Kjell Rosenberg MD, Rangemaster, USCCA, NRA instructor<\/p>\n
Copyright 7 February 2021<\/p>\n
This article is intended for the lay citizen who has no significant training in emergency first aid or trauma.\u00a0 The trained professional is already expected to be able to stop bleeding, perform CPR, etc.\u00a0 We will address the untrained community who desires to provide the service of emergency first aid if they are caught up in an emergency without immediate professional help.<\/p>\n
It is furthermore being directed at the firearms training community.\u00a0 The training community over the last few years has seen a welcomed increase in the interest of learning first aid.\u00a0 This is fostered partially by the decades of war which have returned a number of combat veterans who have been trained in TCCC or more advanced training as medics, navy corpsmen, special forces etc.\u00a0 The military has seen a ten-fold improved survival rate in our combat forces with the introduction of early tourniquet (TQ) use and these veterans seek to pass that lifesaving knowledge on to their civilian counterparts.\u00a0 [1]<\/a><\/p>\n Many medical advances which were beneficial on the battlefield have proven to have benefit in peacetime as well.\u00a0 Thus, it is plausible to consider the use of a tourniquet in the civilian population as a tool to save lives.<\/p>\n As with any solution it is important that the tool be applied to the correct problem.\u00a0 A solution may have multiple uses, but not every problem has the same solution.\u00a0 For example, a \u201ctap, rack, and roll\u201d may clear a misfire or solve a loose magazine issue, but it will not improve a double feed malfunction. To determine which solutions to utilize, we must first understand the problem.<\/p>\n Survivable military wounds occur at a very high rate in the extremities of combat personnel, however; deliberate civilian shootings (including the negligent discharge while aiming a firearm at another human) rarely result in extremity injuries and those that do rarely require a tourniquet to prevent death.[2]<\/a>\u00a0 In civilian shootings, the vast majority of injuries occur in the head and chest and very few (approximately 16%) of the total sustained injuries are survivable.[3]<\/a> [4]<\/a>\u00a0 The situation is further complicated because some of the data contributing to the improved combat survival rate involves the use of junctional tourniquets which are neither readily available to the lay rescuer nor easy to carry in a personal first aid kit.[5]<\/a><\/p>\n There are a variety of reasons why wound patterns are different in war vs active shooter events.\u00a0 They include but are not limited to more effective the nature of armed civilian conflicts, military weapon systems, IEDs, and body armor.<\/p>\n That does not mean that tourniquets have no place in civilian medical training, but it does imply that we may need to look for a different solution for emergent medical care after an active shooting incident.\u00a0 At the emergency room in the hospital in which I work, we see a fair number of improvised tourniquets on patients arriving in the trauma bay.\u00a0 The injuries that result in tourniquet use tend to be industrial accidents, motor vehicle accidents, farming accidents, and non-motorized vehicle accidents.\u00a0 It is therefore reasonable and cost effective to learn to use and carry a tourniquet in your personal first aid kit.<\/p>\n Many facilities and organizations now offer a course called \u201cStop the Bleed\u201d which is typically cheap to take, if not free.\u00a0 This one-hour course will instruct the proper use of a TQ as well as direct pressure to stop bleeding when a TQ is not required.\u00a0 The cost of the most effective tourniquets is typically $30-40.\u00a0 All said and done, the time and money commitment required to become proficient with a potentially lifesaving TQ is very low and I recommend it.<\/p>\n Injuries that occur from accidental shootings both on and off gun ranges are frequently extremity injuries.\u00a0 Although I was unable to find a breakdown of the anatomy affected in such injuries, the experience at our trauma center and occurrences on videos circulating online show people shooting themselves in the hands and lower extremities.