Tourniquet Placement

[doc_robalt]

I have run into a problem with one of the civilian instructors that I work with, who says that during his 18D training... that he didn't complete, that he was taught, that deliberate tourniquets are supposed to be placed 2-3 inches above the wound. Even if the wound is below the elbow and the knee, where as I was taught that trying to place a tourniquet over Tib/Fib or Radius/Ulna will ultimately fail due to the bones being in the way and will not allow the tourniquet to properly work. If any of you guys could please give me your imput on this I would appreciate it. Thanks

[Dusty]

Make sure the tourniquet is placed somewhere between the heart and the wound.

Sorry, I couldn't resist that. My bad. Gave myself a demerit.

[Priest]

In my experience I have had success placing tourniquets on the distal portions, on occasion however, I have had to back it up with a second just proximal to the first or sometimes proximal to the joint. Depends on the wound tract as to where occlusion is going to work

[swatsurgeon]

A tourniquet placed around any part of the body is dependent on the force vectors of "radial' compression....fancy term for it works in a circle and if some structure is blocking a force vector like the tibia, the forces become spread around the rest of the circle so the gastrocnemius (posterior muscle) will literally push anteriorly to compress another area.....bottom line, place the tourniquet as close to but above the injured area unless it is right at a joint then the 2-3 inches makes sense since compressing a joint really won't work. Field, E.D. or O.R., it'a all the same.

ss

[MILON]

Related to tourniquet placement. I just completed BCT3 in preparation for an upcoming deployment and the instructors taught us the latest change to TCCC in terms of tourniquet placement. Guidance was as follows:

Care Under Fire Phase:

If needed, apply a hasty tourniquet as high on the limb as possible and as quickly as possible. This is regardless of injury site.


Tactical Field Care:

Once time allows, apply two deliberate tourniquets side by side closer to the injury site. Slowly release the hasty tourniquet, ensuring the deliberates are effective.


The instructors supported this approach with research and information from the field. I'd like to hear some thoughts on this as my medical section debated this for quite some time following the course.

Milon

[Priest]

That's perfectly reasonable and in common practice. You don't have time to reevaluate the wound during CUF, so by placing it as proximal as possible, you avoid that little bullet fragment that traveled over 10" up the leg and shredded the popliteal artery. In this instance, if you placed a tourniquet just 2-3" above the GSW site, you would have stopped the visible bleeding, but you would be causing a massive compartment syndrome proximal to your tourniquet

[swatsurgeon]

I agree...it does make perfect sense for CUF conditions.......once can evaluate the injury, place another and remove proximal one...common sense wins this one.
This is actually where the blackhawk ITS system (internal TQ system) was coming from...all 4 TQ's (2 UE, 2LE) were all very proximal to get control ASAP, then apply your second one closer to hemorrhage.
ss

[doc_robalt]

I really appreciate all the imput, but I'm just trying to get clarification on the deliberate placement. I even tried placing one on my forearm and my lower leg and sure enough I still had a radial pulse and a dorsalis pedis pulse, of course I could only make the soft-t so tight before I was afraid I was going to break my own bones. But I just need to know if there any documentation to support this so I can get this wanna be 18D to shut up.

[swatsurgeon]

placed appropriately but more importantly, a quality TQ (SWAT-T, CAT, SOFF-T, etc commercially available) used correctly, they will stop all arterial flow. I have used many of the commercially available ones and have had few not stop flow. Each one has its quirks and MUST be deployed as per instructions and not just used to the users discretion which can lead to non occlusion of artrial flow. Trust me, a medical provider or anyone without medical skills but proficient with a TQ who has adequate training on a quality TQ will stop your blood flow.....

ss

tell the wanna be....use it where ever they 'think' they should, then follow their medical direction and SOP to do it 'right'

[doc_robalt]

Ok so I can't find a BCT3 Manual or a SOCM manual to save my life but ironically the old FM 4-25.11 on First Aid even says that to have maximum effectiveness that a tourniquet should be placed above the knee and above the elbow. Is there any where I can get the Manuals for either BCT3, ALC or SOCM so I get this in writing and get this guy to shut up.

[Eagle5US]

Ok so I can't find a BCT3 Manual or a SOCM manual to save my life but ironically the old FM 4-25.11 on First Aid even says that to have maximum effectiveness that a tourniquet should be placed above the knee and above the elbow. Is there any where I can get the Manuals for either BCT3, ALC or SOCM so I get this in writing and get this guy to shut up.
Hey SGT,

How about you take a step back and take a deep breath. It is the principle of medicine that need not be violated. You seem HELL BENT on spotlighting yourself as Mr. Medical Sharpshooter.
CLS Guidelines teach 2-3 inches above. You have ample advice from current providers and recent graduates of BCT3 and TCCC above.
Once you have been in medicine awhile, you will find that it s a PRACTICE...meaning that things can, and are, done and taught differently in different arenas by different people but the principles remain the same.

