. (2015, October 15). In American Red Cross. Retrieved April 26, 2016, from http://www.redcross.org/news/press-release/Red-Cross-and-Heart-Association-Announce-Updated-Guidelines

Scott, R. (Director). (2001). Black Hawk Down [Online video]. Sony. Retrieved from http://www.sonypictures.com/movies/blackhawkdown/

Snyder, D., Tsou, A., & Schoelles, K. (2008, July 31). Efficacy of Prehospital Application of Tourniquets and Hemostatic Dressings to Control Traumatic External Hemorrhage. . In National Highway Traffic Safety Administration. Retrieved May, 2014, from file:///C:/Users/Owner/Downloads/811999b-TraumaHemostasisEvidenceReport.pdf

Tourniquets: From combat to commonplace. (2011). In Boundtree University. Retrieved from http://www.boundtreeuniversity.com/Trauma/articles/1001716-Tourniquets-From-combat-to-commonplace

Authored by Ronald Mason EMT-P (Please direct all question and comments to rmason92@gmail.com)

and a special big thanks to my editor Alison Swanson