The White House and Department of Homeland Security considers rapid control of bleeding so critical to survival in trauma that they initiated the national “Stop The Bleed” campaign a year ago.1 The campaign’s purpose is to provide non-medical first responders and even bystanders with tools and strategies to control bleeding,2 allowing them to fill the gap between the incident and the arrival of medical personnel, and reinforcing the recommendations of the Hartford Consensus.
The application of tourniquet(s) and direct pressure are actively promoted in the campaign in continuance with tried-and-true techniques.2 However, the use of tourniquets and iTClamps (a mechanical direct-pressure device that stops bleeding by sealing the wound closed and using the back pressure of the hematoma to achieve hemostasis) is new to civilian application. While both techniques have been previously documented and proven to stop bleeding from 7.62 mm caliber injurie to the leg on the battlefield,3,4 the following is the first case report combining these two strategies stateside. The use of two tourniquets, in conjunction with the iTClamp, by tactical police stopped the bleeding from a life-threatening femoral artery and vein injury from a 7.62 mm round to the left thigh prior to paramedic arrival.
Case Report
My name is Deputy Joshua Hood and I am a member of the SWAT Team at the Shelby County Tennessee Sheriff’s Office. Before becoming a Deputy Sheriff, I was a paratrooper in the 82nd Airborne Division and conducted combat operations in Iraq (2005—2006) and Afghanistan (2007—2008). I am not a medical professional and to date my only medical training was the Army’s Combat Life Savers Course and an Officer Medical class taught during our annual in-service. The actions taken on-scene were based on two major factors: the amount of blood at the scene and the distance to the closest ED.
On Sep. 29, 2016 my partner Deputy Nick Hjelle, myself and deputies Greg Norrid and Jay Wildermuth were working an overtime detail for the Memphis Police Department in South Memphis. At approximately 22:30, a dark colored sedan made a turn at a high rate of speed. Deputy Wildermuth and Norrid conducted a traffic stop and I assisted.
As I approached the vehicle, I heard Deputy Wildermuth speaking to the dispatcher. He was perfectly calm, but his last sentence got me jogging toward the vehicle: “He’s been shot!”
Dispatch advised that an ambulance was on the way, but the moment I looked inside the vehicle, I didn’t think they would make it in time. The passenger door was open and a large pool of bright red blood had formed in the floorboard. The victim was unconscious and leaning against the doorframe. His breathing was shallow, and by the position and orientation of his left leg it was obvious that the bullet had shattered his femur. On closer inspection, I noticed a small hole on the inside of his left thigh, a few inches above the knee. I was hesitant to move him because I couldn’t tell if this was the entrance or exit wound. I advised Deputy Wildermuth that the victim had a femoral artery bleed, and he relayed the information to dispatch. Behind the wheel, the driver yelled that the victim was his father, and when Deputy Wildermuth asked when he had been shot, the man said that the shooting had just occurred. The driver also advised that the weapon used in the shooting was a high-powered rifle, most likely an AK 47.
In Iraq and Afghanistan, I had seen what a 7.62 round could do to human tissue. My decision not to remove the victim immediately from the vehicle was based on three possible factors. The first was the possibility that the bullet had traveled up into his abdomen and he was bleeding internally. The second was the chance that if the bullet had gone into his abdomen, it could have hit his spine, and moving him could paralyze the victim. Finally, due to the amount of bright red blood rushing into the floorboard, and the location of the hole in his leg, I was worried that his femoral artery had been severed.
I gave my shears to Deputy Norrid and advised him to cut the victim’s pants, hoping to get a better view of the wound. I had already decided to use a SOF-Tactical tourniquet and quickly secured it above the wound. But after tightening and securing the windlass, the bleeding didn’t stop. One possible explanation for this was that there was another bleed we couldn’t see, and it was at this time that Deputy Norrid helped remove the victim from the sedan.
