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Mass Casualty/Preventable Deaths/Bleeds/ Tourniquets

Tourniquets Bleeds Mass Casualty

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#1 armydoc


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Posted 25 November 2015 - 08:12 PM

Hi Folks,


I wanted to address things that you might find in a dealing with a mass casualty event like the recent Paris attacks. In such an event where so many people are injured, dying and dead the regular local emergency services will absolutely be overwhelmed.


So for every prepared citizen and I consider anyone involved in EDC to be a prepared citizens by the nature of what EDC is. We need to be able to help fill the void between the time it takes to respond to such a terrible event by our regular EMS services.


The top 3 leading causes of preventable deaths while I was serving in Iraq were uncontrolled bleeds from the extremities, tension pneumothorax, and airway blockage.


Uncontrolled bleeds made up 90% of the preventable deaths, granted some of these bleeds were to the groin and to the neck which is very hard if not impossible to control.


So bleeds are what I want to address first.  To control bleeding the standard was once apply direct pressure, pressure dressing and elevate the limb and use a tourniquet as a last resort. This rationale of thinking has changed and in the real world of military war fighting and Police tactical teams the aggressive use of tourniquets is 1st choice.


The concern was always potential loss of the limb do to the loss of circulation to the respective limb. As real world studies have shown for a tourniquet to cause a loss of a limb people had to have the tourniquet on for hours. The choice between life and limbs is always life first obviously.


There are several professional military grade tourniquets such as the C.A.T Tourniquets, SOF-TT tourniquets as well as the SWAT tourniquet which look much like a rubber therapy band (Someone is making millions).


http://www.swattourniquet.com/ SWAT Tourniquet


http://www.chinookme...of t tourniquet   Various tourniquets to familiarize yourself with.


The newer generation tourniquets are designated with a W to signify that they are wider than normal for more comfort, less potential damage to a person's flesh when applying one for an extended period of time and more efficient in clamping down on muscle to stop the bleed. The SWAT tourniquet wins in this category but I get the impression there can be some distinct shortcomings with it as well like trying to apply it to yourself and secure it.


These professional grade tourniquets can run around $35-$50. The SWAT tourniquet runs about $10 and is the slimmest of them all.


Another option is improvised tourniquets. Any self respecting EDC loving kind of guy or gal would not be caught dead without at least one bandana on them. Most people who embrace EDC also carry a carabiner of one type or another


With those two items you have a readymade tourniquet in which to stop someone from bleeding to death.


As EDC minded people you are ahead of the curve, you are the leaders in your community. That leadership and the ability to remain calm under pressure is going to play a key role in your success in a situation like this. You are the thinkers, the few among the many that plan ahead for whatever life throws at you and that is why you will have the ability to work under pressure and overcome any situation. Hooah!



Scene Survey/Assessment


Before anything else ask yourself is the scene safe? Are there any threats in your area that could make you another victim? While you are scanning your scene, look at the mechanism of injuries. Was the cause of the mass casualty a bomb blast, gunfire, chemical or something else?


If you come upon a scene where everyone has just been shot as the mechanism of injury then you may need to be scanning for an active shooter and unless you are armed your best 1st option would be to get out and initiate a call to Police and EMS advising them of what you saw.


If the mechanism of injury was a chemical attack then every victim is contaminated and you simply won't have what is needed to treat anyone and need to be more concerned about getting far away from the scene (leading others as you go), contacting EMS and be aware of which way the wind is blowing.


You cannot save someone else if you become a victim yourself. There are exceptions to this and that is left up to each and every individual and situation. As a rule don't compromise your safety, use common sense and realize when the situation is beyond your abilities.


The first thing you may have to do before you treat a victim is move them to a place of safety and then treat them for their actual injuries afterwards.


The scene can be safe one moment and compromised the next, when that happens you pick up and move, or drag the victim to a place of safety. If there are people standing around like sheep direct several people to help you.


I watched a video of a young Police Officer respond to an overturned chlorine truck and he tried to rescue the driver of the vehicle and was quickly overcome by the fumes and lost his life.  Assess the scene and ask yourself is the scene safe??


If the scene is safe and you can treat the victim your next concern is body substance isolation (BSI). If you happen to carry around a pair or nitrile gloves now is the time to grab them. Carry multiple pairs as they can break, you may need to change yours gloves, and you can give a pair to someone else to assist you. 


