View Full Version : TQ vs pressure dressing
Let me preface this by saying I think the proliferation of tourniquets in tactical gear is great. I'm not a first responder or professional shooter but I keep one in my range bag and on my chest rig. And I've seen a lot of folks attaching them to their weapons. I'll throw the number one name out there- Paul Howe, who when I see him do something with his gear I immediately start thinking I should do it.
I'm just wondering if your going to attach a first aid item to your weapon, your basically prioritizing one item over all others. I would think that item should be a pressure dressing. We have much better dressings than we used to (IDF dressings) A pressure dressing will work as a TQ, or as a chest seal in a pinch. I think carrying more dressings would be more important than any other single piece of gear.
Just curious if anyone else has had this thought.
And it's not new...
You look at pics of ANZAC soldiers in Vietnam they all had a field dressing attached to their weapon
http://upload.wikimedia.org/wikipedia/commons/thumb/f/fd/RAR_Vietnam.jpg/220px-RAR_Vietnam.jpg
And I think it was SOP for a lot of the airborne in WWII
http://www.commandposts.com/wp-content/uploads/2011/06/Normandy-Airborne.jpg
Back in my grunt days we only carried one dressing on our LBE, but when on the DMZ we made a point to have several more.
I think that the tq being priority has come about from our current conflicts, alot of amputations from ieds. Personally when I'm deployed I carry 3, one on my belt line kit, one on my PC/ chest rig and one attached to my rifle stock. Reasoning behind it all is even if a tq isn't quite needed as long as we can get the casualty to a role 1 facility in time it isn't going to hurt anything. On the other hand if a dude needs a tq but we first put on an Israeli, then were actually creating another step if a tq is needed.
I'm just wondering if your going to attach a first aid item to your weapon, your basically prioritizing one item over all others. I would think that item should be a pressure dressing. We have much better dressings than we used to (IDF dressings) A pressure dressing will work as a TQ, or as a chest seal in a pinch. I think carrying more dressings would be more important than any other single piece of gear.
:rolleyes:
A pressure dressing will work as a... pressure dressing "in a pinch", it will not work as a TQ or chest seal.
If someone (possibly yourself) has an injury that requires a TQ or chest seal, use the appropriate item for the injury rather than trying to "improvise" a fix designed for something else.
BTW- Israeli bandages are not that much better than the old field dressings, there are better dressings out there than the Israeli bandage.
The US military has the lowest combat fatality rate in the history of recorded warfare, in large part due to the lessons learned from previous conflicts. So pictures of soldiers in past wars (who were never issued TQ's or chest seals) carrying field dressings is irrelevant and misleading.
Having said that, carry whatever you feel is appropriate
:rolleyes:
A pressure dressing will work as a... pressure dressing "in a pinch", it will not work as a TQ or chest seal.
If someone (possibly yourself) has an injury that requires a TQ or chest seal, use the appropriate item for the injury rather than trying to "improvise" a fix designed for something else.
BTW- Israeli bandages are not that much better than the old field dressings, there are better dressings out there than the Israeli bandage.
The US military has the lowest combat fatality rate in the history of recorded warfare, in large part due to the lessons learned from previous conflicts. So pictures of soldiers in past wars (who were never issued TQ's or chest seals) carrying field dressings is irrelevant and misleading.
Having said that, carry whatever you feel is appropriate
I guess you missed the part where I said I carry a couple of TQs huh?
My question is this... if you can only carry so many items, would you rather be heavy on the thing that is more multi-purpose? You seemed to have missed the entire point, because undoubtedly the dressing makes a much better TQ than a TQ makes a dressing.
Kest gave me an awesome answer... makes sense if the most likely injury is a traumatic amputation I would rather have more TQs- makes sense and I will incorporate it in to my knowledge base.
I will say, beyond a doubt, that the IDF dressing is FAR greater than what we were issued in the 90s.... if you think there is something better please enlighten.
I guess you missed the part where I said I carry a couple of TQs huh?
My question is this... if you can only carry so many items, would you rather be heavy on the thing that is more multi-purpose? You seemed to have missed the entire point, because undoubtedly the dressing makes a much better TQ than a TQ makes a dressing.
Kest gave me an awesome answer... makes sense if the most likely injury is a traumatic amputation I would rather have more TQs- makes sense and I will incorporate it in to my knowledge base.
I will say, beyond a doubt, that the IDF dressing is FAR greater than what we were issued in the 90s.... if you think there is something better please enlighten.
Nope, I read where you stated that you kept TQ's in your range bag and chest rig.... and then proceeded to make the point that you think it would be more practical to carry an Israeli dressing.
Your false premise is "if you can only carry so many items"- where does that restriction come from? There are active duty ground pounders that roll outside the wire with 2 or 3 TQ's and an IFAK, if its important to have then bring it with you.
A TQ, Israeli dressing and chest seal do not take up much room. If your medical skills are based on 1990's doctrine then carry on with whatever is appropriate to your level of training.
I only use Israeli bandages for training and that's only because I get them for free.
For my med kits I stock them with Olaes Modular Bandages (http://www.tacmedsolutions.com/store/Products_Detail.php?ProductID=3)
Designed by an 18D, he created the Olaes modular bandage and named it after SSgt Tony Olaes so that it would offer more flexibility in treating different injuries (not designed to be used as a chest seal or TQ by the way)
Nope, I read where you stated that you kept TQ's in your range bag and chest rig.... and then proceeded to make the point that you think it would be more practical to carry an Israeli dressing.
Your false premise is "if you can only carry so many items"- where does that restriction come from? There are active duty ground pounders that roll outside the wire with 2 or 3 TQ's and an IFAK, if its important to have then bring it with you.
A TQ, Israeli dressing and chest seal do not take up much room. If your medical skills are based on 1990's doctrine then carry on with whatever is appropriate to your level of training.
I only use Israeli bandages for training and that's only because I get them for free.
For my med kits I stock them with Olaes Modular Bandages (http://www.tacmedsolutions.com/store/Products_Detail.php?ProductID=3)
Designed by an 18D, he created the Olaes modular bandage and named it after SSgt Tony Olaes so that it would offer more flexibility in treating different injuries (not designed to be used as a chest seal or TQ by the way)
Do I did not suggest that I would get rid of my TQs I think having them is a great idea. The question is, if I'm gonna add one more thing should it be a TQ or a dressing. Sure those things don't take up much space but I carry multiples of each.
Thank you for the link to the dressing, I see the main advantage as being the extra gauze to cover an exit wound.
Treehopr beat me to it...
I carry multiple TQ's on me. I run warrants and track down violent criminals all day long. I keep a TQ in each cargo pocket, along with 3 sets of gloves, and an Oales bandage. The Oales is by far the best thing I've come across in a long time, and they're cheap. The Oales also has the occlusive sheet which could be used for a tension pneumothorax. On top of that I have a kit on my plate carrier and an additional TQ in a LBT horizontal pouch that sits under the cummerbund. I also carry a full med kit loaded down with chem lights and 3 spare rifle mags just in case something goes very bad.
As for only one item, I'd take a TQ over anything else. I'm sure you know, but a TQ is designed to cut off the most severe types of bleeding. A pressure dressing is a step down from that and I would not put that much faith in a pressure dressing to act the same as a TQ. Pressure dressings have elastic in the bands, which isn't conducive to locking down an artery. It also seems much easier to make a pressure dressing than it would a TQ.
Treehopr beat me to it...
I carry multiple TQ's on me. I run warrants and track down violent criminals all day long. I keep a TQ in each cargo pocket, along with 3 sets of gloves, and an Oales bandage. The Oales is by far the best thing I've come across in a long time, and they're cheap. The Oales also has the occlusive sheet which could be used for a tension pneumothorax. On top of that I have a kit on my plate carrier and an additional TQ in a LBT horizontal pouch that sits under the cummerbund. I also carry a full med kit loaded down with chem lights and 3 spare rifle mags just in case something goes very bad.
As for only one item, I'd take a TQ over anything else. I'm sure you know, but a TQ is designed to cut off the most severe types of bleeding. A pressure dressing is a step down from that and I would not put that much faith in a pressure dressing to act the same as a TQ. Pressure dressings have elastic in the bands, which isn't conducive to locking down an artery. It also seems much easier to make a pressure dressing than it would a TQ.
If you could only have ONE item it would be a TQ- an item that, by definition, can only treat a wound to an extremity. OK
To make a reasonable facsimile of a pressure dressing you need a maxi-pad an ACE bandage(or roll of duct tape), to make a TQ you need a belt and a stick. Which would you rather be looking for when someone is bleeding out in front of you?
Let me rephrase the OP... "hey I carry pressure dressings and TQs, I noticed people attaching another something to the weapons, out of those two which would make more sense."
Ok, let me rephrase. I've been in positions where I have applied TQ's, make shift TQ's, pressure dressings, and make shift pressure dressings.
For one item, yes, I'd rather carry a TQ that will cut off spurting blood from an artery, because I'd rather have the blood flow cut off that's actually shooting out of me. A pressure dressing will not stop that nearly as effective.
A pressure dressing is for a lower level of bleeding. Everyone wears clothes. Pressure dressings can be made out of t shirts. The idea is to have an absorbent piece of material and something to hold it down. Hands work well, as will another piece of clothing that you tore off to make that dressing.
I know what I would rather deal with, because I've been in those positions.
thopkins22
08-11-13, 10:37
Part of what you're missing from some of these replies is that with the advent of body armor a larger percentage of serious wounds are going to be in the extremities. Certainly the sides are vulnerable, and inevitably shit will just happen. But I'm willing to bet that the statistics back that up.
John Doe as a citizen driving around town is more likely to come across someone with a crushed leg from a car accident, a missing hand from screwing around with a boat propeller, or a chainsaw accident than he is someone with holes in his torso from a gunfight.
Part of what you're missing from some of these replies is that with the advent of body armor a larger percentage of serious wounds are going to be in the extremities. Certainly the sides are vulnerable, and inevitably shit will just happen. But I'm willing to bet that the statistics back that up.
John Doe as a citizen driving around town is more likely to come across someone with a crushed leg from a car accident, a missing hand from screwing around with a boat propeller, or a chainsaw accident than he is someone with holes in his torso from a gunfight.
Exactly.
I have applied a make shift TQ to a guy who was racing his friend in a SUV while he was riding a motor cycle. He center punched a light pole and severed his leg. I am not sure on this and am only throwing it out there, but I would bet there are more saved lives due to TQ's than there are pressure dressings.
LMT Shooter
08-11-13, 22:46
[QUOTE=Vendetta;1718416]A pressure dressing is for a lower level of bleeding. Everyone wears clothes. Pressure dressings can be made out of t shirts. The idea is to have an absorbent piece of material and something to hold it down. Hands work well, as will another piece of clothing that you tore off to make that dressing.
QUOTE]
Bingo. Yes, this does increase the risk of infection, but those who bleed to death from extremity bleeding will never die from an infection.
I've practiced emergency medicine for 10 years at multiple civilian level 1 trauma centers, 399th CSH Al Asad Iraq, and CJTF 82nd Afghanistan. This is in addition to thousands of hours of prehospital work as a paramedic before medschool and as a physician on Metro Lifeflight out of Cleveland, OH. I generally see 2-3 really FUBAR people per day.
Over 95% of the TQ's that I've used in my career have been on multiple extremity amputations from IED blasts. I've used maybe 1 or 2 TQ's for civilian industrial amputations. The only other civilian TQ that I recall using was for a high brachial artery knife wound where the laceration extended 20 cm from axilla to elbow along with a laceration through the contents of the right femoral triangle. This last TQ was a very unique situation caused by an hombre who knows how to use a knife. In other words, the actual need for a TQ in a civilian environment is actually very, very rare. I cannot recall using or needing a TQ for a civilian GSW in my career. That is because local, direct pressure is all that is needed to control even arterial bleeding from the vast majority of GSW injuries.
If I could only have one dressing, the Israeli Emergency Bandage would be my first choice. I've had great success with this dressing for 99% of the wounds that I've encountered outside of theater. It is also great for bleeding scalp wounds which are not amendable to a TQ ;).
My experience over 30 years as a surgeon on call for trauma at two different hospitals mirrors Sensei's (although in this area, the trauma intensity is lower, there's less penetrating trauma, and time-to-ER is shorter by military standards). Over the years I've been here, a patient coming in with a tourniquet would be extraordinarily rare. Likewise chest seals of any kind.
Tourniquets are great tools. First responders (some locations more than others) should all have one in their bag and know how to use it for the very rare circumstance that they might need it. As for the rest of us, it's likely just another item of useless gear to lug around. OTOH, they're cheap, small, and generally unlikely to do harm. It's not a bad accessory for a civilian to add to their chest rig for just the right look. Along with a blood-type patch.
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In a related discussion on another site, in regards to TQs for use on children, I suggested exploring different intervetions for haemorrhage control before using a TQ, like pressure points or direct pressure.
Someone stated that the use of pressure points/direct pressure was not taught as part of TCCC protocols, and used that fact as an indication of the ineffectiveness of those interventions.
While a TQ is very effective at what it's meant to do, it is a CUF intervention when you are in a situation where other interventions are not feasable. The TQ did not render pressure points/direct pressure obsolete.
As to the OP's question, what is the intended use for your setup? Are you LE/MIL? What other types of medical supplies do you carry?
The reasoning for Mr. Howe's TQ on the buttstock is that the rifle is usually always with him, so a TQ is readily available even if he isn't wearing his vest.
In a military unit, IFAK contents are pretty standard and the same across the board. The patients IFAK contents are for him. Same with the TQ, you preferably use the pt's TQ on them, not your own.
And, as others have stated, the incidence of penetrating trauma is a lot higher in war zones than back home.
So, if you are carrying essentially a bleeder kit, and you have a TQ on your chest rig and in you range bag. Supplement this with combat gauze, rolled gauze and a proper dressing and you will do fine. There really is no need to have medical gear on your gun.
There really is no need to have medical gear on your gun.
It's not a bad accessory for a civilian to add to their chest rig for just the right look. Along with a blood-type patch.
Both of these fads seem to stem from the desire to look cool. They have essentially zero practical application. In the case of TQ's on a weapon, there is a very small chance of harm caused by snagging unintended objects.