\u00a0 This is because the injuries typically result from failure to follow safety guidelines or failure to holster the weapon properly.\u00a0 It is not uncommon for first responders to use tourniquets to treat these wounds. \u00a0It is unknown if those wounds would have been otherwise fatal since the results are typically protected by HIPAA and the opinions of the media which write up the events frequently exaggerate the potential for death.<\/p>\n Another common theme in the use of stateside tourniquets is that they are frequently improvised rather than the high-quality tourniquets recommend by military research.[6]<\/a> [7]<\/a>\u00a0 At our hospital I have seen everything from towels, clothing, belts, and commercially available tourniquets come in through the ER.\u00a0 The patients have two things in common; they did not bleed out before arrival in the ER and the vast majority of them do not die from exsanguination despite the inferior quality of the TQ.\u00a0 Having said that, I strongly recommend using the best available equipment for any task especially if a person\u2019s life hangs in the balance.[8]<\/a><\/p>\n A major concern that many people have regarding tourniquets is the relative safety of cutting off circulation to the extremity.\u00a0 Like every treatment in medicine, we need to consider the risks and benefits.\u00a0 We frequently use tourniquets during surgery to prevent undue blood loss.\u00a0 The guidelines suggest a tourniquet time between one to three hours.\u00a0 If the surgery lasts longer than two and half hours, we take measures to reinfuse the limb.[9]<\/a><\/p>\n It is not recommended for the lay person to release the tourniquet for any reason.\u00a0 When we reinfuse the limb in surgery it is under controlled circumstances and overseen by highly trained professionals.\u00a0 One may be concerned about the lack of blood flow to the limb or direct compression to nerves or other structures after an hour or two has passed but it is important to remember that the risk of losing some function in the limb is better than dying.\u00a0 It\u2019s a relative risk-benefit ratio.\u00a0 It is one reason why we should consider using a tourniquet for life threatening injuries and not necessarily for every injury that bleeds.\u00a0 In the United States, outside of very remote areas, the amount of time it takes to get to a trauma center after severe injury is well within the window of acceptable tourniquet time.<\/p>\n As we discussed above, most deliberate shootings in the USA result in head and chest injuries.\u00a0 While these injuries are not amenable to treatment with a TQ, they still require treatment.\u00a0 The question that we should be asking ourselves in terms of GSWs (gunshot wounds) is not, \u201cDo I have a TQ\u201d but rather; \u201cHow do I treat a GSW that does NOT require a TQ\u201d as this type of wound occurs far more frequently.<\/p>\n This answer to this question is much more dependent on the location of the wound.\u00a0 For head wounds, extremity wounds, abdomen, and pelvic wounds the answer is typically \u201cpack and\/or pressure.\u201d\u00a0 As a lay rescuer, you will likely lack the equipment or expertise required to do much more than that.\u00a0 Chest wounds may require chest seals and potentially needle thoracostomy.\u00a0 The more you can act as a trained EMS provider, the better off your patient will be.[10]<\/a><\/p>\n Since the purpose of this article extends beyond gunshot wounds, I would like to bring up a few more skill sets and training opportunities that are available to the general public.<\/p>\n Most major trauma is going to require definitive care in a major medical center for optimal results.\u00a0 Therefore, one of our primary goals will be to alert the proper professionals by calling 911 as soon as possible in the process.\u00a0 If you are not the sole rescuer, someone nearby should immediately be assigned to this task. \u00a0If you are the sole rescuer there may be immediate actions which need to take place before the call is made to ensure optimal outcomes.