If you don't carry any gloves and are not willing to risk contamination or exposure from blood (which is understandable) your journey ends here until you start packing a few pairs of gloves in your EDC kit.


Keep in mind folks that you are dealing with an injury that is producing major blood loss. It is all but impossible not to get blood on you, the only question is to what degree.  Personal Protective Equipment (PPE) can help reduce exposure to blood to a large degree. PPE can consist of gloves, mask, glasses/goggles, etc.


When applying a tourniquet be aware that your patient/victim could be conscious. If they are, that is a good thing, however having a tourniquet applied to your limb is not the most pleasant experience in the world as it is painful I know this from 1st hand experience.


Talk to the person you are treating, try keeping them calm and explain what you are doing as you treat. Furthermore what does talking with the conscious person that you are treating tell you? It tells you that whatever other injuries or issues they have, they have a patent airway at the moment and that is one less problem you will have to deal with.


Conscious patients also can help express to you where their injuries are and what other issues they are having, ask them as you treat but you will still need to assess the person as they may very well be in the onset of shock and not fully realize the extent of their injuries.


You also should familiarize yourselves with the different pressure points on an anatomical chart to help control bleeding, as the first thing you can do to help stem the flow of blood while you are donning your PPE and prepping your improvised tourniquet is place a knee and some weight above the limb  injury/amputation.


If the person is conscious it is going to hurt and they may already be in a highly agitated mindset because of the sensory overload and pain. Again talk to them while you treat. Tell them why you are doing what you are doing and explain as you go. It really is important.







When to use a Tourniquet


-When dealing with an uncontrollable hemorrhage from a limb from some kind of penetrating wound such as a gunshot or stab wound, blast injury, as well as a partial or complete amputation.


-When dealing with multiple wounds on victim and trying to manage those as well The importance of preventing someone from bleeding out as I was taught takes priority over airway issues. Quickly applying a tourniquet and stopping the bleed will allow you to address other potential issues like a compromised airway.


- When dealing with multiple victims in a mass casualty event such as a terror attack. If you are dealing with multiple victims you can apply a tourniquet to someone who has a severe bleed and if they are unconscious put them in a recovery position (more on the recovery position later) so they have a better chance of keeping a clear airway and then you move to the next person.


- When you are in doubt.  If you see a large amount of blood pooling on the ground, saturating the victims clothes, etc. it is more prudent to quickly apply a tourniquet. If there are others around direct someone to call 911/EMS services while you are treating.



So at this point you have done a scene survey and assessment and deemed the area safe, BSI for my buddy and I, you now have your gloves and PPE on.


When you approach a patient especially one who appears unconscious approach them at their feet, tap their foot "hey buddy can you hear me?! ::tap tap:: As you are calling out to the person you are visually assessing them from head to toe for obvious injuries.


The reason for approaching at the feet and tapping is because a person that has been knocked unconscious and wakes up to your ugly mug hunched over them in their face can cause them to become startled and combative, and you could end up hurt.


No response? Continue on, and for the sake of the discussion the casualty has a deep penetrating wound to the to the left forearm.


You can see this by just looking at the persons arm and see the blood saturated long sleeve shirt they are wearing.


You take out your handy dandy EDC knife and fillet the shirt like it was a fish exposing the wound. The purpose behind this is when dealing with ANY wound or potential wound you want to examine and expose it that way you know what you are dealing with, and you can better address it.


In the case of applying a tourniquet you never want to apply a tourniquet over a persons clothes as clothing and blood can create a situation where it slips off an amputation or down on a wound. If it slips off an amputation the negative aspect of this is obvious. If is slips down on a wound it may no longer be stopping the bleeding either.


The person is bleeding out quickly you have already exposed the penetrating wound. 


You whip out your high speed X-large EDC bandanna and grab a corner with each hand at diagonally opposite ends and you start folding it.  The end result of what you have now is a cloth band that is around 2 inches in width.


Take that cloth band and place it about 3 inches above the wound. Take the ends of that cloth band and cross them underneath the forearm bringing the tips back up  to the top.


When you have done this the band should be snug on the person's arm. From here you cross the tips exactly as you would tie a shoe lace interlacing the ends.


At this point you attach your carabiner on one of the remaining lengths of cloth band and then you repeat the process of crossing the ends as though you were tying a shoelace, and cinch it down tight.


Congratulations! you now have your improvised tourniquet in place. From here you start turning that carabiner and that will start applying pressure to the limb squeezing the muscles and stemming the off the flow of blood.