As for the blood-type patches - it is safe for you to remove them. There is no medical facility in the US or the Middle East that is going to give you type-specific blood based on a patch that you wear on your sleeve or even your dog tags. Even if I wanted to do this, the blood bank at any reputable hospital would not release type-specific blood based on a patch unless they want the Joint Commission to shut them down. So, unless you are at the Battle of Kamdesh you can replace the blood-type patches with Jolly Roger.
NeoNeanderthal
08-12-13, 12:46
Very interesting topic. I roll with a SWAT-T TQ on my buttstock. It is extremely low profile and nestles in the void of the ctr stock. Not as great as a CAT-TQ but it works as a TQ or pressure bandage. It's light small, and low pro so i don't worry about having it there. Might not look very cool, but I'm not a very cool looking guy anyway!
http://i117.photobucket.com/albums/o45/Nickspadaro/Facebook/Gun%20Stuff%20and%20Projects/1005135_10101070881900939_263003718_n.jpg
Very interesting topic. I roll with a SWAT-T TQ on my buttstock. It is extremely low profile and nestles in the void of the ctr stock. Not as great as a CAT-TQ but it works as a TQ or pressure bandage. It's light small, and low pro so i don't worry about having it there. Might not look very cool, but I'm not a very cool looking guy anyway!
Are you a First Responder of some kind? Do you use such bandages much?
NeoNeanderthal
08-12-13, 13:20
Are you a First Responder of some kind? Do you use such bandages much?
Nope, wilderness first responder certified, first aid, cpr ext. Never dealt with life threatening bleeding, just stitch worthy wounds and practice/play with tqs/pressure bandages at my WFR cert.
I know the limitations of the swat-t (hard to apply one handed and doesn't cut off blood flow as much as a real tq). It's there because it's much less of a snag hazard then a SWAT-T and can be used for other things (cut into strips for cordage, used as a sling, fire starter, attaching gear ext).
Gutshot John
08-12-13, 13:55
hard to apply one handed and doesn't cut off blood flow as much as a real tq
It is a real TQ, surgical tourniquets are used in operating rooms all over the world, that's where the idea came from.
It's definitely harder to apply without a lot of practice, but it's very effective.
NeoNeanderthal
08-12-13, 14:14
It is a real TQ, surgical tourniquets are used in operating rooms all over the world, that's where the idea came from.
It's definitely harder to apply without a lot of practice, but it's very effective.
Correct. I should have said "conventional TQ" not "real TQ." Didn't mean to talk shit about my own tq! (i do have a cat on my belt med kit as well, but could never get used to having it mounted on my buttstock).
I'm just wondering if your going to attach a first aid item to your weapon, your basically prioritizing one item over all others. I would think that item should be a pressure dressing.
The OP original premise was a med kit item attached to your weapon, which would presume that you have that med kit item readily available on the weapon rather than simply having something with you as you go about your daily business (minus your rifle)
I wouldn't dispute the real world experiences of the two docs but I would submit that for a long time TQ's were considered a last resort item, so it would make sense that you wouldn't see those items being used until recently.
In a "normal" emergency situation, where there is no continued threat, where the resources outweigh the victim(s) and where professional responders can do what they're trained and paid to do, then much of the direct pressure/pressure dressing/10 min ride to hospital model works without the need for a TQ or a chest seal.
If you're in a scenario where those factors are absent and you may be on your own to self treat, a TQ may be more of a neccessity. The North Hollywood bank robbery being an example of LEO's who had to improvise TQ's. Those situations may be exceedingly rare but they do happen.
Consider the Boston Marathon bombings earlier this year, if that had happened 10 or 20 years ago, would the prevalence of TQ's been more or less likely?
Given the changes in medical protocols and training in the last 10 years, use of TQ's in a .mil setting is all but taken for granted; I believe that trend will carry over to the civilian side- whether its LEO or EMS and eventually trained "civilians"-
I remember the controversy surrounding QuikClot and other hemostatic agents when they first started being used, now you can find QC at Cabela's and TQ's can be ordered off of Amazon.
FWIW- I don't carry med gear on my rifle, but I wouldn't knock somebody else for doing it either.
Gutshot John
08-12-13, 17:27
They used to have the old "paratroop packs" which were a TQ and a syrette of morphine issued to every paratroop on D-Day.
A modern equivalent is what the OP is talking about on a weapon mounted platform. Not a bad idea actually.
I'd vote for a SWAT-T with an H&H H-bandage, provides both options in a much smaller footprint than a OLAES/Israeli dressing, for much less cost than a CAT-T. You can even add a chest seal (non-valved) for no additional space which will plug other holes than just a punctured lung.
The OP's premise is that you are only allowed one.
I'd vote for the tq & morphine if allowed more than one ;-)
To be clear, my thoughts (premise) were that- if you're gonna carry this and that on your person (chest rig BOK etc) and you are thinking about one more thing to attach to your weapon- what would be the most logical?
I keep a BOK with CAT, IZZY and quick clot in my car and on my belt when "kitted out." I keep another CAT on my chest rig set up for self service, and at times keep another old school army pressure dressing on the other side.
My thinking is that if I've got my rifle with me the most likely (treatable) injuries would be torso bullet wounds, with extremity bullet wounds as second most likely.
Point of interest- the only time I have ever needed any of the serious trauma kit I am talking about was when I was 1st person at a traffic accident. I needed an Izzy or similar and was stuck using a towel. Luckily the paramedics showed up quickly. But you know what they say about statistical cases of one.
Neo- seeing your weapon was what started me on this train of thought. I have kept a pressure dressing on my stock before buy didn't like it. But was figuring I would try something attached to the forearm.
Gutshot- Thank you for telling me what was in the "paratrooper pack" I introduced those pics in my OP just to say -what's old is new again.
NeoNeanderthal
08-12-13, 22:14
Neo- seeing your weapon was what started me on this train of thought. I have kept a pressure dressing on my stock before buy didn't like it. But was figuring I would try something attached to the forearm.
I got the idea from paul howe but couldn't stand the full size TQ on there. It's attached with coflex which helps squeeze it down tight but keeps it easy access. Im working on attaching one to a B5 stock in an efficient manner...I thought about getting a forend magpouch but i thought it'd be too big. I don't know how people stand to roll with a pmag or something that size on there.
The OP original premise was a med kit item attached to your weapon, which would presume that you have that med kit item readily available on the weapon rather than simply having something with you as you go about your daily business (minus your rifle)
I wouldn't dispute the real world experiences of the two docs but I would submit that for a long time TQ's were considered a last resort item, so it would make sense that you wouldn't see those items being used until recently.
In a "normal" emergency situation, where there is no continued threat, where the resources outweigh the victim(s) and where professional responders can do what they're trained and paid to do, then much of the direct pressure/pressure dressing/10 min ride to hospital model works without the need for a TQ or a chest seal.
If you're in a scenario where those factors are absent and you may be on your own to self treat, a TQ may be more of a neccessity. The North Hollywood bank robbery being an example of LEO's who had to improvise TQ's. Those situations may be exceedingly rare but they do happen.
Consider the Boston Marathon bombings earlier this year, if that had happened 10 or 20 years ago, would the prevalence of TQ's been more or less likely?
Given the changes in medical protocols and training in the last 10 years, use of TQ's in a .mil setting is all but taken for granted; I believe that trend will carry over to the civilian side- whether its LEO or EMS and eventually trained "civilians"-
I remember the controversy surrounding QuikClot and other hemostatic agents when they first started being used, now you can find QC at Cabela's and TQ's can be ordered off of Amazon.
FWIW- I don't carry med gear on my rifle, but I wouldn't knock somebody else for doing it either.
I don't think anybody is knocking or debating the efficacy of a TQ or saying that is should remain a last resort intervention.
The fact remains, however, that an improperly attached TQ;
-not tight enough
-in the wrong location
can cause issues and compound the bleed that neccessitated the TQ in the first place. Worst case is a venous TQ that could kill the pt quicker du to increased bleeding.
TQ's have great advantages when you are alone, in that it allows you continued use of both hands when applied, so that you can continue to examine the patient while not having to compress a bleed at the same time.
TQ's are great tools, but requires training and regular refreshment training in order to as efficient as it can be.
I don't think anybody is knocking or debating the efficacy of a TQ or saying that is should remain a last resort intervention.
Tourniquets are great tools. First responders (some locations more than others) should all have one in their bag and know how to use it for the very rare circumstance that they might need it. As for the rest of us, it's likely just another item of useless gear to lug around
I was specifically addressing the above point by HMAC. Again, I don't dispute his experience with seeing few TQ's applied in a pre-hospital environment but pose the question as to whether TQ's were un-needed or whether it's because their use was discouraged until (relatively) recently.
The fact remains, however, that an improperly attached TQ;
-not tight enough
-in the wrong location
can cause issues and compound the bleed that neccessitated the TQ in the first place. Worst case is a venous TQ that could kill the pt quicker du to increased bleeding.
TQ's have great advantages when you are alone, in that it allows you continued use of both hands when applied, so that you can continue to examine the patient while not having to compress a bleed at the same time.
TQ's are great tools, but requires training and regular refreshment training in order to as efficient as it can be.
Concur on all points but I think those same standards can be applied to any medical kit item or weapon system.
The OP posed the question of what one item you would have attached to your weapon, which as I read it- meant that you have nothing else.
Not that you have your TQ/Izzy mounted to your weapon and also happen to have a full IFAK on your belt/plate carrier/chest rig/range bag/trunk of your car... which he clarified in his most recent post.
Prior to that, he stated that you would have one item attached to your weapon and you would improvise the other.
If you could only have ONE item it would be a TQ- an item that, by definition, can only treat a wound to an extremity. OK
To make a reasonable facsimile of a pressure dressing you need a maxi-pad an ACE bandage(or roll of duct tape), to make a TQ you need a belt and a stick. Which would you rather be looking for when someone is bleeding out in front of you?
Obviously, if you have the IFAK in any of the above mentioned locations then you wouldn't need to improvise anything. So if I did have a pressure dressing attached to my rifle, I wouldn't be looking for a belt and a stick, I'd be looking for my TQ (along with the rest of my med kit)
Fortunately, I've never had to self treat for a GSW or similar penetrating trauma but I wonder how "easy" would it be to self apply an Israeli bandage to the torso compared to a TQ to an extremity.
I was specifically addressing the above point by HMAC. Again, I don't dispute his experience with seeing few TQ's applied in a pre-hospital environment but pose the question as to whether TQ's were un-needed or whether it's because their use was discouraged until (relatively) recently.
Unneeded. I contend that the need for tourniquet application by civilians is very, very rare.
NeoNeanderthal
08-13-13, 19:07
Unneeded. I contend that the need for tourniquet application by civilians is very, very rare.
Even at a shooting range? Statistically from the hospitals perspective I'm sure it is rare. But one of the ranges I belong to has had 2 self inflicted gunshots (both upper thigh), and thats not even the short bus range.
I do get your point about a TQ not being very likely to be used in everyday life, so it need not be included in EDC. But my rifle is not used in my everyday life. My gun would get used at the range or in response to a lethal threat. I feel like in both of those situations the likelihood of arterial bleeding would be higher than in your average hospital. Thats why i have one on my rifle, and in my kit but i don't carry one in a pocket everyday.
Even at a shooting range? Statistically from the hospitals perspective I'm sure it is rare. But one of the ranges I belong to has had 2 self inflicted gunshots (both upper thigh), and thats not even the short bus range.
I do get your point about a TQ not being very likely to be used in everyday life, so it need not be included in EDC. But my rifle is not used in my everyday life. My gun would get used at the range or in response to a lethal threat. I feel like in both of those situations the likelihood of arterial bleeding would be higher than in your average hospital. Thats why i have one on my rifle, and in my kit but i don't carry one in a pocket everyday.
I gather that neither of those stupidity-inflicted thigh wounds needed a tourniquet?
I think that a tourniquet ought to be part of everyone's first aid kit, including the one that they surely have available at the suicide range you mention. I think first responders (cops, firefighters, EMTs) should have one available to them in their bags too when going about their jobs. In most civilian roles, tourniquets are likely to be at least as useful as direct pressure, and perhaps more so if they free up a caregiver. It's just that the likelihood of a civilian needing to use a tourniquet is so vanishingly low, I just don't see them as being worthy of the kind of magic that's ascribed them these days on most of these shooting forums.
A couple of weeks ago, the guy shooting next to me at carbine course (local dentist) had a state-of-the-art tourniquet rubber-banded to his high-dollar state-of-the-art plate carrier. I showed him how to use it, one of the cops at the course showed him how to attach it better. Everybody needs a hobby, I guess. I forgot to look and see if he had a blood-type patch velcro'd somewhere.
I gather that neither of those stupidity-inflicted thigh wounds needed a tourniquet?
I think that a tourniquet ought to be part of everyone's first aid kit, including the one that they surely have available at the suicide range you mention. I think first responders (cops, firefighters, EMTs) should have one available to them in their bags too when going about their jobs. In most civilian roles, tourniquets are likely to be at least as useful as direct pressure, and perhaps more so if they free up a caregiver. It's just that the likelihood of a civilian needing to use a tourniquet is so vanishingly low, I just don't see them as being worthy of the kind of magic that's ascribed them these days on most of these shooting forums.
A couple of weeks ago, the guy shooting next to me at carbine course (local dentist) had a state-of-the-art tourniquet rubber-banded to his high-dollar state-of-the-art plate carrier. I showed him how to use it, one of the cops at the course showed him how to attach it better. Everybody needs a hobby, I guess. I forgot to look and see if he had a blood-type patch velcro'd somewhere.
I didn't see one.
I've been following this thread, and I see two distinct, different schools of thought. One is on the hospital side where in terms of civilian uses the odds are lower a TQ would be utilized, and thus not a high priority. The second school of thought is more along the lines of as a result of experiences obtained in fighting environments where a TQ is seen as a higher priority because if you need it, it's needed right now. Kinda like how we carry sidearms for self defense. We may go through our whole life without needing it. But if we need to defend ourselves, we need it right now.
