Can we talk about sequence of operations?

[Hell_Bent]

The whole tourniquet issue gets polarized based on what your background is.

I came up in .civ EMS and it was pounded into my head that tourniquets were the stuff of bad action movies - It is good that this is rapidly being reassessed as evidenced by inclusion in mainstream EMS pubs such as JEMS and recent editions of texts. I can say that in a decade and a half or so of civilian employment, I only used them a few times - usually on amputations or severely mangled extremities (such as the boat propeller injury mentioned above).

Then I got exposed to the TCCC side of the house. It was eye opening and I experienced a paradigm shift. It's not always about what you can do to control the bleeding (99.999% of injuries can technically be controlled using more conventional measures - eventually...), but what you should do based on the totality of the circumstances... What works on an MVA scene with a couple of extra sets of hands and a fully stocked Mobile Intensive Care Unit with a 6 minute transport to a LVL 1 Trauma Center may not be the best course of action in the aftermath of a complex VBIED on Route Irish with SAF followup - or an ND into a shooting partner at a remote rifle range. This isn't about proving what a stellar medic you are and showing off your bandaging skills - it's about taking the right course of action in a evolving situation and damn the peanut gallery. Taking such training in a team room during IDF attacks does a great deal to open one's mind to more progressive techniques...

There are times when you can manage things without a TQ - if you think that's the case and the situation allows, then give it a shot. You can always throw a tourniquet on if you start down that road and see it ain't working out.

There are other times when "let's try this, first" is a non-starter... If you're the one who got perforated and you're alone, then it's not a great idea to watch blood go in-and-out instead of round-and-round and end up unconscious while your textbook pressure dressing flips you the bird. In short, if you're working without a net, err on the side of caution and place the TQ. If it's arterial blood flow, then the scale starts tipping towards a tourniquet a little more quickly. Like the poster above stated, the incidence of necrosis over a period of a few hours is low (I have also been taught that less than 4 is basically a non issue, and 6 is probably going to be OK, I'll try to dig up the actual stats in a bit). Worst case scenario? Some neo-god in a response role is going to think you jumped the gun - big deal. Pride related injuries are rarely fatal. The same cannot be said for uncontrolled exsanguination...

As far as hemostatics, I like them as an adjunct. They work well enough in conjunction with your other efforts, but if I had to choose between TQs, pressure dressings or hemostatics to fit in a kit, the hemostatics fall into the "nice to have, but not a deal breaker" category for me. On an extremity wound, it may be superfluous (you stand a really good shot at being successful with a correctly applied TQ), but the hemostatics are a little more useful on wounds not amenable to TQ use due to location - torso, etc.

All that being said, for the OP's original question

For a "bleeder" on a limb, can some of the professionals weigh in with what the sequence of operations would be with regard to the above three items? Do you apply the tourniquet first, then the hemostatic, then the combat dressing? Or is the order of the first two reversed, or what?

Assuming I'm not dodging incoming or having to suppress a threat, my first reaction is always the same - put something on it. Firm direct pressure may not fix it, but it gives your hands something to do for a few seconds while the "oh shit factor" gets back under redline. After a few seconds holding a trauma dressing, t-shirt or whatever on it you're getting an impression of what you're dealing with. If it's a isolated wound (clean GSW or laceration/injury of a size that you can effectively apply pressure), then you may be ready to tie some direct pressure to your dressing and get gone. If you see that bleeding isn't being controlled, then step it up and place your TQ.

As far as where the hemostatics fall into that sequence? I'd normally go with Direct Pressure (if I didn't rule it out as a possible fix on first sight), then TQ if necessary, then augment either or both with the hemostatic if indicated. The impregnated dressings help alleviate that concern by letting you kill 2 birds with 1 stone on the first step.

If the blood loss is adequately addressed/definitive care is within reach/the tactical environment allows, then it should go without saying that the least invasive procedure which is successful and can be maintained becomes the correct answer.

The only hard and fast rule is to make the red stuff stay inside. If a bandaid does the trick, easy day. If you have to escalate to TQ's, multiple hemostatic applications and a bulk order of gauze, vengeful ParaNinjas ain't gonna drop from the sky hurling star-of-life shaped shurikens at you. If they do, have them hold pressure while you reassess the casualty...

Not sure if any of that made any sense whatsoever to anyone but me - I tend to ramble on slow shifts...