<\/p>\n Taking courses such as the American Heart Association\u2019s offerings: Heartsaver, Basic Life Support (BLS) Advanced Cardiac Life Support (ACLS) and Pediatric Life Support (PALS) do not require prohibitive time or money commitments and should be considered by everyone regardless of profession.\u00a0 The information learned in these courses is much more likely to save a life than your tourniquet will be.<\/p>\n There are also classes offered by organizations such as the USCCA course called \u201cEmergency First Aid Fundamentals.\u201d\u00a0 This is a very good introductory course for a lay person which covers multiple aspects of first aid and can point out areas for further training.<\/p>\n More specialized training can be found from companies who focus on teaching niche areas of emergency medicine.\u00a0 One of the courses I recommend outside of the basic programs is offered by Greg Ellifritz and Active Response Training.\u00a0 It is called \u201cTactical First Aid and System Collapse Medicine.\u201d\u00a0 Mr. Ellifritz is highly experienced and practical in his approach to training.<\/p>\n As with any training and equipment, it is vital to understand the problem and have the correct response to the problem.\u00a0 Whenever I go about determining where and how to spend my time and money on training, I consider these things:<\/p>\n Then I combine the answers of those two questions with the next ones:<\/p>\n In the context of this article, if I am a person with no medical background, I would prioritize a BLS class or the USCCA course over a course on tactical medicine.\u00a0 I would do this the same way I would prioritize a basic pistol class and learn to have better situational awareness over a class that teaches single responders to clear a building if I had never used a handgun or been trained to avoid potential dangers before.\u00a0 Learn to recognize symptoms of stroke and heart attack, learn to help a choking victim, and learn to stop significant bleeding with direct pressure.\u00a0 These are the likely concerns you will come across and the high yield training which will enable you to be a valuable resource to your friends, family, and health care professionals who will take over the care you started.<\/p>\n <\/p>\n References<\/p>\n Ellifritz, G. (2019, May 9). The Best Tourniquets- A Research Review. Retrieved February 7, 2021, from https:\/\/www.activeresponsetraining.net\/the-best-tourniquets-a-research-review *updated June 2020<\/p>\n Kotwal RS, Butler FK Jr. Junctional Hemorrhage Control for Tactical Combat Casualty Care. Wilderness Environ Med. 2017 Jun;28(2S):S33-S38. doi: 10.1016\/j.wem.2016.11.007. Epub 2017 Mar 17. PMID: 28318990.<\/p>\n Kragh, J. F., Jr. (2011). The Military Emergency Tourniquet Program\u2019s Lessons Learned With Devices and Designs. Military Medicine,<\/em> 176<\/em>(10), 1144-1152.<\/p>\n Kragh JF Jr, Dubick MA, Aden JK, McKeague AL, Rasmussen TE, Baer DG, Blackbourne LH. U.S. Military use of tourniquets from 2001 to 2010. Prehosp Emerg Care. 2015 Apr-Jun;19(2):184-90. doi: 10.3109\/10903127.2014.964892. Epub 2014 Nov 24. PMID: 25420089.<\/p>\n Kumar, K., Railton, C., & Tawfic, Q. (2016). Tourniquet application during anesthesia: “What we need to know?”.\u00a0Journal of anaesthesiology, clinical pharmacology<\/em>,\u00a032<\/em>(4), 424\u2013430. https:\/\/doi.org\/10.4103\/0970-9185.168174<\/p>\n Murphy, P. (2010, March 31). Shootings: What EMS Providers Need to Know. Retrieved February 7, 2021, from https:\/\/www.emsworld.com\/article\/10319706\/shootings-what-ems-providers-need-know<\/p>\n Otto, M. A. (2016, February 4). Tourniquets overemphasized in mass shooting response planning. Retrieved from https:\/\/mdedge.com\/emergencymedicine\/article\/tourniquets-overemphasized-mass-shooting-response-planning?sso+true<\/p>\n Sarani, B., & E. (2019). Wounding Patterns Based on Firearm Type in Civilian Public Mass Shootings in the United States. Journal of American College of Surgeons,<\/em> 228<\/em>(3), 228-234.<\/p>\n Scofield, D. (2019, July 30). Sandusky police officer uses dog leash as tourniquet to save boy’s life after accidental shooting. Retrieved February 7, 2021, from https:\/\/www.news5cleveland.com\/news\/local-news\/oh-erie\/sandusky-police-officer-uses-dog-leash-as-tourniquet-to-save-boys-life-after-accidental-shooting<\/a><\/p>\n Smith ER, Shapiro G, Sarani B. The profile of wounding in civilian public mass shooting fatalities. J Trauma Acute Care Surg. 2016 Jul;81(1):86-92. doi: 10.1097\/TA.0000000000001031. PMID: 26958801.