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Thread: So does it work or not?

  1. #1
    ToddG Guest

    So does it work or not?

    Just got my First Responder/CPR/AED/O2 certification. OK, yea me.

    Spoke with a very good friend who, as part of a full-time tac team, received quite a bit of advanced emergency trauma training. We talked about the stuff I'd learned in class and his opinion was that most of it was wishful thinking. He doesn't claim to be an expert by any means, but it raised a lot of questions that I thought the experts here might be able to explain.

    Examples:

    Tourniquets: Official DOT/ARC word-of-God is that you never put a tourniquet on unless you've decided, in effect, to amputate the limb. Official procedure is bandage, if bleeding continues more bandage, if bleeding continues pressure point, if bleeding continues then tourniquet if and only if medical help is > 30 minutes out.

    I'm not a doctor, but I have a hard time believing someone with a sliced open femoral artery is going to last 30 minutes. When I raised this point in class, the instructor basically said, "this is what DOT/ARC teaches ... use your judgment."

    My friend's take: if you know you have a serious arterial bleed, it's time for the tourniquet. By the time you've gone through all the other steps, the victim might not have enough blood left to be worth worrying about. Also, contrary to the DOT/ARC view -- "once you put a tourniquet on you've poisoned the limb and it's probably going to be lost" -- apparently there is quite a bit of evidence that limbs have survived hours after a tourniquet.

    So which is it?

    Open chest wound: We were taught occlusive dressing, taped down on three sides, and "burp" the air/blood from a pneumothorax or hemothorax.

    Friend's take: you need to get something inserted into the chest to drain the pressure actively. This is obviously well beyond the scope of what we were taught in EFR.

    CPR: Based on what my friend relayed and what I read here in the "when your patient dies" thread, it sounds like CPR has an almost 0% success rate. WTFO? Is that a matter of timing -- professional rescuers arrive too late for it to matter, but someone on the scene at the moment of arrest might be able to make a difference -- or is it really just a feel-good thing that people learn to say they've learned it?

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    I know it's not going to be the answer you want to hear, but ultimately they are both correct. The question is WHICH is your standard of training.

    You completed a curriculum that only gradually increases in aggressiveness towards hemorrhage control. It subscribes to an ANTIQUATED doctrine that still exists that tourniquets destroy a limb by cutting off all blood flow.

    More recent studies discredit this information and has shown little long-term adverse affects either nerve or vascular due to tourniquet application even for hours. This however is new. The old "bad" information hasn't been fully processed out of the curriculum.

    The issue for you as first responder is whether you can apply that information without some risk. If you deviate from the standards of our training, you open yourself up to significant liability. This may not be a problem if it's YOU that's got the hemorrhage, but if you have to treat someone who might end up suing you, they might make an argument that you deviated from your standards and therefore not covered by good samaritan protections. My suggestion is to be very quickly moving through the different levels (you can probably ignore the pressure point method) until you get to the tourniquet. You talked about 30 minutes of trying to stop bleeding, that's not realistic to my way of thinking...you should have moved through the steps within 2 minutes. You also have to consider that you're probably going to have to move/transport someone.

    If you go through those steps, albeit quickly/perfunctorily, you limit your liability as its still consistent with your training standard. You're a lawyer and you know how it works.

    CPR has almost 0% success, I've never seen it work but I almost always got there several minutes after the person went down. If applied rapidly (within seconds) it might have greater effect. Mostly paramedics do CPR to show the family that we're trying to save the person pumping blood until we can get to a hospital where the Doc can call it. If you're having to apply CPR to a guy for massive hemorrhage he's pretty much dead.

    PS. I don't care what class you take, you're not going to be doing a chest tube. No First Responder is going to have the wherewithal to put in a tube. Your buddy has an exceptional amount of training, but I'd be skeptical that he gets to apply it that often.

    Quote Originally Posted by ToddG View Post
    Just got my First Responder/CPR/AED/O2 certification. OK, yea me.

    Spoke with a very good friend who, as part of a full-time tac team, received quite a bit of advanced emergency trauma training. We talked about the stuff I'd learned in class and his opinion was that most of it was wishful thinking. He doesn't claim to be an expert by any means, but it raised a lot of questions that I thought the experts here might be able to explain.