We also have to remember that medical care can vary. We have one in the field that is obviously connected to an urban area medical center with quick response times of EMS for just about any scenario. Hmac, I'm not sure if you're connected with a center up where I met you or the metro south of you, but that also can make a difference, and everyone really needs to identify why they are using the gear they are using.
I carry 3 TQ's. One is on my rifle, intended because no matter what there is a high likelihood I will have it with me. I have a second on the front of my PC for times I know I'm going into a fight, and it's positioned so others can see it. The third is worn on my patrol duty belt, again where people can see it, so that one is with me all the time I work patrol. Why? Is it for cool guy status? No, it's carefully evaluating my environment and my odds. I wear armor, but I'm just not going to be able to turtle up for most stuff. I still have areas exposed that I can die from if hit. Femoral, brachial, any of my extremities are exposed if bullets are coming at me. If I am wounded and an artery, especially the femoral, is hit I have a very limited amount of time to stop that bleeding. While other bleeds are also serious, I have time to get a pressure bandage, either by making one or one getting to me.
This is important, and something I think our medical guys are overlooking. They are the aftercare. In my environment, and I think a lot of rural environments can be similar, if I'm wounded I'm looking at an hour wait for area LE to react and figure out they need a Bearcat. Then I have to wait for it, and this is because EMS is not going to go into a scene that isn't safe. Then I can get to an ambulance, and I'm still looking at 25-60 minutes transport to a hospital, maybe longer if weather keeps a bird from flying. So I have to depend on myself or maybe a partner if I'm out with a second officer.
I've evaluated my situation and what my needs are. I'm going to have a TQ more available because of the time factors. But we also shouldn't lose sight that a pressure bandage shouldn't be far behind. If we carry a TQ, we will still likely need a pressure bandage, so carry both.
There is a product RCS and Eleven 10 are coming out with soon that will make it so there is no practical reason why you can't carry both.
I didn't see one.
I've been following this thread, and I see two distinct, different schools of thought. One is on the hospital side where in terms of civilian uses the odds are lower a TQ would be utilized, and thus not a high priority. The second school of thought is more along the lines of as a result of experiences obtained in fighting environments where a TQ is seen as a higher priority because if you need it, it's needed right now. Kinda like how we carry sidearms for self defense. We may go through our whole life without needing it. But if we need to defend ourselves, we need it right now.
We also have to remember that medical care can vary. We have one in the field that is obviously connected to an urban area medical center with quick response times of EMS for just about any scenario. Hmac, I'm not sure if you're connected with a center up where I met you or the metro south of you, but that also can make a difference, and everyone really needs to identify why they are using the gear they are using.
I carry 3 TQ's. One is on my rifle, intended because no matter what there is a high likelihood I will have it with me. I have a second on the front of my PC for times I know I'm going into a fight, and it's positioned so others can see it. The third is worn on my patrol duty belt, again where people can see it, so that one is with me all the time I work patrol. Why? Is it for cool guy status? No, it's carefully evaluating my environment and my odds. I wear armor, but I'm just not going to be able to turtle up for most stuff. I still have areas exposed that I can die from if hit. Femoral, brachial, any of my extremities are exposed if bullets are coming at me. If I am wounded and an artery, especially the femoral, is hit I have a very limited amount of time to stop that bleeding. While other bleeds are also serious, I have time to get a pressure bandage, either by making one or one getting to me.
This is important, and something I think our medical guys are overlooking. They are the aftercare. In my environment, and I think a lot of rural environments can be similar, if I'm wounded I'm looking at an hour wait for area LE to react and figure out they need a Bearcat. Then I have to wait for it, and this is because EMS is not going to go into a scene that isn't safe. Then I can get to an ambulance, and I'm still looking at 25-60 minutes transport to a hospital, maybe longer if weather keeps a bird from flying. So I have to depend on myself or maybe a partner if I'm out with a second officer.
I've evaluated my situation and what my needs are. I'm going to have a TQ more available because of the time factors. But we also shouldn't lose sight that a pressure bandage shouldn't be far behind. If we carry a TQ, we will still likely need a pressure bandage, so carry both.
There is a product RCS and Eleven 10 are coming out with soon that will make it so there is no practical reason why you can't carry both.
Yeh, it was the guy shooting next to me. Good shooter. Unastamos "corrected" his use of rubber bands as a means of securing it to his plate carrier.
I'm not anti-tourniquet. I think it's a potentially valuable tool that any cop, firefighter, or EMS should have available. My point has been that, you, or any cop, are far more likely to need to use one of those three tourniquets you carry for the reasons that you mentioned than any civilian. Yet I see many civilians carry that item of equipment over to the way that they outfit their own equipment. I confess I do roll my eyes a little when I see a civilian with a plate carrier outfitted with IFAK, TQ. Oh, and with their blood type velcro'd to their vest. The chances of them, or you for that matter, ever needing to apply a tourniquet are exceedingly low. The chances that anyone at any hospital will ever pay any attention to a blood type patch are zero.
Anyway, none of my comments have pertained to first responders. That's a whole different category with a whole different likelihood of emergently addressing penetrating trauma. I will say, however, that tourniquets on our ambulances up here have been standard equipment for 25 years. I've never seen one needed. Other environments may be different, however the incidence of people being brought into HCMC with tourniquets applied in Minneapolis is likewise very low, so I'm told by my colleagues there. Still, every EMT or rig has one or more as well they should, and I certainly recommend that anyone who goes in harm's way enough that they would ever carry a rifle, or have to wear body armor to work ought to have a TQ attached somewhere close. Highly unlikely to ever be needed, but it's a simple device that doesn't take much space or weight and someday, no matter how unlikely, might save a life.
My department just started issuing TQs. Had the training on it the other night. The SWAT medic who gave the training (certified Paramedic and LPN) said that if only one piece was carried the TQ would be it, but a pressure dressing is also recommended as a way to seal the wound. He recommended an isreali dressing with a clotting agent.
Yeh, it was the guy shooting next to me. Good shooter. Unastamos "corrected" his use of rubber bands as a means of securing it to his plate carrier.
I'm not anti-tourniquet. I think it's a potentially valuable tool that any cop, firefighter, or EMS should have available. My point has been that, you, or any cop, are far more likely to need to use one of those three tourniquets you carry for the reasons that you mentioned than any civilian. Yet I see many civilians carry that item of equipment over to the way that they outfit their own equipment. I confess I do roll my eyes a little when I see a civilian with a plate carrier outfitted with IFAK, TQ. Oh, and with their blood type velcro'd to their vest. The chances of them, or you for that matter, ever needing to apply a tourniquet are exceedingly low. The chances that anyone at any hospital will ever pay any attention to a blood type patch are zero.
Anyway, none of my comments have pertained to first responders. That's a whole different category with a whole different likelihood of emergently addressing penetrating trauma. I will say, however, that tourniquets on our ambulances up here have been standard equipment for 25 years. I've never seen one needed. Other environments may be different, however the incidence of people being brought into HCMC with tourniquets applied in Minneapolis is likewise very low, so I'm told by my colleagues there. Still, every EMT or rig has one or more as well they should, and I certainly recommend that anyone who goes in harm's way enough that they would ever carry a rifle, or have to wear body armor to work ought to have a TQ attached somewhere close. Highly unlikely to ever be needed, but it's a simple device that doesn't take much space or weight and someday, no matter how unlikely, might save a life.
Right...my point is that there is no right or wrong answer. I actually think the original question question was a very short sighted question, since there is no right answer. It depends on ones environment, and so many people seem to focus on the wrong thing. It's like the Cop who wants to start treatment on victims before finding the active shooter-priorities, and understand them. There are people in both schools of thought here that will lose sight of what the situation may be because they stay too focused. People need to remain objective and change what they need with the situation.
My department just started issuing TQs. Had the training on it the other night. The SWAT medic who gave the training (certified Paramedic and LPN) said that if only one piece was carried the TQ would be it, but a pressure dressing is also recommended as a way to seal the wound. He recommended an isreali dressing with a clotting agent.
I strongly recommend looking at the Olaes bandages. They are doing quite well, are cheaper, and provide something in case of an eye injury as well.
I see many civilians carry that item of equipment over to the way that they outfit their own equipment. I confess I do roll my eyes a little when I see a civilian with a plate carrier outfitted with IFAK, TQ.
If you roll your eyes at a "civilian" with a TQ and/or IFAK attached to a plate carrier I would think that the civilian even having a plate carrier or training with an AR would cause the same eye roll.
If you roll your eyes at a "civilian" with a TQ and/or IFAK attached to a plate carrier I would think that the civilian even having a plate carrier or training with an AR would cause the same eye roll.
Nah. Everybody needs a hobby.
Thanks for the heads up. They look good and in my price range.
I strongly recommend looking at the Olaes bandages. They are doing quite well, are cheaper, and provide something in case of an eye injury as well.
I'm not anti-tourniquet. I think it's a potentially valuable tool that any cop, firefighter, or EMS should have available. My point has been that, you, or any cop, are far more likely to need to use one of those three tourniquets you carry for the reasons that you mentioned than any civilian. Yet I see many civilians carry that item of equipment over to the way that they outfit their own equipment. I confess I do roll my eyes a little when I see a civilian with a plate carrier outfitted with IFAK, TQ. Oh, and with their blood type velcro'd to their vest. The chances of them, or you for that matter, ever needing to apply a tourniquet are exceedingly low. The chances that anyone at any hospital will ever pay any attention to a blood type patch are zero.
Anyway, none of my comments have pertained to
first responders. That's a whole different category with a whole different likelihood of emergently addressing penetrating trauma. I will say, however, that tourniquets on our ambulances up here have been standard equipment for 25 years. I've never seen one needed. Other environments may be different, however the incidence of people being brought into HCMC with tourniquets applied in Minneapolis is likewise very low, so I'm told by my colleagues there. Still, every EMT or rig has one or more as well they should, and I certainly recommend that anyone who goes in harm's way enough that they would ever carry a rifle, or have to wear body armor to work ought to have a TQ attached somewhere close. Highly unlikely to ever be needed, but it's a simple device that doesn't take much space or weight and someday, no matter how unlikely, might save a life.
Just a few observations, regarding first responders and, for lack of a better word, priority of or level of care. Granted, I come from the mil side of the house, so it may not apply to everyone.
First responders are seldom FIRST responders. The people present at the time of injury are, and they need to keep the pt alive until first responders arrive on scene.
Granted, many interventions work in regards to haemorrhage control, and my comment in my previous post was not a recommendation against TQ's at all. Like BC520 said, what you use it will be situationally dependant.
The good thing about TQ's is that they are very good at stopping life threatening bleeds effectively. They are ideal for tactical situations, where other interventions are not feasable without exposing the care-giver to great risk. TQ's are, however, not very versatile.
A proper pressure dressing, like the OLAES, can be used for several different applications where a TQ would be useless. That said, it is vastly inferior to the TQ when it comes to controlling bleeds if used as a TQ.
The norwegian mil was very slow to allow TQ's. That was a direct result of the experiences the former Chief Surgeon of the Army had while deployed to Kuwait, where he saw many pt's with irreversible shock due to bleeds insufficiently controlled by improvised TQ's that were applied incorrectly; distally on extremities. Possibly exacerbating the bleed as a resut. Based on this, his recommendation for our treatment protocols was to forego the TQ and to focus on using pressure dressings.
The same thing has been seen with many other interventions as well, such as crics and thoracocentesis. The medical community claimed ownership of these interventions, forgetting the fact that they will not always be present at the time of injury when the intervention is needed.
Fortunately, our experiences during our involvement in Afghanistan has resulted in a more practical approach, and pushing the knowledge down the line.
I don't see anything wrong with carrying a TQ as part of your EDC, in your range bag or on your range kit, or carried when on duty as LE/EMS etc. You might never need it, but it is better to have and not need, than to need and not have.
I don't see anything wrong with carrying a TQ as part of your EDC, in your range bag or on your range kit, or carried when on duty as LE/EMS etc. You might never need it, but it is better to have and not need, than to need and not have.
Neither do I. If I were MIL/LE/EMS, I'd carry one too. And if I had a first aid kit, I'd have one in there too, along with an OLAES or Israeli bandage.
Unneeded. I contend that the need for tourniquet application by civilians is very, very rare.
I haven't had to draw my conceal weapon yet and the odds of needing to make it very rare as well. Doesn't mean I'm going to skip having it as an option.
Gutshot John
08-16-13, 15:24
I've yet to see a compelling argument that civilians have little need for TQs.
Indeed I've yet to see a compelling argument that civilians should not be encouraged to carry TQs in increasing numbers.
As others have noted, the chances of me needing a TQ...or a handgun are pretty rare.
If you need a TQ, you're likely to die without it. A battle dressing is unlikely to mean the difference between life and death even under the best of circumstances.
thopkins22
08-16-13, 15:36
If you need a TQ, you're likely to die without it. A battle dressing is unlikely to mean the difference between life and death even under the best of circumstances.
This is my understanding as well. Pressure can be applied to wounds with bare hands with moderate success. Pressure dressings can be improvised readily out of a ripped t-shirt if need be. But if you need a TQ, you need it right f-ing now, and chances of improvising something workable out of a belt are not that great.
How long do you have with a severed femoral before you fade to black? Thirty seconds? A minute?
Combined with the knowledge that the medical community has developed regarding saving limbs that have had tourniquets applied and it seems like a no brainer.
I don't buy the sterile arguments on improvised dressings, if I've had a hole put in my body, I think it's fair to assume that my insides are no longer a sterile environment.
Pressure can be applied to wounds with bare hands with moderate success.
Moderate success is incorrect. It is a very effective method, just not very feasible when being shot at because it usually requires you to be sitting in order to apply enough pressure.
The TQ did not render direct pressure or pressure points obsolete, although it is a dedicated tool that does the job extremely well.
I don't buy the sterile arguments on improvised dressings, if I've had a hole put in my body, I think it's fair to assume that my insides are no longer a sterile environment.
This is correct. We consider all penetrating injuries sustained in the field as infected. Our medics carry ABX that are administered if time allows before evac. The earlier ABX are given, the less likelyhood of serious infection -> administer sooner than 4 hours.
How long do you have with a severed femoral before you fade to black? Thirty seconds? A minute?
