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.  The trained professional is already expected to be able to stop bleeding, perform CPR, etc.  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.

It is furthermore being directed at the firearms training community.  The training community over the last few years has seen a welcomed increase in the interest of learning first aid.  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.  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.  [1]

Many medical advances which were beneficial on the battlefield have proven to have benefit in peacetime as well.  Thus, it is plausible to consider the use of a tourniquet in the civilian population as a tool to save lives.

As with any solution it is important that the tool be applied to the correct problem.  A solution may have multiple uses, but not every problem has the same solution.  For example, a “tap, rack, and roll” 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.

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]  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] [4]  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]

There are a variety of reasons why wound patterns are different in war vs active shooter events.  They include but are not limited to more effective the nature of armed civilian conflicts, military weapon systems, IEDs, and body armor.

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.  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.  The injuries that result in tourniquet use tend to be industrial accidents, motor vehicle accidents, farming accidents, and non-motorized vehicle accidents.  It is therefore reasonable and cost effective to learn to use and carry a tourniquet in your personal first aid kit.

Many facilities and organizations now offer a course called “Stop the Bleed” which is typically cheap to take, if not free.  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.  The cost of the most effective tourniquets is typically $30-40.  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.

Injuries that occur from accidental shootings both on and off gun ranges are frequently extremity injuries.  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.  This is because the injuries typically result from failure to follow safety guidelines or failure to holster the weapon properly.  It is not uncommon for first responders to use tourniquets to treat these wounds.  It 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.

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] [7]  At our hospital I have seen everything from towels, clothing, belts, and commercially available tourniquets come in through the ER.  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.  Having said that, I strongly recommend using the best available equipment for any task especially if a person’s life hangs in the balance.[8]

A major concern that many people have regarding tourniquets is the relative safety of cutting off circulation to the extremity.  Like every treatment in medicine, we need to consider the risks and benefits.  We frequently use tourniquets during surgery to prevent undue blood loss.  The guidelines suggest a tourniquet time between one to three hours.  If the surgery lasts longer than two and half hours, we take measures to reinfuse the limb.[9]

It is not recommended for the lay person to release the tourniquet for any reason.  When we reinfuse the limb in surgery it is under controlled circumstances and overseen by highly trained professionals.  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.  It’s a relative risk-benefit ratio.  It is one reason why we should consider using a tourniquet for life threatening injuries and not necessarily for every injury that bleeds.  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.

As we discussed above, most deliberate shootings in the USA result in head and chest injuries.  While these injuries are not amenable to treatment with a TQ, they still require treatment.  The question that we should be asking ourselves in terms of GSWs (gunshot wounds) is not, “Do I have a TQ” but rather; “How do I treat a GSW that does NOT require a TQ” as this type of wound occurs far more frequently.

This answer to this question is much more dependent on the location of the wound.  For head wounds, extremity wounds, abdomen, and pelvic wounds the answer is typically “pack and/or pressure.”  As a lay rescuer, you will likely lack the equipment or expertise required to do much more than that.  Chest wounds may require chest seals and potentially needle thoracostomy.  The more you can act as a trained EMS provider, the better off your patient will be.[10]

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.

Most major trauma is going to require definitive care in a major medical center for optimal results.  Therefore, one of our primary goals will be to alert the proper professionals by calling 911 as soon as possible in the process.  If you are not the sole rescuer, someone nearby should immediately be assigned to this task.  If you are the sole rescuer there may be immediate actions which need to take place before the call is made to ensure optimal outcomes.

Taking courses such as the American Heart Association’s 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.  The information learned in these courses is much more likely to save a life than your tourniquet will be.

There are also classes offered by organizations such as the USCCA course called “Emergency First Aid Fundamentals.”  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.

More specialized training can be found from companies who focus on teaching niche areas of emergency medicine.  One of the courses I recommend outside of the basic programs is offered by Greg Ellifritz and Active Response Training.  It is called “Tactical First Aid and System Collapse Medicine.”  Mr. Ellifritz is highly experienced and practical in his approach to training.

As with any training and equipment, it is vital to understand the problem and have the correct response to the problem.  Whenever I go about determining where and how to spend my time and money on training, I consider these things:

1. Have I got any skill in this topic?
2. If so, what is my realistic skill level in this topic? (Have I trained under a true expert?)

Then I combine the answers of those two questions with the next ones:

1. Is the event I am planning for likely to happen? If so, I need training on this topic first.
2. Is the event unlikely to occur but carries severe consequences if I am not prepared for it? If so, I need training on this topic next.
3. Is the event likely to occur but carries minimal morbidity if I am not prepared? If so, I may find time for this topic (especially if it is fun or interesting).
4. Is the event unlikely to occur and carries minimal morbidity if I am not prepared? Let’s be honest, nobody has time to get this far down their priority list.

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.  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.  Learn to recognize symptoms of stroke and heart attack, learn to help a choking victim, and learn to stop significant bleeding with direct pressure.  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.

 

References

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

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.

Kragh, J. F., Jr. (2011). The Military Emergency Tourniquet Program’s Lessons Learned With Devices and Designs. Military Medicine, 176(10), 1144-1152.

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.

Kumar, K., Railton, C., & Tawfic, Q. (2016). Tourniquet application during anesthesia: “What we need to know?”. Journal of anaesthesiology, clinical pharmacology, 32(4), 424–430. https://doi.org/10.4103/0970-9185.168174

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

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

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, 228(3), 228-234.

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

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.

[1] 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.

[2] 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.

[3] 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, 228(3), 228-234.

[4] 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

[5] 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.

[6] Kragh, J. F., Jr, et al. (2011). The Military Emergency Tourniquet Program’s Lessons Learned With Devices and Designs. Military Medicine, 176(10), 1144-1152.

[7] 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

[8] 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

[9] Kumar, K., Railton, C., & Tawfic, Q. (2016). Tourniquet application during anesthesia: “What we need to know?”. Journal of anaesthesiology, clinical pharmacology, 32(4), 424–430. https://doi.org/10.4103/0970-9185.168174

[10] 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