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Thread: Can we talk about sequence of operations?

  1. #41
    Join Date
    Dec 2008
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    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...
    Last edited by Hell_Bent; 03-13-09 at 21:29.

  2. #42
    Join Date
    Apr 2007
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    Excellent post Hell Bent. Joe, I wasn't digging at you, the protocol comment could have been explained better thus: " After reviewing outcomes of our own incidents, and as a consequence of how freely we tourniquet wounds based on the tactical situation as opposed to the medical necessity, we developed a tourniquet release / conversion protocol." You are absolutley right though, it can be highly regional in how it gets implemented.

    As Hell Bent alluded to, once you start down the path of doing trauma care during the wounding process, as opposed to responding to the incident afterward and generally it being safe, a lot of what you used to take for granted about medicine changes. We plan the greatest majority of our ops during low light, so we had to make sure we were constructing policy that would reflect having to function in that and not cause more casualties. I could have done a better job of explaining that.. The training I had in medic school didnt prepare me for it, and I had to do a lot of 'un-learning' so as not to advocate for things that while medically sound were tactically inappropriate.

    To appeal to a wider audience though, and not make this too 'tactical- 'centric, I think that hemostatics do have a place for the outdoorsmen or hunter. We had a bowhunter just a few miles from my house die from a high femoral bleed last year, from somehow shooting himself with his own crossbow. I don't know all the details, but from what I heard it was one of those pesky wounds that would have been difficult to tourniquet. Helluva a way to end a good day hunting.
    Last edited by Doc Solo; 03-14-09 at 12:58. Reason: my focus may be too narrow

  3. #43
    Join Date
    Jun 2006
    SE FL
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    5 (100%)
    One of the things, especially from reading through some TCCC resources that I see a lot is two kinds of care: under fire and not.

    Obviously the vast majority of civilian (even civilian LE) incidents are more likely to be dealing with the injury when NOT under fire as the incident (barring a Red Dawn or West Hollywood scenario) will be over by the time the injured realizes he's hit.

    Clearly, if you're actively under fire you have to finish the fight, and if you're part of a team that responsibility extends to not only preserving your own life but holding up your end of the team.

    I think I'm starting, for my own purposes, to put the type of environment for treating the injury into three potential categories.
    1) Injury is realized, no threat remaining (something like an ND on the square range)
    2) Injury is realized, no immediate threat appears (something like a home invasion where you've neutralized the only visible threat, but there may be more)
    3) Injury is realized, immediate threat remains (multiple assailants, battlefield, etc.)

    Would this seem reasonable, and could one start to break down responses based on which of the three is the case?

  4. #44
    Join Date
    Feb 2008
    Culpeper, VA
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    26 (100%)
    Try not to think of it as "under fire" or not, think of it as scene security. Scene security is something that exceeds that particular consideration or rather incorporates a totality of circumstances that you're going to have to be aware of. This really gets a lot of coverage in PHTLS. Your focus is going to be on the casualty (tunnel-vision), try and see the bigger picture. Not being under fire simplifies things significantly, but that doesn't mean there are no other threats.

    Your first priority irrespective of casualty type is to assure scene security meaning you can't render adequate care if there is a strong possibility of yourself getting injured. You aren't going to do anyone any good as a just another casualty. This might mean ending the fight, but that's not always possible (see North Hollywood Shootout).

    Scene security involves threats from other shooters, but also might be the patient himself, potential environmental hazards (downed powerlines, leaking gasoline, ignition sources, turning off a running engine etc.) or other.

    You're not always going to be able to eliminate the threat first so you think about what you're going to do before charging out into the FOF to either render care or pull someone back.

    Lots of circumstantial variables I'm afraid, but in general your first rule is to CYOA.
    It is bad policy to fear the resentment of an enemy. -Ethan Allen

  5. #45
    Join Date
    Jun 2008
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    Deal with the bullets in the air first.

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