Initially, a severed femoral artery bleeds at a rate of 1 liter per minute. After 15 seconds it has been reduced to about 250ml per minute, a result of the body's own compensating mechanisms.
Studies have been done on pigs, where they severed 2 arteries and 1 vein in the inguinal/groin area, with no interventions until 10 minutes had passed. They had a 100% survival rate. Bleeding out takes time.
Gutshot John
08-16-13, 20:46
I'd put combat gauze way ahead of any kind of battle dressing. But since the FDA has cracked down on QCCG distribution, a non-abusable and life-saving product, to non-public safety personnel is criminally stupid. QC sport? Don't make me laugh.
A TQ, at least, is broadly and cheaply available. Direct pressure can and will work with very aggressive application...of course you might have a squirming/screaming/pissed-off patient underneath you.
You have to be a little sadistic if you're going to treat traumatic injury. :sarcastic:
thopkins22
08-16-13, 20:55
Excellent information Arctic1, thanks for the post.
I'd put combat gauze way ahead of any kind of battle dressing. But since the FDA has cracked down on QCCG distribution, a non-abusable and life-saving product, to non-public safety personnel is criminally stupid. QC sport? Don't make me laugh.
It's my understanding that you can still get proper quick clot that is identical to combat gauze, only without the magnetic strip. But what a ridiculous thing to regulate. Magnetic strips? Just imagine the evil civilians could accomplish with those!
I have a thing or two of the sport in addition to the gauze...but the sport seems to be some sort of sponge instead of a packable gauze. Any reasons it's laughable other than the fact that it's more difficult if not impossible to pack into a wound?
Gutshot John
08-17-13, 06:27
It's my understanding that you can still get proper quick clot that is identical to combat gauze, only without the magnetic strip.
This is NOT my understanding. The distributor I was using said it applied to both mil and le versions.
You can still find some online being sold, but technically you're not supposed to have either x-ray strip or plain.
I'd put combat gauze way ahead of any kind of battle dressing.
Not really identical uses though.
Combat gauze goes inside the wound cavity, preferably where the bleed is, and is the initial packing material. On top of that you use whatever packing material you have available. Ideally some form og gauze or kerlix, as it is easier to pack it into the small tears you will find as opposed to improvised material like t-shirts and so forth. You can of course pack an entire wound with Combat Gauze, if you have that many on you.
The pressure dressing goes on top of this and is wrapped around the wound and packing material in order to 1) secure it and 2) keep some pressure on it.
Gutshot John
08-17-13, 08:36
Not really identical uses though.
No kidding? Really?
If you're going to have only one thing, have something that has the potential to save your life.
In all the trauma I've seen, I can't recall a single time when a pressure dressing would have made the difference between life and death. I can remember several times when I could have used a good TQ when they weren't as prevalent as they are today, same with combat-gauze.
A battle dressing is going to cover and protect the wound, who gives a shit if you're bleeding to death? It's not going to apply enough pressure in itself to stop a severe arterial bleed, and it's a pretty simple concept, if you really need one they can be improved easily with available materials.
If you're not going to do the TQ thing, than Combat gauze is a much better choice than a battle dressing, imo. Hell I'd take an old-fashioned cravat over a battle dressing.
An additional consideration might be protocols one has to run under, which guide/direct treatment options. IF I apply a TQ, questions will be asked as they are considered a "last option" (in our EMS protocols) unlike say TCCC protocols. Having said that, we have them on the ambulance(s) but have never seen nor applied one with the exception of training.
My personal suggestion is have TQ, pressure dressing, and packing gauze all available.
They all work in conjunction. Have some sort of quick clot or celox gauze to pack the wound and hold pressure and put on one or more TQ's.
Remember, one is none-two is one, etc.
Gutshot John
08-17-13, 10:58
Having said that, we have them on the ambulance(s) but have never seen nor applied one with the exception of training.
Primarily this is more due to antiquated protocols and a long-held mythology regarding their employ equating to nerve damage, and amputated limbs due to lack of perfusion. All kinds of stupidity that has been debunked by study after study but the civilian side of EMS refuses to catch up.
Secondarily EMS arrives on scene well after a TQ could actually do some good. Best case scenario is that EMS arrives within 5 minutes...potentially 3 minutes too late for a femoral bleed. TQs are useless if there is no blood left in the system...they have to be applied quickly and aggressively.
Waiting for them to be employed until every other method has failed, as the last ditch method of stopping a bleed, is waiting FAR TOO LONG and it really pisses me off that people keep spouting that nonsense.
TQs, carried around by people, and/or kept/stored as AEDs are, could potentially save thousands of lives per year in this country.
Primarily this is more due to antiquated protocols and a long-held mythology regarding their employ equating to nerve damage, and amputated limbs due to lack of perfusion
Nah, I disagree. I contend that it's primarily because the need for a tourniquet in civilian EMS is so very rarely there.
This is my understanding as well. Pressure can be applied to wounds with bare hands with moderate success. Pressure dressings can be improvised readily out of a ripped t-shirt if need be. But if you need a TQ, you need it right f-ing now, and chances of improvising something workable out of a belt are not that great.
How long do you have with a severed femoral before you fade to black? Thirty seconds? A minute?
Combined with the knowledge that the medical community has developed regarding saving limbs that have had tourniquets applied and it seems like a no brainer.
I don't buy the sterile arguments on improvised dressings, if I've had a hole put in my body, I think it's fair to assume that my insides are no longer a sterile environment.
Exsanguination from extremity gun shot wounds is exceedingly rare in both in civilian low-velocity and in military high-velocity wounds. The very few deaths that I've seen in this manner were due to a person not receiving the most rudimentary care such as simple pressure.
The bottom line is that TQ's are sometimes used by prehospital providers treating an extremity GSW, but I cannot recall a case where they were actually needed. Sure, they stopped the bleeding, but other measures such as direct pressure have always gotten the job done for me and the vast majority of physicians treating non-blast injuries.
Blast injuries from an IED are a whole different bag of worms. These are the only cases where I see TQ making a difference, and blast amputations are the reason for TQ's making a resurgence. Using treatments proven for one injury pattern, and attempting to apply them to unrelated injury patterns is often ineffective. Are you going to cause harm with a TQ? Unlikely, so feel free to carry a TQ in your bag, on your person, etc. I just would not put it on my weapon where the chances of it getting in the way of things by snagging equipment exceeds the chances of it being actually needed to save a life.
No kidding? Really?
If you're going to have only one thing, have something that has the potential to save your life.
In all the trauma I've seen, I can't recall a single time when a pressure dressing would have made the difference between life and death. I can remember several times when I could have used a good TQ when they weren't as prevalent as they are today, same with combat-gauze.
A battle dressing is going to cover and protect the wound, who gives a shit if you're bleeding to death? It's not going to apply enough pressure in itself to stop a severe arterial bleed, and it's a pretty simple concept, if you really need one they can be improved easily with available materials.
If you're not going to do the TQ thing, than Combat gauze is a much better choice than a battle dressing, imo. Hell I'd take an old-fashioned cravat over a battle dressing.
First, what about my comment struck you as condescending or preachy?
Second, since you went there, yes really. Saying that you want to take Combat Gauze over a field dressing is like saying you would take a hammer instead of screwdriver.
And who here works under the constraints of being able to carry only one item? That was never part of the OP's original question.
Also, did you read my description of the intended use for the pressure dressing at all? If you, after having packed the wound with combat gauze, do not apply a pressure dressing, it will most likely start to bleed during the evac phase if pt handling is substandard. If you do not use combat gauze or another form of hemostatic agent, only standard gauze or kerlix, it will start to rebleed after you have packed it unless pressure is continually maintained.
Who has advocated using a pressure dressing as a TQ? I surely have not.
In my IFAK I carry combat gauze, rolled gauze, OLAES, thoracocentesis kit (14ga catheter, syringe, saline), chest seal and airway adjuncts. I also carry two TQ's on my LBE. Additionally I have several more TQ's in my aid bag, in addition to extras of the items listed above. I also carry a cric kit, IV Equipment, drug administration Equipment, BVM and so forth.
Primarily this is more due to antiquated protocols and a long-held mythology regarding their employ equating to nerve damage
This is not a myth. Compartment syndrome is a very real complication of an incorrectly applied TQ -> venous TQ, where there is arterial flow to the limb distally of the TQ, but no venous return. A venous TQ will also increase the bleed.
Waiting for them to be employed until every other method has failed, as the last ditch method of stopping a bleed, is waiting FAR TOO LONG and it really pisses me off that people keep spouting that nonsense.
Again, I have not seen ANYONE advocate this at all in this thread.
You are most likely not going to bleed out in seconds, or two minutes for that matter. Reference my above post for research on this issue. If the bleed is that severe I don't think a TQ will help anyways.
TQs, carried around by people, and/or kept/stored as AEDs are, could potentially save thousands of lives per year in this country.
I would really like to see some hard data supporting this statement, that in your country you have thousands of preventable deaths from extremity bleeds due to lack of TQ use.
Here are some stats from Afghanistan, updated as recently as 2012. All deaths that have occured in Afghanistan are categorized as follows:
84% have catastrophic injuries
16% could potentially be prevented
The reasons for these preventable deaths are:
-Tactical situation -> unable to render care
-Insufficient level of training in first responders -> unable to give appropriate care
-Improper/incorrect care (almost never happens in operational medicine)
In the group of preventable deaths, the causes are as follows:
Haemorrhage: 79%
-Compressible bleed: 33%
-Incompressible bleed: 46%
Airway complications: 7%
Tension pneumothorax: 7% (number could possibly be higher, as tension pneumo's are not visible after death)
Head injuries: 7%
Are you saying that the incidence of penetrating trauma, resulting in deaths from extremity bleeds in the US is greater than in theatre?
I am not advocating putting off TQ use until the last second. If someone really needs it, go for it. If you are alone, and the pt has other wounds needing care, use a TQ. If you are in a mas cal situation, and you can only perform a limited amount of interventions on each pt go for it.
In a tactical situation, aggressively use TQ's.
If have help, the situation is clear with no hostiles trying to kill you, why cause more pain to the pt if direct pressure or pressure points will work? If you are there at the time of injury, he is not going to bleed out unless you have a TQ on him in 30 seconds.
Pt removal of TQ's due to pain is a real issue, and very few civilians have access to morphine/instanyl/fentanyl or ketamine to manage pain.
Gutshot John
08-17-13, 13:51
First, what about my comment struck you as condescending or preachy?
We all know what a dressing is used for. They all protect and cover wounds.
There is this huge potential for very well-trained medical personnel to think that trauma is some arcane and complex subject. It really boils down to two simple concepts: stop bleeding; keep them breathing.
Second, since you went there, yes really. Saying that you want to take Combat Gauze over a field dressing is like saying you would take a hammer instead of screwdriver.
No it's not. It's more like a gun over a knife or a hammer vs. a multi-tool. A hammer does one thing really well. A multi-tool does a myriad of things, not so well. When you really need a hammer a multi-tool isn't going to do. In the case of an arterial bleed, you don't need subtle and versatile...you need a bleeping hammer.
And who here works under the constraints of being able to carry only one item? That was never part of the OP's original question.
Actually it was, and if you read my earlier responses I advocated a barebones kit of a SWAT-T, an H&H H-Dressing, and a valveless chest seal as a lesser footprint than an OLAES or Israeli battle dressing.
Also, did you read my description of the intended use for the pressure dressing at all? If you, after having packed the wound with combat gauze, do not apply a pressure dressing, it will most likely start to bleed during the evac phase if pt handling is substandard. If you do not use combat gauze or another form of hemostatic agent, only standard gauze or kerlix, it will start to rebleed after you have packed it unless pressure is continually maintained.
Again you're talking care under evacuation, when far more definitive resources are being brought to bear. EMS is going to be there in 5-10 minutes, you're buying time until they get there.
What are you going to use to keep as much blood in an open system as quickly as possible?
Who has advocated using a pressure dressing as a TQ? I surely have not.
I didn't say you did, I said that as a hemorrhage control method, it's inferior when dealing with a severe bleed.
In my IFAK I carry combat gauze, rolled gauze, OLAES, thoracocentesis kit (14ga catheter, syringe, saline), chest seal and airway adjuncts. I also carry two TQ's on my LBE. Additionally I have several more TQ's in my aid bag, in addition to extras of the items listed above. I also carry a cric kit, IV Equipment, drug administration Equipment, BVM and so forth.
Good for you, you're obviously trained to use them. Let me ask you, do you think everyone has your training? Do you think everyone needs all that to be effective?
I'd rather 10 lay medics with a TQ in an MCI, than 1 of you.
This is not a myth. Compartment syndrome is a very real complication of an incorrectly applied TQ -> venous TQ, where there is arterial flow to the limb distally of the TQ, but no venous return. A venous TQ will also increase the bleed.
First, Incorrectly applied being the key word. You're talking about using an inferior tool, because of a training problem? All choices in treatment have a cost or tradeoff. Life? Limb? You're really going to make that choice?
Second, the "myth" was that this will happen even with a correctly applied TQ.
Third, numerous studies have blown away the notion that this is a significant risk especially when compared with say...bleeding to death.
Are you saying that the incidence of penetrating trauma, resulting in deaths from extremity bleeds in the US is greater than in theatre?
I'm saying it doesn't matter. We're talking preventable death. Who cares what the incident rate is? Life threatening trauma for the vast majority of people is an extremely rare event. I've made this point repeatedly. I carry a gun, not because I think I'll need it everyday, or even ever, I carry a gun because of something that may never happen. A knife may be more versatile for a variety of things, but when I need a gun, I REALLY NEED A GUN. If I take a bullet to the heart what difference does it make if I have both a gun and a TQ? Shit happens.
In all those cases you mentioned I'm not really seeing many where a pressure dressing would have made a difference.
Actually it was
Respectfully, it was not.
He clearly states, in the very first paragraph, that he keeps a TQ in his range bag and on his chest rig.
His question was, as seen in the second paragraph, if you were going to put a first aid item on the gun, would you choose a TQ or a dressing.