<\/p>\n [1]<\/a> Kragh JF Jr, Dubick MA, Aden JK, McKeague AL, Rasmussen TE, Baer DG, Blackbourne LH. U.S. Military use of tourniquets from 2001 to 2010. Prehosp Emerg Care. 2015 Apr-Jun;19(2):184-90. doi: 10.3109\/10903127.2014.964892. Epub 2014 Nov 24. PMID: 25420089.<\/p>\n [2]<\/a> Smith ER, Shapiro G, Sarani B. The profile of wounding in civilian public mass shooting fatalities. J Trauma Acute Care Surg. 2016 Jul;81(1):86-92. doi: 10.1097\/TA.0000000000001031. PMID: 26958801.<\/p>\n [3]<\/a> Sarani, B., et al. (2019). Wounding Patterns Based on Firearm Type in Civilian Public Mass Shootings in the United States. Journal of American College of Surgeons,<\/em> 228<\/em>(3), 228-234.<\/p>\n [4]<\/a> Otto, M. A. (2016, February 4). Tourniquets overemphasized in mass shooting response planning. Retrieved from https:\/\/mdedge.com\/emergencymedicine\/article\/tourniquets-overemphasized-mass-shooting-response-planning?sso+true<\/p>\n [5]<\/a> Kotwal RS, Butler FK Jr. Junctional Hemorrhage Control for Tactical Combat Casualty Care. Wilderness Environ Med. 2017 Jun;28(2S):S33-S38. doi: 10.1016\/j.wem.2016.11.007. Epub 2017 Mar 17. PMID: 28318990.<\/p>\n [6]<\/a> Kragh, J. F., Jr, et al. (2011). The Military Emergency Tourniquet Program\u2019s Lessons Learned With Devices and Designs. Military Medicine,<\/em> 176<\/em>(10), 1144-1152.<\/p>\n [7]<\/a> Scofield, D. (2019, July 30). Sandusky police officer uses dog leash as tourniquet to save boy’s life after accidental shooting. Retrieved February 7, 2021, from https:\/\/www.news5cleveland.com\/news\/local-news\/oh-erie\/sandusky-police-officer-uses-dog-leash-as-tourniquet-to-save-boys-life-after-accidental-shooting<\/p>\n [8]<\/a> Ellifritz, G. (2019, May 9). The Best Tourniquets- A Research Review. Retrieved February 7, 2021, from https:\/\/www.activeresponsetraining.net\/the-best-tourniquets-a-research-review<\/p>\n updated June 2020<\/p>\n [9]<\/a> Kumar, K., Railton, C., & Tawfic, Q. (2016). Tourniquet application during anesthesia: “What we need to know?”.\u00a0Journal of anaesthesiology, clinical pharmacology<\/em>,\u00a032<\/em>(4), 424\u2013430. https:\/\/doi.org\/10.4103\/0970-9185.168174<\/p>\n [10]<\/a> Murphy, P. (2010, March 31). Shootings: What EMS Providers Need to Know. Retrieved February 7, 2021, from https:\/\/www.emsworld.com\/article\/10319706\/shootings-what-ems-providers-need-know<\/p>\n","protected":false},"excerpt":{"rendered":" Kjell Rosenberg MD, Rangemaster, USCCA, NRA instructor Copyright 7 February 2021 This article is intended for the lay citizen who has no significant training in emergency first aid or trauma.\u00a0 The trained professional is already expected to be able to Read More …<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-821","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"http:\/\/conditionredresponse.com\/index.php?rest_route=\/wp\/v2\/posts\/821","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/conditionredresponse.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/conditionredresponse.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/conditionredresponse.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/conditionredresponse.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=821"}],"version-history":[{"count":1,"href":"http:\/\/conditionredresponse.com\/index.php?rest_route=\/wp\/v2\/posts\/821\/revisions"}],"predecessor-version":[{"id":822,"href":"http:\/\/conditionredresponse.com\/index.php?rest_route=\/wp\/v2\/posts\/821\/revisions\/822"}],"wp:attachment":[{"href":"http:\/\/conditionredresponse.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=821"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/conditionredresponse.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=821"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/conditionredresponse.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=821"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}\n
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