Take the information you have been given and move out smartly.

Unless you have been through SFAS and even attempted the 18D Course, you really have exactly ZERO room to be chastising your "18D Wannabe"...

At least he stepped up to be assessed, and was selected. Though he failed - AT LEAST HE TRIED.

EDITED TO ADD
Looking in the most current CLS INSTRUCTORS MANUAL, ISO 0873, Chapter 4 "Combat Application Tourniquet" (Arm or Forearm) page 4-14, Step #2, it reads:
Position the CAT Tourniquet band two inches above the wound

You have your Reference, now man up and apologize to your "18D Wannabe"

[Shadow1911]

Hey SGT,

Unless you have been through SFAS and even attempted the 18D Course, you really have exactly ZERO room to be chastising your "18D Wannabe"...

At least he stepped up to be assessed, and was selected. Though he failed - AT LEAST HE TRIED.

You have your Reference, now man up and apologize to your "18D Wannabe"


Thank you Eagle,
I saw so many really good medics not make it thru the course. I would have been happy to have most if not all of them work on me. Just the way it is. People who have not been thru it should not ever call someone who tried and didn't make it a wannabe.

[doc_robalt]

The reason I call him a wanna be is because all he talks about is how he was in group and that he is pretty much an 18D but guess what he's not. And the reason I am so critical about this is because I teach CLS for an IRT company so I'm teaching privates that are deploying ASAP to a unit that is already down range and if they put a tourniquet on wrong and get somebody killed because they had to get taught by the book, when the book is wrong, how do you think that soldiers confidence in not only himself but in medics and CLS training going to be. Also as far as going to selection I'd be more than willing to go if t weren't for having to learn my job all over again for a year, because I'm sry but a seasoned medic with deployment experience on not only the line but in the aidstation side of he house as well is going to be just as good if not better than a 18D straight outta the school house. I met and worked guys straight outta the school house and I can't say I'm too impressed.

[Eagle5US]

The reason I call him a wanna be is because all he talks about is how he was in group and that he is pretty much an 18D but guess what he's not.
Guess what? NEITHER ARE YOU - but at least he manned up and gave it a shot.
And the reason I am so critical about this is because I teach CLS for an IRT company so I'm teaching privates that are deploying ASAP
Guess what again YOU ARE TEACHING IT WRONG

if they put a tourniquet on wrong and get somebody killed because they had to get taught by the book, when the book is wrong, how do you think that soldiers confidence in not only himself but in medics and CLS training going to be.
Unless they put the TQ around their patient's neck, they aren't going to kill someone by "incorrect" placement. The book isn't wrong YOU ARE :rolleyes:

Also as far as going to selection I'd be more than willing to go if t weren't for having to learn my job all over again for a year,
BLAH BLAH BLAH - never heard that EXCUSE before :boohoo: Thank you for saving us the training slot.

I'm sry but a seasoned medic with deployment experience on not only the line but in the aidstation side of he house as well is going to be just as good if not better than a 18D straight outta the school house.
The only thing that outweighs your arrogance here is your ignorance. As a "seasoned medic" you have the medical knowledge equivalent of a 1st grader when you look at the big picture. You can patch holes in the field and wipe snot and take vitals in the Aid Station.:munchin

I met and worked guys straight outta the school house and I can't say I'm too impressed.
I have the distinct impression that they most certainly were NOT impressed with you either.

Your attitude, and your SA, both suck balls.

[Don]

The reason I call him a wanna be is because all he talks about is how he was in group and that he is pretty much an 18D but guess what he's not. And the reason I am so critical about this is because I teach CLS for an IRT company so I'm teaching privates that are deploying ASAP to a unit that is already down range and if they put a tourniquet on wrong and get somebody killed because they had to get taught by the book, when the book is wrong, how do you think that soldiers confidence in not only himself but in medics and CLS training going to be. Also as far as going to selection I'd be more than willing to go if t weren't for having to learn my job all over again for a year, because I'm sry but a seasoned medic with deployment experience on not only the line but in the aidstation side of he house as well is going to be just as good if not better than a 18D straight outta the school house. I met and worked guys straight outta the school house and I can't say I'm too impressed.

With your grammar, spelling, major penis fixation, and abject lack of any situational awareness whatsoever...I can't say I am too impressed with you.

Edited to read: (Dammit...Eagle got to the post button first).

[head]

...because I'm sry but a seasoned medic with deployment experience on not only the line but in the aidstation side of he house as well is going to be just as good if not better than a 18D straight outta the school house. I met and worked guys straight outta the school house and I can't say I'm too impressed.

No, you are definitely wrong and probably a liar, but, hey, at least you got the "I'm sry" part right. "Seasoned medics" don't ask where to put tourniquets.