Let me preface this by saying I think the proliferation of tourniquets in tactical gear is great. I'm not a first responder or professional shooter but I keep one in my range bag and on my chest rig. And I've seen a lot of folks attaching them to their weapons. I'll throw the number one name out there- Paul Howe, who when I see him do something with his gear I immediately start thinking I should do it.
I'm just wondering if your going to attach a first aid item to your weapon, your basically prioritizing one item over all others. I would think that item should be a pressure dressing. We have much better dressings than we used to (IDF dressings) A pressure dressing will work as a TQ, or as a chest seal in a pinch. I think carrying more dressings would be more important than any other single piece of gear.
So he was never under any constraints regarding the amount or type of first aid supplies he could carry.
We all know what a dressing is used for. They all protect and cover wounds.
There is this huge potential for very well-trained medical personnel to think that trauma is some arcane and complex subject. It really boils down to two simple concepts: stop bleeding; keep them breathing.
I commented not because I thought you ignorant and that you did not understand what a dressing is for. I commented because I disagreed with your comment in that Combat Gauze and a field dressing cannot be compared since they are tools that do different jobs.
And yes, the basic concept of trauma care is pretty straight forward. However, knowing how to do the right intervention at the right time is something that requires knowledge and training. There are indications and counter-indications for various interventions that need to be known by the care-giver. There are priorities that need to be followed on how to treat a patient.
I find it strange that so many people have so many discussions with differing opinions on marksmanship, gunfighting, tactics, drawstrokes and so forth, and why training is so important, but when it comes to trauma care everybody can do it.
In the case of an arterial bleed, you don't need subtle and versatile...you need a bleeping hammer.
What are you going to use to keep as much blood in an open system as quickly as possible?
I'm not really sure what you are getting at here. Still, you don't need a TQ to stop an arterial bleed, although it does a very good job at doing so. I don't think anyone disagrees with this at all. Also, I would never use a pressure dressing/field dressing to stop an arterial bleed; sans a TQ I would use direct pressure in the wound or proximal pressure points.
I didn't say you did, I said that as a hemorrhage control method, it's inferior when dealing with a severe bleed.
This I agree with. I have suggested using pressure points or direct pressure, not a pressure dressing. And to re-emphasize, in a tactical situation a TQ is the way to go. If you are the single care-giver, on a multi-trauma pt, a TQ makes more sense. For MCI's, TQ's can be very handy depending on injury mechanism.
First, Incorrectly applied being the key word. You're talking about using an inferior tool, because of a training problem? All choices in treatment have a cost or tradeoff. Life? Limb? You're really going to make that choice?
Huh? I have never advocated carrying pressure dressings over a TQ, I have never advocated using a pressure bandage as a TQ. I personally believe that improvised TQ's should never be used, due to the increased likelyhood of creating a venous TQ.
And my point of contention is not that TQ's shouldn't be used because they are dangerous, it is that they are not "harmless" in the sense that people with little or no training can make the situation worse. This has happened.
One common situation when training new advanced medics is that they become so enamored with the "cool" interventions like cric'ing, decompressing tension pneumo's or establishing IV access that they completely forget the basics, just because they want to do an advanced technique.
I'll concede that using proximal pressure points can be a bit challening if you have no anatomical knowledge, but I have also seen people fumble and spend waaay too much time applying a TQ, and still do it incorrectly. Yes, this is a training issue, but that is also my point. If your TQ is still in the plastic wrapper and you have never trained on it, my guess is you are pretty ineffective.
Second, the "myth" was that this will happen even with a correctly applied TQ.
Third, numerous studies have blown away the notion that this is a significant risk especially when compared with say...bleeding to death.
There are possible complications from TQ use, due to ischemia. I am fully aware that most TQ use is done with no compliactions at all. Still, current TCCC protocols state that if the TQ has been on for more than two hours, you are not to release it. Only caregivers at a definitive care facility are to remove it, in order to handle the toxins that have built up. Hospitals can handle this, a medic in the field...not so much.
Granted, in a civ setting EMS will most likely be quick to respond so the two hour timeframe is not very realistic.
I'm saying it doesn't matter. We're talking preventable death. Who cares what the incident rate is?
That is an odd position, considering that current TCCC protocols were developed BECAUSE they looked at incidence rates and causes of death. That is why EMS (at least here) does not have haemorrhage control as the first priority, because they rarely deal with penetrating trauma. Most of the pt's they see are medical emergencies; chest pain, MI, COPD pt's, strokes and so forth. I have worked with and know many who work for the ambulance services, and the treatment to transport only ratio is leaning pretty heavily towards transport only.
After re-reading the original post it seems this has gone way of track.
My belief and the way our teams train is that a TQ, Homeostatic gauze, or anything in an IFAK are used as a first responder type treatment. Its a self aid/buddy aid treatment to keep you from bleeding out, keep the airway open, and prevent tension hemo/neumo thorax. These items are highly advanced rudimentary methods to quickly attend to major hemorrhage trauma and help start the attempt to stabilize someone in a major incident. We run with multiple combat paramedics with access to flight surgeons who do a very good job of sustaining life until transfer to higher medical care if available so maybe we look at it differently.
Also my opinion, I think the reason Paul Howe and others have a TQ taped to his butt stock is for very quick access to a simple way to self or buddy aid UNDER FIRE or in the field when a severe hemorrhage has started from whatever reason. If you jump past the "its cool" because a {insert special forces group name here} operator uses it and analyze what a lot of tier 1 operators do and why they do it, you will see that most civilians don't need to do what they do because they simply don't operate in the same conditions. Is that saying not to carry a TQ/Israeli/Combat Gauze, etc.? No, just adapt it to your needs instead of doing it because it looks cool.
I personally think everyone who takes part in dangerous sports/hobbies/etc. should have some sort of IFAK. Whether its in a cool multi-cam pouch with a velcro red cross on it or its in a Zip Lock baggy in your truck/car/pack it could potentially save someones life. Adapt it to your skills/certification, situational needs, and don't just buy stuff, train with it to become proficient.
Realizing and knowing there might be a need means you have some sort of plan. While the best laid plans can go haywire quick, its better then nothing at all and starting with chaos.
Gutshot John
08-17-13, 20:31
Sorry but I really have better things to do than go round and round. Look at the thread title. The implication of having a weapon on your gun is that you somehow get separated from your kit and you have only one thing that you somehow managed to hold onto. That was clearly the application I had in mind.
I will reply to this
"I personally believe that improvised TQ's should never be used, due to the increased likelyhood of creating a venous TQ."
That's your choice, I think it's a deeply flawed one.
Dead is dead. What difference does it make if they died bleeding to death with a venous TQ or nothing?
You're getting far too deep into the weeds my friend.
You're getting far too deep into the weeds my friend.
:D lot of that going around
Gutshot John
08-18-13, 15:04
:D lot of that going around
Indeed. :dirol:
Sorry but I really have better things to do than go round and round. Look at the thread title. The implication of having a weapon on your gun is that you somehow get separated from your kit and you have only one thing that you somehow managed to hold onto. That was clearly the application I had in mind.
I will reply to this
"I personally believe that improvised TQ's should never be used, due to the increased likelyhood of creating a venous TQ."
That's your choice, I think it's a deeply flawed one.
Dead is dead. What difference does it make if they died bleeding to death with a venous TQ or nothing?
You're getting far too deep into the weeds my friend.
I guess I read the OP differently than you.
Regarding my choice on not using improvised TQs, I'm pretty confident I can stop a bleed using direct pressure and then pack it. I am not going to spend time trying to improvise a TQ, and try to make it work if it isn't.
In a tactical situation, not having a proper TQ is unrealistic for me, so in that sit I would use a TQ, or direct the pt to apply a TQ on himself if I am unable to provide buddy aid.
About me getting to deep into the weeds, I guess you and Hmac have to explain what you mean by that in this regard; I am getting into too much detail or out of my depth?
Gutshot John
08-18-13, 16:24
Regarding my choice on not using improvised TQs, I'm pretty confident I can stop a bleed using direct pressure and then pack it. I am not going to spend time trying to improvise a TQ, and try to make it work if it isn't.
Really? That confident huh? Well if you're sure...
Incidentally the timing comment is the best argument you've made on forgoing an improvised TQ.
Sadly there's a bit of a straw man in that I've never espoused an improvised TQ as anything but a last-ditch choice. I only said it beats bleeding to death without one, especially when one lonely battle dressing isn't going to be enough.
Regarding my choice on not using improvised TQs, I'm pretty confident I can stop a bleed using direct pressure and then pack it.
I'm inclined to agree. Exsanguinating hemorrhage from an extremity is exceedingly rare. Exsanguinating hemorrhage that can't be controlled with direct pressure is going to be vastly rarer than that.
About me getting to deep into the weeds, I guess you and Hmac have to explain what you mean by that in this regard; I am getting into too much detail or out of my depth?
I think the entire concept is being way over-thought, and I didn't have you in mind when I said that. Way too much emotional energy being expended on a very simple first aid concept with very simple solutions in the civilian world.
It's bleeding. Just stop it. If direct pressure doesn't work, or you need two hands, or you're alone, or you're the one bleeding, apply a tourniquet if possible. If you want to apply a tourniquet in an extremity arterial injury even though its not necessary but just because you're a true believer, go for it. In the civilian world it's unlikely that you'll do any damage and as the guy who reviews the run and does the trauma review for the ambulance service, I wouldn't criticize you for it. You can slap that ol' TQ on there and go on to your next problem...deciding if you should stick a needle in the guy's chest and save him from his possible tension pneumothorax. I'll be looking a lot closer at that decision.
@Gutshot John:
My apologies that I am not the arrogant type to state that I can guarantee a successful intervention. I will always try to do the best I can with what I have.
I am confident in my abilities, but not to the point of arrogance. That is not the same as approaching a trauma with a defeatist attitude.
I am not a miracle worker, nor do I have the training, skills or experiance that a surgeon has.
As to your last comment, a TQ that doesn't stop the bleed is no better than no TQ at all; as I've alluded to previously, it can actually be worse. There is no "sorta/kinda stopped the bleeding" protocol.
And I really don't understand your hostile tone. I have never disagreed with you on the issue of TQ vs. battle dressing at all. I haven't really discussed battle dressings at all. Like I said in my last post, we obviously read the OP's issue differently.
I am trying to have a discussion, so that hopefully everyone involved can learn so they are better prepared. Instead of making snide comments when you disagree with something I say, maybe you can add some knowledge of your own....
I'm inclined to agree. Exsanguinating hemorrhage from an extremity is exceedingly rare. Exsanguinating hemorrhage that can't be controlled with direct pressure is going to be vastly rarer than that.
I think the entire concept is being way over-thought, and I didn't have you in mind when I said that. Way too much emotional energy being expended on a very simple first aid concept with very simple solutions in the civilian world.
It's bleeding. Just stop it. If direct pressure doesn't work, or you need two hands, or you're the one bleeding, apply a tourniquet if possible. If you want to apply a tourniquet in an extremity arterial injury even though its not necessary but just because you're a true believer, go for it. In the civilian world it's unlikely that you'll do any damage and as the guy who reviews the run and does the trauma review for the ambulance service, I wouldn't criticize you for it. You can slap that ol' TQ on there and go on to your next problem...deciding if you should stick a needle in the guy's chest and save him from his possible tension pneumothorax. I'll be looking a lot closer at that decision.
Roger that. And that has been my point all along, that the situation on the ground is vastly different in a tactical situation in Afghanistan, than back home. You might not even get to the casualty for several minutes, because the correct intervention is fire superiority, so your job at that moment in time is to shoot.
And I agree that we are mostly just arguing details...
And understood about tension pneumo treatment. I think people overestimate how rapidly a tension pneumo develops; it's far from spontaneous, to say the least. It takes time.
Gutshot John
08-18-13, 18:19
As to your last comment, a TQ that doesn't stop the bleed is no better than no TQ at all; as I've alluded to previously, it can actually be worse. There is no "sorta/kinda stopped the bleeding" protocol.
Again, what's the functional difference between bleeding to death because of a venous TQ and bleeding to death without a TQ at all?
How is the venous TQ worse?
Dead is dead.
Gutshot John
08-18-13, 18:26
I'm inclined to agree. Exsanguinating hemorrhage from an extremity is exceedingly rare. Exsanguinating hemorrhage that can't be controlled with direct pressure is going to be vastly rarer than that.
Really? Documentation please on the relative rarity of extremity vs. other uncontrolled hemorrhages? Because you've made this claim repeatedly without any documentation to back it up.
THat said, I agree, most extremity wounds are easily cared for by direct pressure? So what? Those same wounds can be controlled with direct pressure using anything.
If you need a TQ, only a TQ will do.
Really? Documentation please on the relative rarity of extremity vs. other uncontrolled hemorrhages? Because you've made this claim repeatedly without any documentation to back it up.
THat said, I agree, most extremity wounds are easily cared for by direct pressure? So what? Those same wounds can be controlled with direct pressure using anything.
If you need a TQ, only a TQ will do.
30 years of experience as surgeon covering two hospitals one-in-three, dealing with trauma in the civilian world. Before that, residency at a level 1 trauma center covering trauma call every other day. Over those 30 years, looking at the number of times a tourniquet was necessary on patients that I treated (zero).
Tourniquet can be a valuable tool, but the circumstance where "only a TQ will do" is exceedingly rare.
Again, what's the functional difference between bleeding to death because of a venous TQ and bleeding to death without a TQ at all?
How is the venous TQ worse?
Dead is dead.
True, dead is dead, but if he dies because I made the situation worse by using an inferior intervention, then that is on me.
I've tried to explain the possible complications of a venous TQ, and in a pt with a life threatening bleed, this is the last thing you want to happen. If there is arterial flow distally of the TQ, the bleed has not stopped and the TQ is not working. Solution; try something else, screw the improvised TQ.
In the same vein that you seek data backing up Hmac's claim, I remind you that I asked you for data regarding the thousands of people who die preventable deaths from extremity bleeding in the US each year. I would like to see those numbers, because if true, the lack of TQ use as part of the EMS treatment protocol would probably qualify as criminally negligent.
Really? Documentation please on the relative rarity of extremity vs. other uncontrolled hemorrhages? Because you've made this claim repeatedly without any documentation to back it up.