Deputy Wildermuth went to his truck to retrieve his QuikClot gauze in case we needed to pack the wound, while Deputy Norrid helped me pull the victim to the ground. It was at this time that I saw the exit wound, which was about the size of a silver dollar and adjacent to the victim’s groin. The wound showed signs of significant tissue damage and was bleeding heavily.
By this time we had been working on the victim for about three minutes and I was concerned that we had not been able to stop the bleeding. Both Deputy Hjelle and myself were worried that he was going to bleed out, and while I prepped a second tourniquet, which I planned to place along the crease formed between the upper thigh and the victim’s torso, Deputy Nick Hjelle produced an iTClamp.
This was the first time I had ever seen the device, and for those unfamiliar with the iTClamp it is manufactured by Innovative Trauma and resembles a plastic hair clip. Honestly, it doesn’t look like much, and I was skeptical that it would work. However, Deputy Hjelle had seen it in action, and had gotten the clamp at a recent training session.
Deputy Hjelle handed the clamp to Norrid and quickly walked us through how to use it. The instructions were concise and simple: 1) Place the clamp over the wound; 2) Ensure there is enough skin on each side to clamp; 3) Squeeze the edges of iTClamp until it locks in place.
While Deputy Norrid followed the instructions, I continued working to secure the second tourniquet. By the time I tightened and secured the windless, I noticed that the bleeding had stopped and a subdermal hematoma had formed around the wound. The victim immediately regained consciousness, followed a moment later by the arrival of the ambulance. The first thing the paramedics said after securing the patient was, “I was planning on using an iTClamp when dispatch advised he had a femoral bleed.”
A few days later we were advised of the following in regards to the victim: “He transected his superficial femoral vein, large hole in superficial femoral artery and transected his saphenous vein. Huge injury, but he is actually doing OK at this point. He had the veins ligated, his SFA bypassed and fasciotomies that night. Went back with plastic surgery the next today to get a muscle flap to cover all that. He is now extubated and doing OK.”
It is my opinion that the iTClamp played a major role in saving the victim’s life, and I am now convinced that it is a critical tool that should be made available to all first responders.
Discussion
The idea behind having hemorrhage control tools quickly available to bystanders empowers them to become “immediate responders” and is a critical first step to saving lives.2 Similarly, police officers are often on the scene before professional medical responders, and they are in a position to employ lifesaving tools and strategies.2 Not every tool is going to work in all situations, so having multiple options that work by different mechanisms makes sense to help overcome the limitations of each of them individually.
Tourniquets are indicated for extremity bleeding, but are limited by anatomy as to how high they can be placed, are difficult to tighten enough to ensure occlusion of blood flow in the thigh5 and cannot be placed around the head or neck. The iTClamp works well for scalp, neck, axillary, groin and extremity bleeds, but requires that wound edges be approximated.6 Also, if there is a large wound cavity, there is additional benefit from packing the wound before placement of the iTClamp to replace manual digital pressure, since prolonged manual pressure is required after packing with hemostatic dressings or regular gauze.7 As evidenced by this case, the iTClamp is intuitive in its ease of use, even for those completely unfamiliar with the device.
Aside from wound characteristics, the rapidity of device deployment and result need to be considered. Mortality in hemorrhage patients is directly related to prehospital time.8 The application time of iTClamp is measured in seconds,9 as opposed to one full minute for tourniquets10 or several minutes for hemostatic dressings.11 Prolonged field time greater than two hours can create additional limb ischemia12 and time spent training and retaining skills9 needed to be factored into hemorrhage control approaches.
Conclusions
Simple, easy-to-use hemorrhage control tools need to be made available to police and bystanders to enable them to control bleeding even before paramedics arrive. In this particular case, a combination of tourniquets and the iTClamp stopped a life threatening femoral artery bleed from a 7.62 mm gunshot wound to the thigh before paramedics arrived.
Disclosures
The officers have no financial relationship with the manufacturers of the iTClamp or tourniquets.
References:
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10. Higgs AR, et. al. Effect of uniform design on the speed of combat tourniquet application: a simulation study. Mil Med. 2016 Aug; 181(8):753—755.
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