The makeshift tourniquets used by bystanders at the Boston Marathon bombings included runners' shirts tied in knots and belts that had to be tightened well past any pre-punched holes.
When you're trying to stop massive bleeding from an arm or a leg, you do what's necessary.
Doctors said tourniquets saved many lives in Boston. But until the past couple of years, tourniquets weren't standard equipment on fire rescue vehicles and were down the list of preferred responses. Direct pressure on a wound was and still is the first option for stemming blood flow, but the experiences of medics in Iraq and Afghanistan have demonstrated the value of tourniquets.
The loss of life from the Boston blasts could have been greater if emergency medical crews had not used tourniquets to tie off the bleeding wounds of some patients as they were transported to the hospital, Joseph Blansfield, a nurse practitioner and program manager for the trauma center at Boston Medical Center, told the Washington Post.
“Tourniquets are a difference maker. Tourniquets can save a life,” Blansfield said.
Within the past 18 months, tourniquets have been added to every Omaha Fire Department vehicle, from ambulances to the pumper trucks to the ladder trucks, said Lloyd Rupp, the Omaha Fire Department's battalion chief over emergency medical services. “It's now our protocol that if direct pressure is not working, to go straight to the tourniquet.”
Rupp said rescue crews have noticed improved patient care with tourniquet use. “On some of our trauma patients with a tourniquet, it stopped bleeding a lot better than direct pressure and distal pressure points,” he said. “Everything seems easier with it.”
The Bellevue Fire Department also stocks its vehicles with tourniquets, said Dan Pojar, assistant emergency medical services supervisor. “We carry upwards of four tourniquets to every single call,” he said. “On our mass casualty trailer, we have, I'd say, 20 to 30 tourniquets on that thing.”
Fire crews aren't the only ones using tourniquets. Last year, the Omaha Police Department trained its 700-plus officers, from lieutenants down, on how to apply tourniquets and pressure dressings, said Officer Devin Crinklaw, who works at the department's training academy.
“The whole purpose is not to replace our ambulance or emergency services personnel,” Crinklaw said. “This is a stopgap measure. ... We basically do hemorrhage control on scene until we can get (victims) to a trauma center, where advanced care can take over.”
Dr. Keith Clancy, trauma medical director at Creighton University Medical Center, said there are times when the wound is too big to apply direct pressure or, with multiple wounds, when there is no single place to apply pressure. And if an emergency responder is using both hands to keep pressure on a wound, he said, the responder isn't able to start an IV or help transport the patient.
Combat-style tourniquets used by first responders can be applied with one hand. They utilize Velcro and an easy-to-use hand crank called a windlass to tighten the band above a wound.
The American Red Cross discourages people who aren't trained from applying a tourniquet, recommending direct pressure instead.
“Clearly, if a leg is blown off, it's OK to go straight to tourniquet,” Dr. Richard Bradley, a member of the Red Cross' scientific advisory council, told the Associated Press.
Rupp said an improvised tourniquet can cause damage. “Say they use a real thin rope. When they tighten it down over the skin, it can actually compress into the skin, causing damage like a cut. You want something wide, like a belt. Then you can pull the belt tight.”
Clancy said he once treated a farmer badly injured by some farm equipment who had removed his belt and used it as a tourniquet.
If left on too long, tourniquets can basically kill a limb, cause the blood in the limb below the tourniquet to clot and lead to a buildup of toxins. In an urban setting where a trauma center is minutes away, the threat of complications from tourniquet use is diminished, Clancy said.
“We go right to the operating room and take it off,” he said.
With severe injuries, people might end up losing their limb anyway, said Jeff Jones, deputy chief in the Papillion Fire Department, which also uses tourniquets. “The blood loss is obviously going to compromise the person's life. Which would you rather have? You're doing something that saves a life, because a person can bleed out pretty quickly.”
Evidence of tourniquet effectiveness on the battlefield had been accumulating for some time, but a wealth of convincing data was compiled during the Iraq War, said Dr. John F. Kragh Jr., an orthopedic surgeon and researcher at the U.S. Army Institute of Surgical Research. In a 2009 study, Kragh reported that tourniquet use in Baghdad was strongly tied to the survival of people with major limb trauma. Using tourniquets before shock onset was very strongly linked with saved lives. Use before the injured arrived at the hospital also was linked to survival.
In addition, the American College of Surgeons and the FBI met early this month with law enforcement and trauma care specialists to develop strategies to improve the survival of victims of mass shootings. One of the group's conclusions was that life-threatening bleeding from extremity wounds is best controlled initially through the use of tourniquets.
Dr. Natalie Stavas, a 2011 University of Nebraska Medical Center graduate who is doing her residency in Boston, was almost finished with the marathon Monday when the bombs exploded. She rushed to the blast sites to help.
The devastating bloody wounds to victims' lower extremities required tourniquets, she said. “What we were left with were belts and shirts off of runners' backs and shirts off of bystanders to stop the bleeding.”
One of the victims she treated before he was whisked away in an ambulance had a mangled foot from the blast. “We applied direct pressure to the foot, to the bleeding, then I was handed a belt,” Stavas said. “We strapped it above the calf and pulled it as tight as we could.”
Stavas, who worked as a trauma nurse before going to med school, said she was able to act instinctively. “My medical training and my nursing training all kind of added to that.”
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