THat said, I agree, most extremity wounds are easily cared for by direct pressure? So what? Those same wounds can be controlled with direct pressure using anything.
If you need a TQ, only a TQ will do.
A simple google search of "exsanguination extremity injury" produced this article from the J Trauma:
http://www.ncbi.nlm.nih.gov/pubmed/16096567
Only 14 deaths due to exsanguination from an extremity injury out of more than 75,000 trauma visits over a 5-year period in Houston, TX. That is less than 0.02% of all trauma visits which equals very, very rare in my book. There are other studies with similar results, but finding them will require that you now carry the ball in educating yourself on this topic.
Nah, I disagree. I contend that it's primarily because the need for a tourniquet in civilian EMS is so very rarely there.
Doc, I have interacted with EMT's and First Responders for nearly 30 years as well. I can firmly state that no one would have considered a TQ because it was considered to be basically evil since the patient was going to lose a limb, and protocol wouldn't allow it. So I think there is some cause to consider those mindsets of the past 50+ years in TQ's not being used more in emergencies.
http://www.weau.com/news/headlines/155509735.html
He happens to live in the town the ambulance responds from. Many of us in a rural area aren't that lucky. Depending on which ambulance gets dispatched, I'm looking at a 15-25 minute response time, and that's when the EMT's GET to the rig. God help me if the backup rig has to be dispatched, or a rig from another county. It's a real situation for many in the US, and it looks as if many of you are stuck on the assumption that rapid medical care is only a few minutes away. For those of us on here that hunt, that response time may increase drastically. TQ's in a lot of ways are basically insurance.
http://twincitiesfirewire.com/2012/09/25/st-paul-units-called-to-person-struck-by-school-bus/
Another one from the same time period within a 120 miles. Packaged and went.
I'm not talking about the number of times EMTs have applied tourniquets or are hobbled by protocols, I'm talking about retrospectively looking at every trauma run for 30 years in this rural medical system with lots of hunters and long response times and asking whether or not, in any of those cases, a tourniquet would have made a difference. I understand the theoretical usefulness and I'm all for it. For those rare events where a tourniquet might be needed, certainly there is no reason NOT to carry a tourniquet or three if it makes one feel more secure. They're cheap, small, easy to use, and unlikely to cause damage. I say go for it on the basis of "can't hurt, might help".
Glad this patrol officer had his TQ with him...
http://www.am-news.com/content/blackfoot-policeman-hero-accident
Gutshot John
08-19-13, 13:39
Tourniquet can be a valuable tool, but the circumstance where "only a TQ will do" is exceedingly rare.
It doesn't surprise me that in 30 years you've never applied a TQ. It was considered anathema for decades for the reasons specified above. Does that mean that all those outcomes would have been the same with or without a TQ? I don't see how you could possibly make that claim.
Of course it's exceedingly rare, once again so what?
Lifethreatening trauma is exceedingly rare also.
You carry a gun? If so, why?
The circumstance where "only a gun will do" is exceedingly rare. So rare that in 20 years of personal gun ownership do you know how many times I've had to pull and point my gun at anyone, let alone shoot? (zero)
A knife would be a far more versatile and useful tool on any given day, and is probably a decent self-defense option.
Gutshot John
08-19-13, 13:43
There are other studies with similar results, but finding them will require that you now carry the ball in educating yourself on this topic.
I'd suggest you carry your own ball and educate yourself on this topic because you're doing a great disservice here and you don't even realize it. Never mind that your article is almost a decade old, moreover you should read it better because it doesn't say what you says it does. Indeed, it came to very different conclusions, notably that all of those people were treated without TQ, with a mortality rate of 100% with 93% dying within 12 hours.
Every review of the literature I've done points to improved outcomes with more aggressive TQ usage and that is now starting to change in civilian EMS departments.
And again you missed the point which I've addressed repeatedly, who cares how rare it is? When it occurs, you're going to die without aggressive intervention.
Simple risk management: Probability of an event (0.02%) * Cost of an event (death = infinite cost) = expected cost of said event (death = infinite cost)
You get the same result irrespective of whether it's 0.02%, 20%, or 2000%.
It doesn't surprise me that in 30 years you've never applied a TQ. It was considered anathema for decades for the reasons specified above. Does that mean that all those outcomes would have been the same with or without a TQ? I don't see how you could possibly make that claim.
No, no....I've never seen the need for a tourniquet, even in retrospective trauma reviews. I retrospectively look at whether or not a tourniquet should have been applied in any given scenario. I'm not the guy that applies them, I'm the guy that does the second-guessing after the incident. I see every single trauma run and we review them once a month.
As to carrying guns, I rarely do that either, but it's an apt comparison. Those who feel the need to do so for whatever reason, or whose job makes it advisable...they should carry one. It can be a very valuable tool, rarely, in some circumstances.
@Gutshot John:
I don't think anyone here is actively advising against carrying a TQ or arguing that they are not valuable tools. I, at least, have said time and time again that I will use a TQ when indicated, especially in tactical situations.
And, just for interest's sake, what is your background in this field? I ask because I don't know.
Arctic and Gutshot John,
I've enjoyed seeing both of you guys' viewpoints (even thoughthey seem to be fairly similar) and am learning a bit just by the discussion...
Can either of you explain (in lay terms) what a veinous TQ situation is and how that situation comes to be? Also, how to spot it?
For example, I've got a femoral bleed and I need to apply a TQ. The point of the bleed is a few inches inched above the knee joint. I will obviously apply the TQ as high as possible proximally, and tighten until blood flow is stopped. How can this situation result in a veinous TQ?
I think this article explains it better than I can:
http://www.ap-services.dk/Files/Billeder/Artikler/TCCC%20Kragh%20Tourniquet%20Effects%20on%20Foot%20Ankle%20Clin%202010.pdf
But, the simple explanation is that a venous tourniquet occurs when the TQ is not tight enough to stop arterial blood flow below the TQ, only venous return flow. This can cause a myriad of complications, to include an increase in the bleed making it more difficult to control, and possibly compartment syndrome.
A venous TQ is more prevalent with either improvised TQ's where it is difficult to achieve enough pressure to occlude arterial flow or incorrectly placed TQ's. Morbidity, death and reduced survival rate is often associated with venous TQ issues.
I think this article explains it better than I can:
http://www.ap-services.dk/Files/Billeder/Artikler/TCCC%20Kragh%20Tourniquet%20Effects%20on%20Foot%20Ankle%20Clin%202010.pdf
But, the simple explanation is that a venous tourniquet occurs when the TQ is not tight enough to stop arterial blood flow below the TQ, only venous return flow. This can cause a myriad of complications, to include an increase in the bleed making it more difficult to control, and possibly compartment syndrome.
A venous TQ is more prevalent with either improvised TQ's where it is difficult to achieve enough pressure to occlude arterial flow or incorrectly placed TQ's. Morbidity, death and reduced survival rate is often associated with venous TQ issues.
Thanks for the link and explanation, Arctic. I'll read it all over when I get a chance.
I'd suggest you carry your own ball and educate yourself on this topic because you're doing a great disservice here and you don't even realize it. Never mind that your article is almost a decade old, moreover you should read it better because it doesn't say what you says it does. Indeed, it came to very different conclusions, notably that all of those people were treated without TQ, with a mortality rate of 100% with 93% dying within 12 hours.
Every review of the literature I've done points to improved outcomes with more aggressive TQ usage and that is now starting to change in civilian EMS departments.
And again you missed the point which I've addressed repeatedly, who cares how rare it is? When it occurs, you're going to die without aggressive intervention.
Simple risk management: Probability of an event (0.02%) * Cost of an event (death = infinite cost) = expected cost of said event (death = infinite cost)
You get the same result irrespective of whether it's 0.02%, 20%, or 2000%.
I suppose that you care how rare it is because you asked the question in post #69. The article does a very good job of answering that question which you asked. The article does not answer the question as to whether a TQ would have saved any of those lives.
In terms of my disservice to the conversation, why is that? Is it because I'm suggesting that we do not need to apply a TQ on more extremity gunshot wounds, and that we do not need to strap TQ's on our weapons? God forbid that I suggest we withhold a treatment (TQs) for a disease that essentially does not exist (exanguination from civilian extremity GSWs).
This thread has just went all over the place, and I'm still torn between taping a TQ or PD to my rifle.
This thread has just went all over the place, and I'm still torn between taping a TQ or PD to my rifle.
Neither. I maintain that any such device is more likely to cause problems with snagging than save your life. If you must attach a hemorrhage control device to your weapon, my suggestion is an Israeli Combat Dressing. While it is perfectly reasonable to keep a TQ in your aid bag or on your person if it makes you feel better, it should not be your default hemorrhage control method for extremity gunshot wounds.
Doc, I have interacted with EMT's and First Responders for nearly 30 years as well. I can firmly state that no one would have considered a TQ because it was considered to be basically evil since the patient was going to lose a limb, and protocol wouldn't allow it. So I think there is some cause to consider those mindsets of the past 50+ years in TQ's not being used more in emergencies.
http://www.weau.com/news/headlines/155509735.html
He happens to live in the town the ambulance responds from. Many of us in a rural area aren't that lucky. Depending on which ambulance gets dispatched, I'm looking at a 15-25 minute response time, and that's when the EMT's GET to the rig. God help me if the backup rig has to be dispatched, or a rig from another county. It's a real situation for many in the US, and it looks as if many of you are stuck on the assumption that rapid medical care is only a few minutes away. For those of us on here that hunt, that response time may increase drastically. TQ's in a lot of ways are basically insurance.
http://twincitiesfirewire.com/2012/09/25/st-paul-units-called-to-person-struck-by-school-bus/
Another one from the same time period within a 120 miles. Packaged and went.
This I agree with. If response times are long, and as a result transport times to hospital, treatment protocols should reflect this.
This thread has just went all over the place, and I'm still torn between taping a TQ or PD to my rifle.
I tried having a TQ fixed to my rifle, but did not care for it, so I dumped it. It kept snagging on my load carrying gear and interfered when I was carrying a pack.
My suggestion is to have a properly equipped IFAK and/or range bag, where you have a good mix og medical gear required to fix injuries that you are most likely to encounter. In addition, keep a TQ or two on your rig, and maybe a few spares in your range bag.
My last suggestion, seek out some sort of medical training (if you don't have it) so that you have the knowledge to assess injuries and perform the correct intervention based on how the pt presents.
I am a huge TQ proponent, and do carry TQs in my EDC pack. That said, I do not expect to find myself in many Care Under Fire situations in civilian life. Remember that during the Tactical Field Care phase, if the MEDEVAC takes a while to arrive, you are supposed to pack the wound and dress it with a pressure dressing and loosen the TQ.
TQ application is very painful, then you have the pain associated with ischemia. This is why we try to administer pain meds as soon as possible when treating the pt. There have been many cases where pt's have removed their TQs because of the pain.
Gutshot John
08-20-13, 11:08
Can either of you explain (in lay terms) what a veinous TQ situation is and how that situation comes to be? Also, how to spot it?
Veins (low-pressure blood return to the heart) tend to lie close to the surface of the skin while arteries (high-pressure blood from the heart to the body) are much deeper.
Venous TQs are typically used when you get your blood drawn, they prevent the return of blood to the heart even as arteries continue to pump blood to the area. The result is that the vein bulges with the higher pressure so blood can be drawn or injections given.
Theoretically the higher pressure may result in increased blood flow, in practice, the backpressure still results in less blood lost, but still needs to be tightened to be effective.
There is little way to recognize it other than continued arterial hemorrhage indicating that the TQ needs to be readjusted or tightened. This is covered in the directions for a TQ, you tighten until the bleeding stops.
Theoretically the higher pressure may result in increased blood flow, in practice, the backpressure still results in less blood lost, but still needs to be tightened to be effective.
Not theoretically. It happens.
During our Advanced First Aid courses, we do a real life application of TQs on a bleeding pt; a RN or MD inserts a 14ga IV catheter in the "victims" arm, usually the cephalic vein or median cubital vein, releases the TQ and the blood flows.
The trainee medic must then apply the TQ in order to stop the bleeding. It is quite challenging, as we do it realistically with the pt wearing full uniform and combat gear. Very different than when applied directly on the skin. After a few rotations of the windlass, when the veins have been occluded, the bleeding INCREASES severely until enough pressure has been applied to occlude the arteries.
This is not a random occurance, it happens in every patient. If you try to write this off as a theoretical issue, you are the one doing people a disservice here.
ETA:
I have had it done to me as well, as a demonstration to show the exercise to the medic students. It bled like crazy, and hurt like hell.
Gutshot John
08-20-13, 13:34
Not theoretically. It happens.
And yet you remove a venous TQ once you hit the vein when drawing blood...
Increased pressure can but does not always equal increased flow...see tamponade.
Gutshot John
08-20-13, 13:48
That said, I do not expect to find myself in many Care Under Fire situations in civilian life.
Fair enough but that it's being attached to a firearm should indicate that CUF is exactly what the expected scenario is.
That said, TCCC is not some sort of archetypal example of when TQs should and should not be applied.
TCCC is only secondarily about treatment, it's about evacuation. The techniques taught in TCCC are no different.
Who cares when TCCC says a TQ should be applied? If you need a TQ, apply it...under fire or otherwise.
It's a lot easier to keep blood inside the system than it is to replace it.
That said, TCCC is not some sort of archetypal example of when TQs should and should not be applied.
TCCC is only secondarily about treatment, it's about evacuation. The techniques taught in TCCC are no different.
Who cares when TCCC says a TQ should be applied? If you need a TQ, apply it...under fire or otherwise.
I disagree with that assessment.
TCCC protocols are about performing the correct medical intervention at the correct time, in order to avoid additional casualties and additional injury to the pt.
TCCC protocols contain tried and proven interventions and recommended equipment to use.
I would argue that TCCC is the bible when it comes to TQ application in a tactical setting. TCCC has been in development since 1995, the main champions have been US SOF. If you don't place a TQ when you are supposed to, during the CUF phase, you might not even get to the TFC phase, much less the TEC phase (besides a dead body needing to be picked up).
The main priority during CUF is fire superiority; everything else is secondary. The pt must apply his own TQ if able to, he should move to cover if able to, he should fire his weapon if able to.
