For centuries—dating as far back as ancient Rome—tourniquets have been used in surgery and on the battlefield;1,2 however, after noting increased nerve damage and limb loss during WWI, widespread use declined.3 Other morbidities tainting the use of tourniquets included venous thromboembolism, rhabdomyolysis, renal failure, myonecrosis, nerve palsy and compartment syndrome with subsequent need for fasciotomy or amputation. Military use continued throughout WWII and the Korean and Vietnam wars, with the true change in tide occurring in the Middle East. Wars in Afghanistan and Iraq brought an increase in explosives warfare, both for the soldiers in the line of fire as well as Afghani and Iraqi citizens who were victims of the warfare in their homes and cities. This overwhelming shift toward explosive injury patterns forced battlefield triage to include controlling massive hemorrhage prior to airway assessment.2 The military took action, adding tourniquets to soldiers’ individual first aid kits and requiring training for proper use.
This environment also created a hotbed for tourniquet research. One study during this time revealed 57% of field deaths may have been preventable.4 Another two-part study demonstrated applying tourniquets before the onset of shock increased survival.5,6 This study was groundbreaking. First, it was a prospective study; second, it found a complication rate of 1.7% limited to nerve palsies. These updated findings on complications of the device have helped to allay prior fears of morbidity that deterred tourniquet use.
Following suit, the civilian community conducted its own research. Yielding low complication rates and high potential benefits, this research bolstered the recommendation for aggressive early tourniquet use.7 Mirroring the wave of change in military protocols, by 2012 some large metropolitan areas began equipping ambulances with commercial tourniquets and training EMS providers on proper use.8
Adapting military protocols into civilian medicine is a long-time practice. The integration of tourniquet use and education for early hemorrhage control should become a common arm of first aid in the civilian sector.2,9 There’s no doubt that domestic mass casualty incidents (MCIs) related to weapons are on the rise and the threat of warlike extremity injuries occurring at home is becoming more apparent with mass shootings, gun violence and attacks using explosives. The Boston Marathon bombings of April 15, 2013, highlighted this threat and delivered a true civilian MCI.10 The response to these bombings revealed our deficiencies in tourniquet availability and use, exposing a delay in the transition of battlefield hemorrhage management protocols to the civilian sector.11
In an effort to resolve this delinquency, in April 2013, the Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events met, and the Hartford Consensus was published. Motivated by the uniform belief that no one should die from uncontrolled bleeding, the crux of the Hartford Consensus assigns the duty of early hemorrhage control to any first responder, whether it’s the bystanders, walking wounded, first law enforcement officer on scene or EMS personnel.12-14 The policy addresses the need to increase the availability and education on lifesaving first aid equipment to the public, first responders and EMS personnel. Specifically, it calls for tourniquets and hemostatic dressings to be part of every public safety member’s armamentarium, as well as widely available within the EMS system.14 This generated a simple set of research questions to specify, “Where are tourniquets in the civilian world?”
A SURVEY OF EAGLES
To examine the current status of the use of tourniquets by EMS agencies, the authors conducted a survey of the U.S. Metropolitan Municipalities EMS Medical Directors Consortium (the “Eagles” coalition). These physicians, medical directors of some of the largest EMS agencies in the world were surveyed between November 2015 and February 2016, and the following questions were posed:
- Do you have tourniquets on ambulances?
- Do you have tourniquets on first responder vehicles?
- Are your tourniquets commercial products or improvised?
- If commercial, what brand?
There were 70 medical directors who responded to the survey, representing EMS agencies that serve a population of over 80 million persons in the U.S., Canada, England, New Zealand and Australia. They provide direction to more than 240 agencies that responded to more than 10 million EMS responses in 2014.
The survey is summarized in Table 1. Every agency reported that tourniquets are in place in essentially every EMS vehicle and in most fire vehicles. Some directors mentioned law enforcement providers in their jurisdiction were carrying devices like those of the fire/ EMS system. Some are also deploying tourniquets and training the civilian population on tourniquet use.
All agencies are using commercial tourniquets: 43 mention the Combat Application Tourniquet (CAT) from North American Rescue and seven mention the SOF Tactical Tourniquet from Tactical Medical Solutions. Both have a list price of about $30 per unit.
The immediate threats to life—those requiring virtually instant response from bystanders or rescuers—are actually few in number: the obstructed airway, the apneic patient, the pulseless patient and the patient with uncontrolled bleeding. Rescuer management of airway and breathing failure are described in many other publications.
The patient with uncontrolled external hemorrhage is the focus of this study. An incident resulting in a patient having major visible bleeding must have the condition controlled or exsanguination will occur. Temporizing or partial control may be achieved by first aid techniques such as direct pressure, use of pressure points and elevation of an injured extremity. But major injuries such as near amputation, shrapnel injuries and explosive blasts require occlusion of blood flow to the injured area. The military and civilian incidents resulting from explosive devices are a frequent cause of such life threatening limb destruction.
Past perspectives in emergency patient management led to the practice of using tourniquet application as a last resort. The detailed research from the battlefield and from standard practice in the operating room refutes these prior perspectives. As shock looms, there’s an immediate need for hemorrhage control in an exsanguinating patient. Ultimately, the benefit of stopping bleeding to save a life outweighs the risk of any potential harm to the limb from the use of a tourniquet. Literally, the consideration in these cases must be “life or limb.”
Delivering this lifesaving knowledge to public safety personnel, first responders and ultimately to the lay public is of utmost importance. For success, there are two waves of education that must propagate. First, there needs to be a well-established, standardized prehospital guideline educating public safety responders on hemorrhage control.15 Second, public education programs must be developed and promulgated, along with providing the necessary equipment to allow widespread civilian involvement.
Educational programs to bring members of the public into the realm of emergency responders have been ongoing for years, from first aid to CPR to the activation of AEDs and 9-1-1 systems. The “Stop the Bleed” program developed by the U.S. Department of Homeland Security is “a nationwide campaign to empower individuals to act quickly and save lives.”16 The program’s objectives include training the public in hemorrhage control and disseminating tourniquet materials to appropriately trained individuals.17 Forty individual organizations and companies have offered support to this new campaign.
The control of active bleeding ranks with other immediate threats to life. It’s a critical action that must be taken by both emergency responders as well as appropriately trained citizens alike. The authors call for wide action to be taken to provide appropriate training and equipment across the spectrum of potential emergency conditions to reduce the life and limb threats from acute external hemorrhage.
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16. United States Department of Homeland Security. (Nov. 20, 2015.) Stop the Bleed. Retrieved Feb. 16, 2016, from www.dhs.gov/stopthebleed.
17. United States Department of Homeland Security. (Jan. 13, 2016.) Partner Efforts to Support the Bystander “Stop the Bleed” Initiative. Retrieved Feb. 16, 2016, from http://www.dhs.gov/efforts-support-stop-bleed.