There are other things you can use in place of a carabiner, such as an EDC flashlight, tactical pen, a stick, a large closed folding knife etc. Anything that you have handy that will allow you to get the job done and that you believe won't break.


Keep in mind folks that the advantages of the professional grade tourniquet are ease of use not just on treating someone else but most of all treating yourself if ever you needed to, especially when it comes to an arm wound. So hands down if you have $30-$50 to spend treat yourself to a professional grade one and have the knowledge and gear to improvise one if more are needed.


Here are some of the better videos I found so you can actually see tourniquets being applied. You may find things that differ from what I posted here in this thread regarding technique, etc. but overall it is the same darn thing. I posted how I was taught, standards can change over time.


What I posted here and these videos will give you insight and a good foundation may in fact help you save someone's life in a crisis, however since we live in the land of lawsuits and such I post this for academic purposes , use at your own risk and I advise you to all use common sense.


This thread while beneficial is no substitute for getting professional HANDS ON training from your local community college 1st responder class, or Red Cross chapter.


If the only instruction you ever get is from this thread, you still need to actually practice doing it. When the SHTF and you actually need to improvise and apply a tourniquet your motor skills due to stress are going to tank, and trying to do something for the very first time when someone is bleeding to death in front of you is not the time to do it for the first time.


I would recommend if at all possible that you guys take an EMT/Basic course, it is only one semester in length, and very empowering.



https://www.youtube....h?v=mOv9BwSr8Sg  SWAT-T Tourniquet instructional video


https://www.youtube....h?v=Y_p5-cmJmAg    SWAT-T Tourniquet used to stop bleeding on an actual amputation. The victim lost the lower portion of leg from the knee down, and the SWAT-T is being applied to the thigh. WARNING VERY GRAPHIC


https://www.youtube....h?v=SLeKX5MVt9U  SWAT MAGAZINE Tourniquet training.


https://www.youtube....h?v=pDP5Cy0nguU ITS TACTICAL/ LONESTAR MEDICS How to prep, store and supply and apply a tourniquet.


https://www.youtube....h?v=K5FTV7MUm7Y  Improvised tourniquet with a carabiner, triangular bandage, and the ring from your car keys.


https://www.youtube....h?v=7NbHImVQ4us  Tactical Medical Solutions SOF Tactical Tourniquet  


https://www.youtube....h?v=FT1ZsyRxdck   Tourniquet Use Deemed A Lifesaver During Boston Bombing Incident


http://www.sun-senti...1129-story.html   From the Sun Sentinel "The answer to a terror attack? A simple medical device









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#2 Nathaniel P

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Posted 25 November 2015 - 09:05 PM

Very nice guide! I never saw the use in carrying a handkerchief/bandanna before (never had a need for one), but I might carry one if only to use as an emergency TQ. 


By the way, have you seen ITS Tactical's kits? They make specific kits designed for EDC to treat external hemorrhage, which contain a SOFTT-W tourniquet, combat gauze, and nitrile gloves. They also have larger kits for all three of your mentioned categories, (Extremity Hemorrhage, Tension Pneumothorax, Airway Obstruction)


Any advice for carrying nitrile gloves in pockets/not in a bag?

#3 armydoc


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Posted 25 November 2015 - 10:11 PM

Hi Nathaniel,


You can use a bandanna, handkerchief, cravat as a headband to keep the sweat off your brow as a doo rag to keep you cool, filter to remove sediment in water you are prepping to sanitize and drink, signaling, tinder, soak up the morning dew off of plants so you can drink it, sling and swathe, and the list goes on.


Always try and make sure whatever you carry on you that they have multiple uses. The more uses each item you carry has, the better.

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#4 Ludovic Babin

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Posted 26 November 2015 - 04:21 AM

Helpfull, thanks.

#5 Joshua Denton

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Posted 26 November 2015 - 10:14 AM

You can use a bandanna, handkerchief, cravat 


... And that is why Scouts have always had a neckerchief/scarf 

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#6 WallyGator


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Posted 26 November 2015 - 11:02 AM

ArmyDoc, this is a very informative and real world presentation. Well done. The only thing I'd add, as I did in the other tourniquet thread, is that there are things that take a priority  over  bleeding control, ie. Airway and Breathing. A simple tilt of the head or an application of occlusive dressing* to a chest wound is something that can be done quickly and will insure that the greatest number of folks stay alive. This no way negates the proper and correct use of a tourniquet, just a word of caution to not get tunnel vision and to keep in mind the other tasks that should come before bleeding control. I hope that none of ever are faced with a mass casualty situation but being prepared is not just for Boy Scouts.