We don't follow these protocols because they are cool or a fad, we follow them because they WORK.
And yet you remove a venous TQ once you hit the vein when drawing blood...
What bleeds the most; venous TQ applied or released when drawing blood or inserting IV catheter? I don't see the point you are trying to make...
Gutshot John
08-21-13, 13:17
I disagree with that assessment.
Most people who don't really understand the point of TCCC feel the same. You keep forgetting that the OP is NOT you.
The medical techniques taught in TCCC and PHTLS (or basic first aid for that matter) are pretty much identical.
TCCC is a philosophy of evacuation, not care. It presumes you have several echelons of care supporting you. Still the phases of "care," are really phases of evacuation.
This does not apply at all for the civilian/lay medic, who has no BAS, C&C hospital, hospital ships and a chain of evac hospitals that lead back to CONUS.
There is ZERO reason for a civilian/lay medic to take TCCC. Any knowledge he needs can be gotten elsewhere, for much cheaper.
I would argue that TCCC is the bible when it comes to TQ application in a tactical setting.
TQs have been used effectively in combat/tactical settings for 200 years. Calling it the bible is hardly correct. It undid conventional wisdom that a TQ was the last resort, and advocated earlier placement under CUF, but it only changed when, not how it was employed.
TCCC has been in development since 1995, the main champions have been US SOF.
Partially correct.
I was in the first group of Corpsman in the entire USN/USMC to receive TCCC and PHTLS and helped significantly in both courses being given to the the 3rd Marine Division in 1995-1996.
The main champions in that time were NOT SOF. I don't recall a single SOF person in my class nor in any of the subsequent classes I taught. I did see plenty of SOF in my Jungle Survival classes at the NTA so they were around.
Blood flows more freely into the vial once you REMOVE the venous TQ. If what you were saying was always true than the venous TQ would result in filling the tube more quickly.
Most people who don't really understand the point of TCCC feel the same. You keep forgetting that the OP is NOT you.
The medical techniques taught in TCCC and PHTLS (or basic first aid for that matter) are pretty much identical.
TCCC is a philosophy of evacuation, not care. It presumes you have several echelons of care supporting you. Still the phases of "care," are really phases of evacuation.
Ok, so I guess the Committee on Tactical Combat Casualty Care do not understand what TCCC is then:
Casualty care on the battlefield must be the best possible combination of good medicine and good small-unit tactics.
TCCC recognizes this fact and structures its guidelines to accomplish three primary goals:
1.Treat the casualty
2.Prevent additional casualties
3.Complete the mission
From the Intro to TCCC ppt:
-Prehospital care is the most important aspect in ensuring the survival of the casualty.
-If the casualty does not arrive alive at the Forward Surgical Team or the Combat Support Hospital, then the surgeon’s skill can’t help.
-There may not be any combat medical personnel available when the casualty occurs.
-Initial care may have to be provided by the combatant.
-The goal of TCCC is to identify and treat those casualties with preventable causes of death, and keep them alive long enough to reach the hospital.
Again, I disagree with your assessment of what TCCC is.
And yes, protocols and interventions used in TCCC and PHTLS are based on the same principles, but there are very clear cut differences as well. These are:
Hostile fire
Darkness
Environmental extremes
Different wounding epidemiology
Limited equipment
Need for tactical maneuver
Long delays to hospital care
Different medic training and experience
TQs have been used effectively in combat/tactical settings for 200 years. Calling it the bible is hardly correct. It undid conventional wisdom that a TQ was the last resort, and advocated earlier placement under CUF, but it only changed when, not how it was employed.
It has actually been used for longer than 200 years, but that is beside the point. During no point in time has TQ use, and success, been so well document as during the last 12 years or so. That is why today, TCCC is the bible.
I was in the first group of Corpsman in the entire USN/USMC to receive TCCC and PHTLS and helped significantly in both courses being given to the the 3rd Marine Division in 1995-1996.
The main champions in that time were NOT SOF. I don't recall a single SOF person in my class nor in any of the subsequent classes I taught.
I am just going by what I have been taught, info supplied by the TCCC committe:
Original paper published 1996
First used by Navy SEALs and Army Rangers in 1997
http://www.health.mil/dhb/downloads/Butler%20TCCC.pdf
I was off by one year on the timeline, the article was published in '96, not 95.
Blood flows more freely into the vial once you REMOVE the venous TQ. If what you were saying was always true than the venous TQ would result in filling the tube more quickly.
I am not a nurse, so I have never drawn blood, but isn't there vacuum in many containers used? Vacutubes? I also think that they release the TQ when they are almost done drawing blood....
Gutshot John
08-21-13, 14:34
Ok, so I guess the Committee on Tactical Combat Casualty Care do not understand what TCCC is then:
Reading is fundamental...
Casualty care on the battlefield must be the best possible combination of good medicine and good small-unit tactics.
We're not talking about a battlefield...we're talking about civilian medicine. TCCC applies to the military, it does not apply to your average CCW holder.
I didn't EVER say that TCCC was a bad program. I said it didn't apply to those who lack a chain of evacuation...like your average CCW holder.
I also said that the medical techniques themselves are essentially the same as they are in Red Cross First Aid/First Responder.
TQs have seen documented use since the Napoleonic wars, and incidentally the French have some very interesting studies on their use dating back 200 years, in fact the French under Napoleon pioneered modern research medicine going back that far, and indeed it was them that discovered the physiological effects of and named "Shock." The French army was the first army in history to standardize and widespread issue TQs to their men.
I am not a nurse, so I have never drawn blood, but isn't there vacuum in many containers used? Vacutubes? I also think that they release the TQ when they are almost done drawing blood....
Really not even in medic school?
The vacuum exists irrespective of whether there is a Venous TQ or not...therefore with a venous TQ, and all other things being equal (like a vacuum tube) the venous TQ should result in increased flow if your theory holds. I've given at least one example where that's not the case.
And no they release the TQ when they get the flash to allow the blood to flow better.
I am confused....
First, you state this:
Fair enough but that it's being attached to a firearm should indicate that CUF is exactly what the expected scenario is.
Now, you state this:
We're not talking about a battlefield...we're talking about civilian medicine. TCCC applies to the military, it does not apply to your average CCW holder.
:confused:
Really not even in medic school?
Nope, just IV access, and IM and subcutaneous injections.
Gutshot John
08-21-13, 15:08
Nevermind, this is pointless.
OP get whatever you want.
Nevermind, this is pointless.
OP get whatever you want.
Well my original question was not either TQ or PD- more if you have both and were gonna carry one more, what would it be?
I have learned some stuff from this thread though.
Well my original question was not either TQ or PD- more if you have both and were gonna carry one more, what would it be?
I have learned some stuff from this thread though.
2 TQ's, a pressure dressing, and at least one hemostatic gauze.
To spite all the ongoing debate in this thread, they all have a purpose and can compliment each other. Plus you will be able to improvise with those 3 for most situations involving bleeding and some other stuff as well.
thopkins22
08-23-13, 17:29
Nevermind, this is pointless.
OP get whatever you want.
Actually despite the fact that it went round and round without a definitive conclusion, I found it to be quite educational and beneficial.
I for one was grateful to be subscribed to it.
Gutshot John
08-23-13, 18:03
Well my original question was not either TQ or PD- more if you have both and were gonna carry one more, what would it be?
If you have both, I'd consider a hemostatic agent and/or a chest seal.
I think I spelled it out a few pages back for the same cost in real estate as a TQ and Israeli/OLAES dressing you can get: 1. SWAT-TQ; 2. H&H H Bandage; 3. Chest Seal (I'm impressed by the Russell though I've never personally used one); 4. LE Combat Gauze
My apologies to Arctic1.
If you have both, I'd consider a hemostatic agent and/or a chest seal.
I think I spelled it out a few pages back for the same cost in real estate as a TQ and Israeli/OLAES dressing you can get: 1. SWAT-TQ; 2. H&H H Bandage; 3. Chest Seal (I'm impressed by the Russell though I've never personally used one); 4. LE Combat Gauze
My apologies to Arctic1.
Same situation -never used one- but ive been reading a lot of good thing about HALO seals.
Gutshot John
08-23-13, 18:14
Honestly Currahee this has been a very thought provoking thread for me, it's especially timely as I'll be giving a small class tomorrow on civilian FAK options.
I think a second, small kit is an excellent idea for a host of reasons. Attached to an unobtrusive place on your carbine (depending on how much other crap you already have on it) is as good a place as any.
People overlook how versatile a decent chest seal can actually be. It isn't just for SCWs.
Actually despite the fact that it went round and round without a definitive conclusion, I found it to be quite educational and beneficial.
I for one was grateful to be subscribed to it.Same here, thank you guys for giving your viewpoints and debating while keeping it civil. Your discussion has bumped up med training even higher on my priorities list.
My apologies to Arctic1.
No need for that, no hard feelings on my part. Besides, it takes two to tango.
Yes, yes. This thread has me thinking, and maybe over thinking, about my TQ's.
I appreciate the conversations, viewpoints, opinions and such that were expressed.
Here is a good blog post by Chris from CTOMS:
http://privatebloggins.ca/?p=704
Gutshot John
09-09-13, 15:16
Here is a good blog post by Chris from CTOMS:
http://privatebloggins.ca/?p=704
Sadly this is an example of why the internet sucks, people (not you specifically) read something on a blog and give it the same credibility as a scientific journal.
The author acknowledges that the modern TQs hadn't been invented yet and moreover the casualty lived. His qualifications? This incident and he's an EMT (not a paramedic mind you, just an EMT).
He had substandard equipment, and by his own admission, this was the first time a Canadian had used a TQ since the Korean war.
The failure, if there was one, was far more likely the result of an inexperienced medic, or bad gear. I don't see how it discredits the use of a properly employed, quality TQ.
This is anecdotal case that contradicts numerous, scientific studies to the contrary.
For example:
http://www.jems.com/article/major-incidents/tourniquet-first
http://www.jems.com/article/patient-care/civilian-ems-should-consider-tourniquets
http://emj.bmj.com/content/24/8/584.full
That represents 5 minutes of searching on google. I'm confident I can find more.
The first JEMS article validates everything I posted in this thread, oddly enough....
And I did not state that the blog post was the end-all be-all commentary on TQ use, I simply stated that it was a good blog post. A fact that is also corroborated by the first article.
And you CLEARLY missed the part where he says he supports the use of TQs.
I also linked to a TQ report earlier in the thread, a report that is cited as a TCCC source. It supports what I say as well.
ETA: Both JEMS articles support what I have said in this thread.
Gutshot John
09-09-13, 17:23
ETA: Both JEMS articles support what I have said in this thread.
I'm not seeing that.
Just like any other medical intervention, TQ requires proper training, gear and application.
Just like EVERY other medical intervention, a TQ has complications.
So what?
The risks you've mentioned exist, but are vastly overstated, especially when compared to death.
Did you even read the articles?
Where do they differ from my POV presented in this thread?
Have I ever stated that there is a high likelyhood of the complications I brought up? No, I have not.
That, however, does not mean that people should not be aware of them, and receive proper training.
You obviously have made your mind up that I despise TQs, and any form of discussion is anti-TQ.
Gutshot John
09-10-13, 12:02
Did you even read the articles?
Yep, I saw nothing regarding venous TQs as a risk factor, plenty of talk about how they should be more broadly used/applied/distributed as the risk of complication is less than the risk of imminent death.
It requires a lot more training/skill to insert an IV cath than it does to apply a TQ. Cheap, easy, and typically pretty effective. Sure you might fail and the patient might die, but they would probably have died anyways.
Most medics who don't deal with trauma frequently forget that the standard is not perfection (preservation of limb), the standard is the alternative (death).
The articles EXPLICITLY made that point.
"Meanwhile, a more systematic approach has occurred. A series of studies have looked at the efficacy of prehospital tourniquets and their safety.(16–18) The conclusions are overwhelmingly in favor of applying tourniquets to control severe extremity hemorrhage. In addition, they highlight the near-total absence of significant complications attributable solely to the use of tourniquets."
Granted, the articles do not mention venous TQ specifically, but addresses application and tightness of application several times, in addition to stressing the need to constantly reassess in case of re-haemorrhage.
And that is the whole teaching point of addressing the venous TQ;
-apply TQ in an anatomically feasable area
-apply TQ tight enough to stop all bleeding
-reassess TQ frequently
-get proper training to ensure you are able to apply TQ effectively and successfully.
I have never stated that a venous TQ will happen with every TQ applied; I said it is a possible complication and that bleeding increases in the moments before arterial occlusion occurs.
If you deny it and won't believe me, have someone with the proper credentials place a 14g catheter in your arm and then apply a TQ. Observe and see for yourself.
If you are still hell bent on arguing a point I never made, be my guest.
You can also read the article I linked to, the Kragh study on TQs in combat use. It addresss the venous TQ. That article is listed as a source on the TCCC site.
And I understand perfectly that the standard is life, not preservation of limb. That is why I prefer to apply the TQ successfully, as opposed to not helping the guy bleed to death.
Gutshot John
09-10-13, 12:47
Sure I concede a TQ has to be tight enough and placed properly (duh), but I don't recall anyone, anywhere saying otherwise, so I'm not sure what your point is? I likewise don't understand why it's either TQ OR Pressure. Every time I've seen them used it was AND.
Have you ever tried to stop an arterial bleed only using direct pressure? I have...it's really really hard to do using pure muscle power. It also ties up one set of hands, never mind that it's physically difficult and exhausting, it also causes a lot of pain and ties up one caregiver's hands that could be used for something else. I was very grateful when the modern generations of TQs came out, as they virtually eliminate the complications you've mentioned.
Honestly the only time I've seen direct pressure work on an extreme hemorrhage is when I used my knee as a pressure point and my entire body weight. Let me tell you how much that poor guy screamed. TQs are far less painful and 99% far more effective at what they do.
You're essentially saying that the complications of a TQ are reasons to use a less effective and more painful technique that has greater risk of death.
Sorry but that dog don't hunt.
Do complications exist? Sure as they do for EVERY medical procedure, but the risks of using a TQ are VASTLY overstated even if imperfectly used.
