P1 Exclusive: Tactical tourniquet use – Part one

Ed Note: This is the first of a two part series.  In part one below, author Chuck Soltys explores self/buddy care, gear placement, basic hemorrhage control, as well as a few of the vital arteries and nerves in the leg. In part two (appearing in coming weeks), Chuck will look at the types of tourniquets as well as the best practices for their use.

By Chuck Soltys

In November of 2007, NFL player Sean Taylor was shot during a home invasion at his residence in an upscale Miami neighborhood. Taylor sustained a gunshot wound in the leg, injuring his femoral artery. He bled to death. In May of 2008, a Portland, Maine police officer unintentionally discharged his firearm while preparing for duty. The bullet struck the officer in the upper leg and he died shortly thereafter.

To many, it may seem unlikely – if not impossible – to die from a gunshot wound to the leg. The fact is that many lives have been lost on the battlefields of every war due to rapid blood loss from extremity wounds.

It is entirely possible that the proper and immediate application of a tourniquet may have saved both of these men’s lives. And, with the advancements in medical technology and depending on the extent of the injury, Taylor may have been able to resume his NFL career.

In July 2008, a Wichita, Kansas police officer survived after being shot in both legs. One of the responding officers had military medical training and applied a tourniquet. He is credited with saving the officer’s life. While there may be relatively few civilians that know how to use a tourniquet and even fewer that would have one available if faced with a situation such as Taylor’s, everyone in law enforcement and the military should be skilled in the use of a tourniquet and have one available or at least know how to improvise one.

In civilian Emergency Medical Service (EMS), they have an aversion to the use of a tourniquet. In the Tactical Combat Casualty Care (TCCC) or Tactical Emergency Medical Support (TEMS) environment, it is the preferred method of controlling life-threatening extremity hemorrhage. In the Viet Nam War alone, more than 2,500 deaths have been attributed to hemorrhage caused by extremity wounds. These casualties had no other injuries.

Remember that you and the casualty (assuming you are not the casualty) are in grave danger while applying a tourniquet or treating life-threatening injuries in a hostile environment. Non life-threatening injuries should be ignored until the scene is safe. The decision regarding the relative risk of further injury versus that of bleeding to death must be made by the person rendering care.

Remember, the first step in TCCC or TEMS is to ELIMINATE THE THREAT!

Battlefield Case Studies
Civil War (fatality)
• Leading Confederate General (Albert Sydney Johnston)
• KIA at Shiloh April 7, 1862
• Gen. Johnston’s Surgeon, Dr. David Yandell, directed that tourniquets be issued. During the battle, Gen. Johnston sustained an injury to the popliteal artery (located just above and behind the knee) and bled to death
• Tourniquet was in his pocket

Operation Iraqi Freedom (fatality)
• Marine shot in the leg
• Pulsatile femoral artery bleeding
• Corpsman arrived 10 minutes later
• Attempted to use hemostatic material-failed
• IV attempted – failed
• Tourniquet finally applied-too late
• Casualty died

Vital Arteries and Nerves in the Leg
The femoral artery, located deep in the thigh, is the major vessel that supplies blood to the thigh, while the anterior (front) and posterior (back) tibial arteries are the primary blood vessels in the lower leg. The major nerve in the leg is the sciatic nerve – the largest nerve in the body – which carries motor information to, and sensory information from most of the leg and foot. Another primary nerve is the tibial nerve, which branches off the sciatic nerve in the lower leg.

According to trauma surgeon and tactical physician Dr. Andrew Dennis, “the anatomy is very predictable and even in the fattest of people the vessels are palpable (able to be felt by the hands) in the groin.” The femoral artery would be no more or less prone to penetrating injury in a highly conditioned athlete with very low body-fat or a high percentage of lean muscle tissue (such as Sean Taylor). It would be anatomically indifferent.

Basic Hemorrhage Control
The vast majority of extremity hemorrhage caused by penetrating trauma can be controlled by direct pressure and elevation. Hemorrhage control by direct pressure is best accomplished by applying firm circumferential pressure around the limb trapping the injured artery against the bone and elevating the limb until bleeding is completely occluded. There are currently a variety of emergency compression dressings on the market that work very well to control hemorrhaging.

The OLAES Modular Bandage (www.tacmedsolutions.com) and the Israeli Battle Dressing (www.ps-med.com) are two of the most popular bandages available. If the mechanism of injury has caused a large open wound or considerable tissue damage (i.e. shotgun wound or blast injury), packing sterile gauze into the wound is essential prior to applying a compressive dressing. Once direct pressure and/or a compressive dressing have been applied, the injured extremity should be elevated. The casualty’s body temperature should be monitored and arrangements made for immediate transport to a trauma hospital.

Self Care/Buddy Care
Training in the area of Self Care and Buddy Care has long been overlooked in basic law enforcement academy curriculums as well as in-service programs. If you or your fellow officers are seriously injured during a hostile attack on the street, for an unspecified amount of time, you are on your own! Even the best intentioned EMTs and paramedics will likely not be able to get to come to your aid until the threat has been eliminated. That time lapse could be the difference between life and death. The steps that need to be taken to ensure your survival are simple. But, you must have the training and equipment necessary to accomplish this available to you when something bad happens.

Gear Placement
“The need for immediate access to a tourniquet in such situations makes it clear that all soldiers on combat missions should have a suitable tourniquet readily available in a standard location in their battle gear and be trained to use it” (Butler, Hagmann, and Butler, Military Medicine 1996).

Some experts feel that rather than to hide the tourniquet in a cargo pocket/pouch somewhere different on each operator, the "perfect" location for a tactical tourniquet on an operator is to mount it on the front center upper chest area of the tactical vest, attached via two large black rubber bands. Sections cut from bicycle inner tubes are ideal for mounting tourniquets on the vest. When an operator is injured, he can simply grab the tourniquet and rip it away and immediately put the tourniquet into use. With proper training, he should be able to accomplish this with either hand, day or night. Ideally, getting your team to carry emergency equipment such as a tactical tourniquet on the front 180 degrees of their vest, in a standardized location would be beneficial.

For patrol officers, a tourniquet should be on your person. If that is not possible, it should be included in a basic individual emergency medical kit and stored in the compartment on the driver’s side door or in the center console. Keep in mind that there is a serious compromise when the decision is made to store the tourniquet in the vehicle as opposed to on your person. In all likelihood you may be separated from your patrol car making it potentially difficult – if not impossible – to get to when needed.

You are not afforded the luxury of choosing when, where, and how you will be attacked. That will be decided for you. Therefore, these are come as you are events. By virtue of the oath you took, you have an obligation to be prepared. All of the highest speed equipment and training is useless if it is not with you when you need it.