    Examples:

    Tourniquets: Official DOT/ARC word-of-God is that you never put a tourniquet on unless you've decided, in effect, to amputate the limb. Official procedure is bandage, if bleeding continues more bandage, if bleeding continues pressure point, if bleeding continues then tourniquet if and only if medical help is > 30 minutes out.

    I'm not a doctor, but I have a hard time believing someone with a sliced open femoral artery is going to last 30 minutes. When I raised this point in class, the instructor basically said, "this is what DOT/ARC teaches ... use your judgment."

    My friend's take: if you know you have a serious arterial bleed, it's time for the tourniquet. By the time you've gone through all the other steps, the victim might not have enough blood left to be worth worrying about. Also, contrary to the DOT/ARC view -- "once you put a tourniquet on you've poisoned the limb and it's probably going to be lost" -- apparently there is quite a bit of evidence that limbs have survived hours after a tourniquet.

    So which is it?

    Open chest wound: We were taught occlusive dressing, taped down on three sides, and "burp" the air/blood from a pneumothorax or hemothorax.

    Friend's take: you need to get something inserted into the chest to drain the pressure actively. This is obviously well beyond the scope of what we were taught in EFR.

    CPR: Based on what my friend relayed and what I read here in the "when your patient dies" thread, it sounds like CPR has an almost 0% success rate. WTFO? Is that a matter of timing -- professional rescuers arrive too late for it to matter, but someone on the scene at the moment of arrest might be able to make a difference -- or is it really just a feel-good thing that people learn to say they've learned it?
    Last edited by Gutshot John; 07-03-09 at 12:22.
    It is bad policy to fear the resentment of an enemy. -Ethan Allen

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    Tqs:
    In short, properly used and designed, Tqs save limbs with very small risk of limb damage. Of course, direct pressure should be used before hand, but National Registry recently removed limb elevation and pressure points from their hemorrhage control skill sheet - so its now direct pressure then tqs if hemorrhage control fails. Check with your local protocols, so agencies (like mine) still feel like tqs are a no go.

    Open Chest wound:
    Your friend is right in that needle decompression then chest tubes will relive a tension pnemuo, but burping the wound might do the job as well. Do the best you can within your scope.

    CPR:
    Traumatic arrest has very low to no chance in getting a patient back. However, for most civilians, non traumatic cardiac arrests have the best possible chances with high quality CPR (minimize hands off time, let the chest fully recoil), rapid AED use and rapid transport. CPR alone has a very low (if at all) chance of getting someone back.
    Last edited by JamesL; 07-03-09 at 12:48. Reason: Addition

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    Quote Originally Posted by ToddG View Post
    Tourniquets: Official DOT/ARC word-of-God is that you never put a tourniquet on unless you've decided, in effect, to amputate the limb. Official procedure is bandage, if bleeding continues more bandage, if bleeding continues pressure point, if bleeding continues then tourniquet if and only if medical help is > 30 minutes out. I'm not a doctor, but I have a hard time believing someone with a sliced open femoral artery is going to last 30 minutes. When I raised this point in class, the instructor basically said, "this is what DOT/ARC teaches ... use your judgment." My friend's take: if you know you have a serious arterial bleed, it's time for the tourniquet. By the time you've gone through all the other steps, the victim might not have enough blood left to be worth worrying about. Also, contrary to the DOT/ARC view -- "once you put a tourniquet on you've poisoned the limb and it's probably going to be lost" -- apparently there is quite a bit of evidence that limbs have survived hours after a tourniquet. So which is it?
    That's the current curriculum for AHA, ARC, DOT, and several other first aid programs. Current PHTLS curriculum is teaching direct pressure (manual or mechanical), followed by a tourniquet is DP isn't effective. The new proposed (and approved, IIRC) DOT curriculums follow that. Research showed that pressure points and elevation didn't have much effect on patient outcomes, and tourniquets didn't have the negative effects once thought.

    There have been folks that knew better and taught alternatives all along, but the data from Iraq/Afghanistan is now change in the mainstream. War is useful in that way.

