Did you ever use a tourniquet?

[Tyler_EMT]

Note: Medics, don't forget to remove the tourniquet from the patients arm after successfully starting an IV. Medics on my department are really bad about this.

[DwayneEMTP]

Great points all Spork, though I don't completely agree.

As was stated by another, the patients that I've seen most often with life threatening hemorrhagic shock have not been to the extremities, though the extremities have sometimes been involved.

I think the reason that it's common to use tourniquets in the OR and not so much in the streets is that it's uncommon to see OR docs and nurses running around freaked out making them less likely to crank a limb off with it, or forget to take it off later. Now, I know that WE are all perfectly calm on scene and have been from day one, but I've heard rumors that some can get a bit wound up on nasty traumas, particularly when newly released.

Once again I'm going to open myself up to a beating and admit to breaking a cardinal rule. When I needed to break it, as before that, I had no idea why it was an unbreakable rule, so couldn't in good conscience follow it when it seemed counter productive. And, to tell the truth, I still have not a single clue as to why it's a rule.

I once, here we go....put on a tourniquet and then removed it before getting my patient to the doctor. I know...I'm a bad person...but here's the reason.

In Afg we had a construction worker working on the second story of some containers, so say, approx 20ft up. He fell off of the side and on the way down caught his arm on a piece of scrap metal that had been sitting on one of the scaffolds. The exposed metal was terribly sharp and caught him just under the armpit, missing his Brachial artery by, I'm guessing, smidges, caught under the skin and pulled through much of his bicep, exposed nearly the entire elbow joint, followed down the the outside of his arm exposing muscles, bones and tendons and the incision stopped at his wrist.

We were maybe two miles from the Role3 and back in the middle of construction, he was running around like a madman throwing blood everywhere, it was a pretty good mess. One of the few times when I really wish he would have hit his head too...at least he would have been quiet and still.

Long story short, I got him on the ground, I was with another medic but he was kind of freaked out and no help, and after a quick glance put a tourniquet on it. That stopped the blood flow while I did a quick physical exam, and my partner was wrapping the arm. I'd helped him pull the wound margins together, as the wound sort of a spiral around the arm, the margins were relatively clean and complete. We aligned the margins, wrapped them tight-ish in the hope that they would stay at least partially approximated, and loaded him in the "ambulance" for transport. (Parentheses will make sense to most that have been there.)

Enroute I began to worry about feeding the wound margins as I wanted to try and leave the best chance for repair. I released the tourniquet slowly so as not to hurt him to bad but also to see if there was a chance that the dressings would hold.There was some bleeding, so I added another, tighter wrap, and other than some very slow seepage it seemed to hold for the 20 minute or so winding drive to the Role3.

I don't really remember what happened after we dropped him. I gave my report to the trauma team, non batted an eye at my story, and I went about my business.

I can see your point that had there been undiscovered injuries that the time it took to wrap it, or the blood that I spent testing my dressings could have retarded his condition. I get that...I really do.

But I also can't get onboard with the flip side of, "He's already kind of fucked. So I need to do everything in my power to keep him from getting more fucked. And should my good intentions cause him even more damage than necessary....well, that's just a bad turn of luck."

The above is not meant to be disrespectful, but a bit of a paraphrase of the "don't risk feeding the margins" part of your post. (My words of course, not yours. Judging from your post I'm willing to bet you have a much smarter way of describing these topics.)

I stayed away from this thread when I saw it continue to grow in the belief that nothing good could come of this topic if it was being discussed so much...boy did I screw the pooch on that. Great conversation I think...thanks to all for participating.

Dwayne

[DFIB]

I don't think there is reason to bang you up too much. By design touniquets are made to reduce catastrophic blood loss. Once that objective was achieved the risk/benefit of leaving a touniquet on changes. I know our local protocols say something different. I think in part because Medical Direction need to make sure their EMS personel don't end up off the reservation trying weird procedures or doing dumb stuff. Aplying a touniquet is pretty basic and a guy with your experience should be able to tell when you are getting into uncharted territory.

