As an instructor of multiple combat medical courses, I have had the privilege of instructing many courageous and dedicated young corpsmen and medics in Tactical Combat Casualty Care (TCCC), Pre-Hospital Trauma Life Support (PHTLS) and Combat Lifesaver (CLS), as well as other courses. Out of all of the information I have taught, I am amazed at the feedback I receive from many of these students returning from the wars in Iraq, Afghanistan and other areas of the world.
Tourniquet use is documented as far back as Roman times; examples have been found composed of bronze and leather. The first practical tourniquet use was by Joseph Lister, and it was improved upon over the course of time by utilizing pneumatic air bladders and control pumps designed to restrict the flow of blood past the device itself. Tourniquets were issued and used by US military medical personnel during the course of our conflicts, but eventually the use of these tourniquets fell off due to inadequate control of bleeding, or irrecoverable damage to limbs, causing loss of most or all of the limb below the tourniquet.
In 1945, an article in the Journal of the Army Medical Department, a physician cited the following: “We believe that the strap-and-buckle tourniquet in common use is ineffective in most instances under field conditions… it rarely controls bleeding no matter how tightly applied.”
In the 1970’s, civilian emergency medical training was instituted, and Emergency Medical Technicians took to the streets. Training for the use of tourniquets was minimal, as they were to be used only when direct pressure over the wound, elevation of the wounded extremity and utilization of pressure points to restrict arterial blood flow had failed. The mantra ‘use only if you have to save life versus limb’ truly discouraged most emergency medical personnel from using these devices.
Even in the mid 1990s, the strap-and-buckle tourniquet was still being used; medics and corpsmen were still receiving them as issue, but were encouraged not to use them. However, in the mid 1990s, Special Operations personnel began looking for another way to treat heavy bleeding from limbs due to combat trauma. Dr. Frank Butler, a Navy physician working with the elite Navy SEALs published an article in the 1996 Military Medicine supplement titled ‘Tactical Combat Casualty Care in Special Operations’. This marked the birth of a radical change in combat medicine.
While many of the advanced skills taught in TCCC are beyond application by the average person due to both the medical knowledge required and the materials used, the tourniquet is easily acquired, quickly taught and understood, and effective in immediate lifesaving. Currently, tourniquets are used for 6+ hours in surgical procedures such as knee joint replacements to prevent patients from severe bleeding during the actual operation.
Currently, the US military is using the Combat Application Tourniquet, or CAT. As described at CombatTourniquet.com, it is a simple device that can be applied (with practice) one-handed to oneself, or to another victim to rapidly control severe bleeding. The windlass and strap system is simple to use, and when properly applied, will hold pressure well. Other tourniquets are available on the market, but this is the one most commonly referred to in our courses.
A word of caution: Modern tourniquets work because they are broad bands which apply pressure to all the vessels around an arm or a leg. The broad band prevents tissues underneath the band from being crushed – this is vitally important, as crushing or strangulating the tissues with a narrow width, such as a rope or a bootlace, will cause the tissues to die, followed by the possibility of the dead tissues entering the blood stream and poisoning the body. Do not use any item as a tourniquet except on specifically designed for use as a tourniquet!
Why Use A Tourniquet?
It’s five o’clock in the morning, and the goblins have decided that now is the time to get into your retreat. You, or a partner are wounded, be it in an arm or a leg (you are wearing body armor during the assault, right?), from a bullet or a shrapnel wound. What will happen to the wounded person?
When an artery is severed, a casualty can bleed to death in three minutes. Shock will probably occur, and will deteriorate your ability to think and fight back. Your defense has now lost two people – the casualty, and a person who is now trying to stop the bleeding. While this is appropriate in a non-emergent situation, it is vital to ‘get back into the fight’ as quickly as possible. The tourniquet can be applied to control the bleeding and allow one, or possibly both individuals to continue resistance; multiple testimonies from wounded Soldiers, Sailors, Airmen and Marines can attest to this.
Because of it’s construction, the CAT tourniquet can be applied to yourself,. This will save your life if you are alone and bleeding severely. Apply the tourniquet, and tighten until the bleeding has stopped. In practice, you will find that a tourniquet properly applied will stop a person’s pulse in their wrist or foot. In addition, you will find that it hurts like the devil! I tell my students ‘if it doesn’t hurt, it’s not tight enough’ – followed by a yank which dislodges the tourniquet, proving that it didn’t work.
If the first tourniquet hasn’t stopped the bleeding, a second should be applied just above the first; the combination will usually stop the bleeding. However, don’t apply the device on the elbow or knee, and don’t apply over items in pockets, holsters or other bulky items – it won’t work properly.
The most difficult decision is when to use it. It is quite startling to see a person bleeding – after 18 years in emergency and combat medicine, I’m still startled when I see copious amounts of blood. But you have to assess the situation – is this life threatening bleeding? I’ve been cut and have bled a mess all over my clothes and the floor – but it’s not life threatening, just ugly and in need of stitches. Arterial blood is the most common indicator of needing a tourniquet, as well as gunshot wounds and crushing injuries. It’s a judgment call – in the end, it’s all based on the knowledge you’ve learned and practiced.
It’s On – What Next?
In the TCCC course, once a tourniquet is applied and the bleeding is stopped, that is all that you should do until the danger is over. Once this is done, and you are certain that it’s safe, the tourniquet can be addressed. Once you’ve identified the fact that you are safe, you can proceed. However, if a tourniquet is applied, it should not be loosened to ‘let the blood flow’. This will cause more blood loss and will dislodge any blood clots that are established; it will allow more poisonous materials into the bloodstream, leading to infection. You should not remove the tourniquet – you have to get your casualty to ‘definitive medical care’ – a doctor or other medical personnel capable of doing surgical interventions. You should not remove the tourniquet if the limb was ‘traumatically amputated’ (blown into hamburger). If your casualty is in shock, Do not remove it! They are already battling the effects of blood loss, more will make it worse. Instead, use your medical training to treat for shock, and get them to whatever advanced medical care you can reach.
The tourniquet has come quite a way from it’s origins in Roman times. It is saving multiple lives every day since it’s new birth into combat medicine. They are light weight, easily purchased, go into any first aid kit, easy to use – and it could save your life or the lives of your loved ones in an emergency as well.