Gutshot John
09-10-13, 12:57
As for the Kragh study, here is the abstract...http://www.ncbi.nlm.nih.gov/pubmed/18376170
BACKGROUND:
Previously we showed that tourniquets were lifesaving devices in the current war. Few studies, however, describe their actual morbidity in combat casualties. The purpose of this study was to measure tourniquet use and complications.
METHODS:
A prospective survey of casualties who required tourniquets was performed at a combat support hospital in Baghdad during 7 months in 2006. Patients were evaluated for tourniquet use, limb outcome, and morbidity. We identified potential morbidities from the literature and looked for them prospectively. The protocol was approved by the institutional review board.
RESULTS:
The 232 patients had 428 tourniquets applied on 309 injured limbs. The most effective tourniquets were the Emergency Medical Tourniquet (92%) and the Combat Application Tourniquet (79%). Four patients (1.7%) sustained transient nerve palsy at the level of the tourniquet, whereas six had palsies at the wound level. No association was seen between tourniquet time and morbidity. There was no apparent association of total tourniquet time and morbidity (clots, myonecrosis, rigor, pain, palsies, renal failure, amputation, and fasciotomy). No amputations resulted solely from tourniquet use. However, six (2.6%) casualties with eight preexisting traumatic amputation injuries then had completion surgical amputations and also had tourniquets on for >2 hours. The rate of limbs with fasciotomies with tourniquet time <or=2 hours was 28% (75 of 272) and >2 hours was 36% (9 of 25, p = 0.4).
CONCLUSIONS:
Morbidity risk was low, and there was a positive risk benefit ratio in light of the survival benefit. No limbs were lost because of tourniquet use, and tourniquet duration was not associated with increased morbidity. Education for early military tourniquet use should continue.
When, during this ENTIRE discussion have I said that? Please show me.
That is not my view at all, and I have repeatedly said so. Please stop using strawman arguments and a condescending tone.
I might be having difficulty in getting my point across, or you are intentionally misrepresenting my arguments....
I have never, ever said either/or when discussing direct pressure/pressure points and TQs. If the situation allows, I will use one while making ready the other.
Have you ever had a TQ applied to yourself, meant to stop a venous bleed? Over uniform and everything? I can tell you that it hurts A LOT! Much more than any pressure point use I have had done to me.
As for the Kragh study, here is the abstract...http://www.ncbi.nlm.nih.gov/pubmed/18376170
BACKGROUND:
Previously we showed that tourniquets were lifesaving devices in the current war. Few studies, however, describe their actual morbidity in combat casualties. The purpose of this study was to measure tourniquet use and complications.
METHODS:
A prospective survey of casualties who required tourniquets was performed at a combat support hospital in Baghdad during 7 months in 2006. Patients were evaluated for tourniquet use, limb outcome, and morbidity. We identified potential morbidities from the literature and looked for them prospectively. The protocol was approved by the institutional review board.
RESULTS:
The 232 patients had 428 tourniquets applied on 309 injured limbs. The most effective tourniquets were the Emergency Medical Tourniquet (92%) and the Combat Application Tourniquet (79%). Four patients (1.7%) sustained transient nerve palsy at the level of the tourniquet, whereas six had palsies at the wound level. No association was seen between tourniquet time and morbidity. There was no apparent association of total tourniquet time and morbidity (clots, myonecrosis, rigor, pain, palsies, renal failure, amputation, and fasciotomy). No amputations resulted solely from tourniquet use. However, six (2.6%) casualties with eight preexisting traumatic amputation injuries then had completion surgical amputations and also had tourniquets on for >2 hours. The rate of limbs with fasciotomies with tourniquet time <or=2 hours was 28% (75 of 272) and >2 hours was 36% (9 of 25, p = 0.4).
CONCLUSIONS:
Morbidity risk was low, and there was a positive risk benefit ratio in light of the survival benefit. No limbs were lost because of tourniquet use, and tourniquet duration was not associated with increased morbidity. Education for early military tourniquet use should continue..
Uhm....yeah?
I said it adressed the venous TQ, not that it advocated AGAINST TQ use.
I have read it, you know....
Gutshot John
09-10-13, 13:08
.
I have read it, you know....
You didn't read well enough...
"Total ineffectiveness (continued bleeding) was worse than partial ineffectiveness (persistent distal pulse) in that 61% and 51% had morbidity and 9% and 2% mortality rates, respectively. Ineffective tourniquets were associated with this clinical progression: persistent pulse, venous congestion, venous distention, rebleeding after a period of hemorrhage control, expanding hematomas, compartment syndrome, fasciotomy, and death, but this progression led only to 4 deaths. The persistent distal pulse risked high morbidity and low mortality, whereas persistent bleeding risked both high morbidity and high mortality." Page S44
In short using an ineffective venous TQ was MORE effective than not using one at all.
That is exactly the opposite of what you said.
Uhm....isn't that what I have been saying!? That a venous TQ is frigging dangerous!?
I don't know what the issue is here, but what you just posted frigging supports my comment on venous TQ....
There is no point in discussing this further, as you seem hell bent on "winning" over me personally, rather than having a constructive discussion.
I have stated several times that I advocate using TQs, that I carry TQs. I have also stated that direct pressure/pressure points work if the situation allows.
Waiting for the next strawman to come from you..
And no, I said that if the bleeding didn't stop, then the TQ isn't working. And a venous TQ means continued bleeding, not merely a distal pulse.
Gutshot John
09-10-13, 13:21
Uhm....isn't that what I have been saying!? That a venous TQ is frigging dangerous!?
Are you a native English speaker? If so, it might explain much of your inability to understand.
It says the exact opposite.
One more time... "Total ineffectiveness (continued bleeding [i.e. no TQ at all]) was worse than partial ineffectiveness (persistent distal pulse) [i.e. improperly placed Venous TQ]".
Yes, I can read and speak english.
Your example was the choice between NO TQ or a venous TQ.
Not two different kinds of ineffective TQ's. You made this comment when we discussed my choice not to use improvised TQs.
I just re-read the thread to make sure. Read post #64 and #66.
Any other insults about my reading comprehension, or are you done with these straw men?
Lastly, I suggest you look at your own reading conprehension ability, as the text compares a TQ with continued bleeding to a TQ with a distal pulse.
I admit...I can't tell which of the two of you has the bigger dick.
Gutshot John
09-10-13, 14:52
Yes, I can read and speak english.
Your example was the choice between NO TQ or a venous TQ.
Not two different kinds of ineffective TQ's. You made this comment when we discussed my choice not to use improvised TQs.
I just re-read the thread to make sure. Read post #64 and #66.
Any other insults about my reading comprehension, or are you done with these straw men?
Lastly, I suggest you look at your own reading conprehension ability, as the text compares a TQ with continued bleeding to a TQ with a distal pulse.
I meant no insult, I just noticed you listed your location as Norway and so I thought that might explain how you came to the exact opposite conclusion of what the study actually stated.
Improvised or not doesn't matter. What's the worst case scenario of an improvised TQ? That it may be "partially ineffective"?
The study that you cited explicitly states that 'partially ineffective is better than totally ineffective.'
In short doing something beats doing nothing.
I admit...I can't tell which of the two of you has the bigger dick.
I am not trying to measure dick size. I am trying, in futility it seems, to clarify my position.
Gutshot John
09-10-13, 15:09
I am trying, in futility it seems, to clarify my position.
It might help if your position was consistent with the sources you cite.
Well, that is very hard when you cite stats that have no correlation to what I have said.
I discussed a venous TQ vs no TQ at all.
A venous TQ is a very specific physiological occurence, that manifests as INCREASED bleeding:
http://www.joacp.org/article.asp?issn=0970-9185;year=2010;volume=26;issue=4;spage=551;epage=552;aulast=Chandrappa
The use of a tourniquet was not contraindicated as the popliteal and dorsalis pedis pulses were palpable. After exsanguinations, the tourniquet was inflated to 350 mm Hg and surgical site prepared and operation commenced. Upon incision, significant bleeding was noticed from the skin and subcutaneous planes. Suspecting tourniquet inadequacy, inflating pressure was increased to 425 mm Hg, which resulted in increased bleeding. Surgery was temporarily interrupted and the tourniquet cuff and inflator were changed, but with similar results. Suspecting bleeding due to incompressible artery and venous tourniquet effect, the tissues were closed and surgery deferred pending investigation and workup.
And I agree that the stats say what you claim they say; that a partially effective TQ is better than a totally ineffective TQ. That does not mean that a partially or totally ineffective TQ is a good thing, which was sort of my point. Morbidity and mortality is higher than with an effective TQ.
Like I said, if there is still bleeding (by default a distal pulse), the TQ is not working.
But hey, if you choose to read it that way, fine.
Lastly, here is the paragraph from the article that supports what I said:
The immediate aim of the applicant is to stop bleeding, thereby making the other goals attainable; however, hemorrhage control may be temporary if the distal pulse persists. When a distal pulse is present in a limb with a tourniquet, it is a venous, not arterial, tourniquet, and problems soon arise.
With each systole blood is driven into the distal limb and lost to the core circulation. Shock onset is hastened or worsened by such core blood loss. Pooling of blood distally engorges veins leading to limb congestion and more severe edema. Bleeding can increase with the onset of venous hypertension. Distal to the venous tourniquet, expanding hematomas and development of compartment syndrome can lead to a need for more extensive debridement or fasciotomy, respectively.
Mortality rates have been shown to increase with venous tourniquet use. Survival rates, survival times, and limb salvage rates are better with modern tourniquet use but are worse with improvised tourniquets so tourniquet design seems important to survival. Elimination of pulses distal to the tourniquet decreases these problems in both emergent and elective tourniquet use.
http://img689.imageshack.us/img689/9713/080o.png
But clearly, I am inconsistent in my arguments............
With that I bow out, as I don't have the time nor interest in discussing with someone whose intent is clearly focused more on "winning" the discussion and cornering me, than actually imparting or sharing knowledge....
Gutshot John
09-10-13, 15:44
Survival rates, survival times, and limb salvage rates are better with modern tourniquet use but are worse with improvised tourniquets so tourniquet design seems important to survival.
Dude reading is fundamental.
All this is saying is that modern TQs are better than improvised TQs, well no s#!^ huh? It DOES NOT say that a venous TQ is worse than nothing at all.
I never once said use an improvised TQ if a modern one was available.
According to your post above...if you have a applied TQ and still have a distal pulse than tautologically you have a venous TQ.
The Kragh study YOU cited specifically states that this is preferable to no TQ at all. Indeed it states explicitly there is less mortality and morbidity.
Yes you should keep tightening until there is no distal pulse.
Yes an improvised TQ is less effective than a real TQ.
No it is not a reason to try and staunch the bleeding with belt or other improvised TQ method...something that the studies I cited specifically stated.
PS. I'd point out that you were the one that first questioned whether I had even read the article I cited, so I'm a bit confused why you're getting butt-hurt when I returned to your doorstep what you delivered to me. Especially when you clearly didn't understand the article you cited.
You sure can dish it out, but you sure can't take it.
Gutshot John
09-10-13, 16:01
One more time...
"Total ineffectiveness (continued bleeding) was worse than partial ineffectiveness (persistent distal pulse) in that 61% and 51% had morbidity and 9% and 2% mortality rates, respectively. Ineffective tourniquets were associated with this clinical progression: persistent pulse, venous congestion, venous distention, rebleeding after a period of hemorrhage control, expanding hematomas, compartment syndrome, fasciotomy, and death, BUT this progression led only to 4 deaths. The persistent distal pulse risked high morbidity and low mortality, whereas persistent bleeding risked both high morbidity and high mortality." Page S44
Again, I don't read the stats to mean that a totally ineffective TQ bleeds at the same rate as a pt with no TQ at all. Is that how you read it?
And I don't read it to mean that a partially effective TQ is something to view positively, which has been my point all along. The same for a wound that continues to bleed after TQ application. This interpretation of the numbers is IMO pretty twisted in order to try to corner me.
And I don't think we are talking about the same article.
I think you got the stats from this article:
http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA480277
I linked to this article:
http://rapidshare.com/files/2500709738/TCCC%20Kragh%20Tourniquet%20Effects%20on%20Foot%20Ankle%20Clin%202010.pdf
My upload, as the original link doesn't work anymore.
And way to cherrypick one sentence from the entire paragraph, and dodging the main point of the paragraph.
Gutshot John
09-10-13, 16:35
You don't know what you're talking about, and I won't waste anymore time trying to help you.
Good luck.
You don't know what you're talking about, and I won't waste anymore time trying to help you.
Good luck.
Real mature.
You are using stats saying that an ineffective TQ, either partially or totally, leads to increased morbidity and mortality to prove that I am clueless and inconsistent in my stance. I don't get it, as that has been my point all along. Now I am stupid for not interpreting the stats to mean that a TQ that doesn't stop the bleed bleeds at the same rate as a bleed with no TQ?
No explanation I have given you seems satisfactory, and you continously change angle of attack after every explanation in order to corner me.
You have questioned my ability to read and understand english, you have questioned my knowledge and you use a hostile and condescending tone in your posts.
You have, despite my efforts to the contrary several times in this thread, decided that I am anti-TQ.
I really don't know what I have done to piss you off or have you dislike me.
This thread has been the biggest load of mental masturbation I've seen here. And for M4C, that's saying a lot.
Gutshot John
09-10-13, 17:08
you are using stats saying that an ineffective TQ, either partially or totally, leads to increased morbidity and mortality to prove that I am clueless and inconsistent in my stance.
Ok I'll try one more time...how do you get that from this?
Total ineffectiveness (continued bleeding) was WORSE than partial ineffectiveness (persistent distal pulse) in that 61% and 51% had morbidity and 9% and 2% mortality rates, respectively.
That quote is from the article YOU cited (page S44) the stats EXPLICITLY state that an ineffective TQ has DECREASED MORBIDITY AND MORTALITY OVER DOING NOTHING AT ALL.
Either you can't read or you can't count. Neither gives you much credibility.
I want to apologize for the needless back and forth, and for the thread bump linking to the blog post.
I have given my advice to the OP, and will bow out of this discussion.
@Gutshot John:
We'll have to agree to disagree. Good night.
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