    Good stuff with burn treatment as well, but not for pre-hospital.

    Open chest wound: We were taught occlusive dressing, taped down on three sides, and "burp" the air/blood from a pneumothorax or hemothorax.

    Friend's take: you need to get something inserted into the chest to drain the pressure actively. This is obviously well beyond the scope of what we were taught in EFR.
    Relieving a ptx is easy, and is now commonly taught to deploying soldiers and other groups. Curriculums for lay rescuers (ARC, AHA) still turn their noses up at it.

    Chest tube is quirkier.

    CPR: Based on what my friend relayed and what I read here in the "when your patient dies" thread, it sounds like CPR has an almost 0% success rate. WTFO? Is that a matter of timing -- professional rescuers arrive too late for it to matter, but someone on the scene at the moment of arrest might be able to make a difference -- or is it really just a feel-good thing that people learn to say they've learned it?
    I've done CPR umpteen times, and only brought back folks to die at the hospital.

    Best stats are with witnessed SCA in otherwise healthy folks. All others have consistently poor outcomes. In the case of cardiac arrest as a result of trauma, most systems won't resuscitate.

    Add in things like ~10% survivability loss with each passing minute, response time realities in most systems, and the picture is pretty darn bleak.

    Do what you can, save those you can, but some folks will die.
    Last edited by ST911; 07-03-09 at 12:55.

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    Listen to what these guys are saying. The fact is, less than 1% of cardiac arrests survive, but high quality CPR and electrical therapy have been the only two therapies shown to have even a slight improvement on patient survival. As far as trauma goes, the only thing that's going to save the guy is surgery, plain and simple, so your goal should be aimed at getting the patient to a surgical center alive. As was said, the NREMT has moved away from the old pressure, elevate, pressure point, then tourniquet method of bleeding control and moved to tourniguets as the second line treatment for bleeding control. This comes from the fact that tourniquets are used routinely in surgical situations with little to no damaging effects. Studies of trauma patients have shown a significantly higher survival rate with patients treated and transported by basic level responders over advanced level responders (ie Paramedics) because the basic guys just load the patient and run, while the Medics want to hang around and play with IV's and what not, when in reality, they should be doing that stuff enroute to the hospital. So do what you're trained to do, very quickly and get on the road. And don't think that your CPR will have no effect, in reality, it probably has more effect on the patient than all the drugs and IV's in the world. The only thing an advanced level responder can do that has a proven effect is intubation, and even that only has an effect on outcome if the patient's airway is compromised to the point where BVM and basic airway adjuncts are useless.

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    Quote Originally Posted by Gutshot John View Post
    PS. I don't care what class you take, you're not going to be doing a chest tube. No First Responder is going to have the wherewithal to put in a tube. Your buddy has an exceptional amount of training, but I'd be skeptical that he gets to apply it that often.
    I've done one. Extremely f'd up situation. I hope like hell I *NEVER* am in a situation like that ever, ever again. The suck-meter was pegged. This was a decade + ago, as a street paramedic.

    I took a very bad patient (bad off, not bad person) into the trauma center. He'd been stabbed (by someone who wanted his shoes, for God's sake... his shoes...) in the flank. Tension hemothorax. Evac via air was unavailable, so we scooped him up and hauled ass. Two large-bores, a chest seal, and some of the craziest stuff I've ever seen on a monitor. Decent consult, and trauma was definitely ready for us when we rushed through the door... and I was at the head of the stretcher. The surgical trauma team is some kind of amazing... everything happens like RIGHT THE F NOW in a team like that. I knew the doc from clinicals and from multiple past patients - good rapport. He looked at me, basically said "you doing this or me?" and talked me through it.

    Again... NEVER AGAIN do I want to be there. I was shaking for an hour afterward.



    Protocols, jurisdiction, and level of care/training do play in to this very, very heavily. Had I attempted something like that in the street without being supervised, I'd have at least lost my certs, if not much worse. The furthest we were instructed at that time was to use a large-bore catheter to decompress the lung, and that would have required consult or paperwork for weeks to justify.