Usually in places like Afg folks work under what could be called "relaxed" protocols if protocols exist at all. I don't know if that was the case with you. Many times we will do what is reasonable based on our experience and the developing situation.

I think your logic was good and you probably helped your patient and the trauma team that would patch him up.

Did you ever get to follow up on him?

[DwayneEMTP]

Yeah, your point is spot on regarding Afg. If you wanted to look like a complete asshole over there just bring a damaged patient into the Role3 and explain that you didn't provide what you felt would have been a benificial intervention because 'my protocols don't allow it.'

Working there ruined me forever I think. After that it's very hard to say, "I know you'd feel better if I give you another Litre of fluid during our 2 hr transport to the hospital, but my protocols only allow for a 500cc max."

Very difficult to follow up on these types of patients there as they either get stabilized and sent out of country to Dubai, or stabilized and loaded on an ambulance to an Afg hospital..neither conducive to follow ups..

This is an excellent example I think of, "Of course I did the right thing. I lost only a little bit of blood, and feeding the wound margins is obviously a benificial intervention with very little risk involved!"

But then of course I have to hold my argument up against the one used to support MAST...which of course bitch slaps me right back to the real world. Maybe one of the Drs can comment, as my treatment plan made sense to me, but it's possible that the wound margins will be fine if left with no treatement for days, in which case I'm just an idiot dicking around when I should in fact have been taking another set of vitals or something...

I have no data support either argument really, but I feel like a rock star medic when I follow mine..and at the end of the day that really is the most important thing I think... :-)

And for the record, why should a tournequet not be removed except by a doctor once it's been placed? I've assumed in the past that it is so the Dr can see where it was placed and assess any vascular damage that may have been caused by extended use or over tightening, but I really have no idea...

Dwayne

[tcripp]

Funny (to me) scenario about a TQ.

Had a gunshot patient not too long ago who, himself, put a TQ above the "entry" wound to stop the bleeding prior to EMS arrival. The pt stated that he tripped over a basket where a handgun fell out and discharged entering in to his thigh. Because my "training" said "never ever remove a tourniquet", I did just that and left it in place. And, all my decisions were based then on what I could see. I looked all around the tourniquet for an exit wound and didn't find one. Just the entry wound based on the GSR. Contacted the local ER who said to take him to a trauma 1 facility because of the lack of exit wound for further care.

So...the moral of my story? We deliver the patient to the ER who immediately removes the TQ and...VOILA...there sits the exit wound...6 inches away from the entry. Talk about the "duh" feeling moment.

Next time, I assess the situation and decide on the situation based on someone once saying "never ever" and go from there. This patient required no surgery and was released that same day. We could have done this at our trauma 4 facility.

One more lesson learned after graduation.

[DFIB]

Tampons do a good job in gunshot wounds in the absence of arterial bleed.

[tcripp]

Tampons do a good job in gunshot wounds in the absence of arterial bleed.

You carry tampons on you?

[DFIB]

You carry tampons on you?

Only in my jump kit. Tampons work for epistaxis as well. I use kotex for lacerations. They are really fast on scalp lacerations. Slap a kotex on and wrap with a previously cut to size bandage and I am done before the buzzer. My daughter freaks every time I ask someone in walmart where the nighttime extra absobent no wings sanitary napkins are she will squeal "daaaaddd" and run down the isle. I get a kick out of that.

If the patient is giving us a hard time I can flip the pad around like a feather before I wrap it. Always gets a smile from the ER doc.

Edited to insert quote

Edited October 20, 2011 by DFIB

[Chief1C]

I keep a bagging w/ a puke bag, towel, two nasal cease swabs and two cold packs; and call it the epistaxis kit. (on the ambo) You can get the swabs in most drug store first aid sections. Of course I wouldn't suggest stuffing anything up there if it was trauma related. But lots of folks naturally have horrific nose bleeds.

[flamingemt2011]

Did you ever use a tourniquet ?

every time i start an IV, lol