* An occlusive dressing is anything that air can't get through. The idea is with a chest wound, air is entering the chest through some other route than the mouth. This dressing can be tape, plastic wrap, a wrapping off of a cigarette pack or even the commercial packaged version. It is applied to the chest wound and secured on three sides. Why three sides, it allows air to escape around the bandage but will seal tight when the patient breaths in.  

#7 armydoc


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Posted 26 November 2015 - 01:45 PM

Hi Wally,


I cannot speak for the civilian side of EMS, I only served as a Combat Medic, so protocols will no doubt vary. I know that when I went through my initial training now more than ten years ago the Combat Medic portion of the training run by an old Special Forces war horse was always at odds with the hospital and conventional side of the house. The conventional side operates in a hospital setting and the Combat side of the house operates in an open environment away from advanced life support and a higher level of care.


For the military when I was still in bleeds took priority over airway as you can throw on tourniquet in 10 seconds or less if you practice, and on the outside 15 seconds ( that is with a professional tourniquet folks).


When you have an amputation or even a penetrating wound your body will respond by contracting the tissues to try and clamp down to stop the blood loss, that will last a very short before your body is overwhelmed.


Due to the blood loss your heart rate kicks up so you can keep your oxygen level at what would be the norm as well as keep your blood pressure normal.

So that means the heart is pumping harder and faster and you start losing blood at an increased rate depending on the severity of the wound(s) you can bleed out beyond a point of no return while still working on an airway and respirations issues.


There is a WWII Combat Manual "Get Tough" that dealt with hand to hand fighting with edged weapons and inflicting cuts to the arteries and the approximate time it took to lose consciousness and bleed to death, The chart was called the time table of death and is shown below.


LTC Fairbairn in conjunction with Anthony Sykes created the world famous British Commando Dagger, and no I did not steal one of gundose's beautiful knife pics...  I swiped a photo from some gentlemen named H. Williams LOL! Not to worry though it was a public domain photograph.


If you guys are interested I found what appears to be the entire book Get Tough online here. http://www.vrazvedka....html?showall=1


http://www.fairbairn...tingknives.com/ Great site for those interested in the Commando Dagger and other knives of WWII


Okay, enough of the military history.


Wally I want to thank you for your kind words and constructive criticism. I would hope you and the rest of the medical EMS professionals in the forums contribute to this thread and the other ones that will follow as I post them to make them even better and more well rounded. Everyone brings a different aspect to the table. My experience and training  only comes from one facet of a much larger picture.


In preparing for this thread I contacted the National Registry of Emergency Medical Technicians (NREMT) for clarification of tourniquet placement as someone told me that the new standard is not 3 inches above the injury but way up on the limb away from the wound. I left a message but the NREMT has yet to get back to me.


The concern over that folks is that if the tourniquet is left on beyond a certain point the person will have an amputation or at the very least nerve damage on a much greater portion of their limb than needed. The person I spoke with online stated that the reasoning was that the higher it is the better chance of stopping the bleed and that the upper portion of the limbs contribute to better stoppage due to the increased muscle mass on the biceps and thighs. When I find out if the standard has changed I will update and amend that on this thread.


One thing about medical training and how to deal with any kind of medical issue. It is constantly changing and improving upon itself.














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Posted 30 November 2015 - 02:54 PM

Everything recently I have heard Doc is "High and Tight" is the new preferred way of putting a TQ on. Current TCCC guidelines reflect this. Because TCCC is baked into PHTLS and PHTLS is NAEMT, if it is not already, I think NAEMT will start to reflect this as well. NREMT skill sheets do not reflect 2-3 inches or high and tight, although they probably should as placement is kind of important. 


It is a simpler, one way approach to do it. It takes the stupidity out (soup sandwich), and allows for simpler training and application.

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#9 armydoc


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Posted 30 November 2015 - 03:13 PM



Thanks for the heads up. I will still work on getting clarification from the governing bodies, but that is what I heard as well. Which I think in an urban environment would not be an issue and that may in fact negate the possibility of needing a 2nd tourniquet if the 1st one failed to stop the bleed. 


If you are in a remote environment it would probably be better to keep in 3 inches above the wound just in case you did not get help in time and ended up with an amputation.

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