    After this, I went on to do some remote location stuff that required additional training. Even there, where we were taught to do surgical crichothyrotomy, we still were not taught to do a surgical chest tube.

    None of my training was military.

    This was MY experience. Others may have significantly different ones. Things may also have progressed as time moved forward, too. I'm not on the street or in the business anymore... everything lapsed about 3 years ago. Someone else's watch now...

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    Quote Originally Posted by meisterhau View Post
    I've done one. Extremely f'd up situation. I hope like hell I *NEVER* am in a situation like that ever, ever again. The suck-meter was pegged. This was a decade + ago, as a street paramedic.

    I took a very bad patient (bad off, not bad person) into the trauma center. He'd been stabbed (by someone who wanted his shoes, for God's sake... his shoes...) in the flank. Tension hemothorax. Evac via air was unavailable, so we scooped him up and hauled ass. Two large-bores, a chest seal, and some of the craziest stuff I've ever seen on a monitor. Decent consult, and trauma was definitely ready for us when we rushed through the door... and I was at the head of the stretcher. The surgical trauma team is some kind of amazing... everything happens like RIGHT THE F NOW in a team like that. I knew the doc from clinicals and from multiple past patients - good rapport. He looked at me, basically said "you doing this or me?" and talked me through it.

    Again... NEVER AGAIN do I want to be there. I was shaking for an hour afterward.



    Protocols, jurisdiction, and level of care/training do play in to this very, very heavily. Had I attempted something like that in the street without being supervised, I'd have at least lost my certs, if not much worse. The furthest we were instructed at that time was to use a large-bore catheter to decompress the lung, and that would have required consult or paperwork for weeks to justify.

    After this, I went on to do some remote location stuff that required additional training. Even there, where we were taught to do surgical crichothyrotomy, we still were not taught to do a surgical chest tube.

    None of my training was military.

    This was MY experience. Others may have significantly different ones. Things may also have progressed as time moved forward, too. I'm not on the street or in the business anymore... everything lapsed about 3 years ago. Someone else's watch now...
    Exactly, on average it's a once in a lifetime event for most medics, and should be even rarer for first responders. The only time I had significant chest tube protocols was when I worked in Wilderness EMS and transport times averaged 3+ hours. The only time I had to do one was in the military in the same sort of capacity. Doc talked me through it on the radio and pretty intense/imperfect conditions. Guy was in agony.

    Todd, see if you can take a PHTLS or ITLS class or whether you need to be an EMT, this should have more modern training relative to tourniquet application. You can be sure however that the old information is being rapidly phased out.
    It is bad policy to fear the resentment of an enemy. -Ethan Allen

  8. #8
    ToddG Guest
    Thanks for the feedback so far, gentleman. It's genuinely appreciated.

    PHTLS = ?
    ITLS = ?

    Two things I need to clear up:

    1. I don't think our instructor was ignorant of what you're saying, she was just very clearly being held to the ARC training protocol.

    2. Didn't mean to imply that my buddy considered himself a combat medic. Far from it. When he mentioned needle decompression, e.g., it was in terms of "someone is going to have to do that" not "this is what I'd do!"

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    CPR does work, our survival to hospital discharge rate is in the low 20's last I checked. Not great but definitely not not 0%, and our ROSC (return of spontaneous circulation)(AKA getting pulses back) rate is almost 50% now i believe.

    You will never convince me that the typical civilian not on an ambulance will ever generally need to decompress a tension pneumo, it is rare enough even on a high-volume urban/suburban/rural ambulance.

    PHTLS = Pre Hospital Trauma Life Support
    ITLS = International Trauma Life Support (formerly known as BTLS which is basic trauma life support.

    ETA - I believe those figures are for pt's whose initial rhythm is something other than asystole.
    Last edited by NinjaMedic; 07-03-09 at 19:14.

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    Todd, see if you can take a PHTLS or ITLS class or whether you need to be an EMT, this should have more modern training relative to tourniquet application.
    Unfortunately, not. Tourinquet as last resort only was standard in the Basic class I just finished.
    Last edited by Barbara; 07-03-09 at 19:14.
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