[Priest]

Seeing how you also feel that your opinion, as a "seasoned medic," of how things should work in YOUR MIND- seeing how you, yourself have yet to present any documentation to support your argument - is not only more correct than an 18D straight out of the house, but also a trauma surgeon. swat surgeon gave you the down and dirty, and as someone who uses, trains and tests these devices on a regular basis, he would be the one to know. But, as your arrogant attitude isn't limited to your poor medical skills:

"I like to go hiking in the mountains of Colorado, and I like to work on my tactical skills playing Airsoft with some of my friends, seems I get better training outta that than in the army." -quoted from your profile

I think your problem is a deep rooted one and your arrogance is more likely to kill someone than placing a tourniquet around the fibula and tibia.

You don't ask a question, get well informed answers, and then keep asking until someone agrees with you.

[Richard]

This thread reminds me of something that happened one weekend to the Chief of the ER at Womack Army Hospital back in the early 70's, one of the brightest MDs I ever worked with and an officer who appreciated having two of us SF Medics SD on every shift in the ER at Fort Bragg.

He was from GA and an Emory grad so would make a monthly trek back to Atlanta by taking a three day weekend off. One weekend, he came upon a bad vehicle accident on the interstate and began providing emergency Rx to the most seriously injured victim. He said he was working on the patient when a woman came up, saw the victim and declared, "Oh my God! I'm a nurse, let me through!"...and pushed him aside to get at the injured victim. Stu (the MD) said he got up and told the woman, "Well, nurse, let me know when you need a doctor - I'm an ER physician."

He used to use that story to make a point with newly assigned ER staff about the importance of SA when facing an emergency...something this guy doesn't seem to have acquired.

Anybody wanna hand this guy a fire extinguisher so he can put himself out? :rolleyes:

Richard :munchin

[Old Dog New Trick]

Dusty gave the best (and correct) answer!

The only question remaining is how much of the extremity or function below the joint you want the patient to have a chance of survival. Remember, it's life over limb. Limbs are attached to the torso. Everything below the joint is prostetic bonus material.

[DDD]

The reason I call him a wanna be is because all he talks about is how he was in group and that he is pretty much an 18D but guess what he's not. And the reason I am so critical about this is because I teach CLS for an IRT company so I'm teaching privates that are deploying ASAP to a unit that is already down range and if they put a tourniquet on wrong and get somebody killed because they had to get taught by the book, when the book is wrong, how do you think that soldiers confidence in not only himself but in medics and CLS training going to be. Also as far as going to selection I'd be more than willing to go if t weren't for having to learn my job all over again for a year, because I'm sry but a seasoned medic with deployment experience on not only the line but in the aidstation side of he house as well is going to be just as good if not better than a 18D straight outta the school house. I met and worked guys straight outta the school house and I can't say I'm too impressed.

ME, ME, ME!!! I'm on fire, put ME out!!! I have wasted hours trying to unteach stupid s#!t that supposedly squared CLS instructors taught (taping TQs in place:confused:). I'm not sayin', I'm just sayin'.

[Guy]

Unless they put the TQ around their patient's neck, they aren't going to kill someone by "incorrect" placement. The book isn't wrong YOU ARE :rolleyes:

Stay safe.

[MTN Medic]

The reason I call him a wanna be is because all he talks about is how he was in group and that he is pretty much an 18D but guess what he's not. And the reason I am so critical about this is because I teach CLS for an IRT company so I'm teaching privates that are deploying ASAP to a unit that is already down range and if they put a tourniquet on wrong and get somebody killed because they had to get taught by the book, when the book is wrong, how do you think that soldiers confidence in not only himself but in medics and CLS training going to be. Also as far as going to selection I'd be more than willing to go if t weren't for having to learn my job all over again for a year, because I'm sry but a seasoned medic with deployment experience on not only the line but in the aidstation side of he house as well is going to be just as good if not better than a 18D straight outta the school house. I met and worked guys straight outta the school house and I can't say I'm too impressed.

Kid, you have been told what doctors and 18D use. Your disrespectful tone towards your superiors and those here (which I assure you, are your superiors) speaks largely as to your quality as a soldier. Previous remarks about you being a "medical sharpshooter" are right on.

If you have any qualms with what I have said to you, or need some NCOPD, I share post with you. When you get back, seek me out and I will help you understand why your attitude is UNSAT.

Quit running your mouth about an 18D wannabe. He probably has more medical experience than you will even have. If you don't want to do this the solution is simple: Go to SFAS! Also, if you talk about being "not impressed" with my cohorts again, It will be I, seeking you out instead of vice versa for some NCOPD. Capiche?

[Warchief]

Also as far as going to selection I'd be more than willing to go if t weren't for having to learn my job all over again for a year, because I'm sry but a seasoned medic with deployment experience on not only the line but in the aidstation side of he house as well is going to be just as good if not better than a 18D straight outta the school house. I met and worked guys straight outta the school house and I can't say I'm too impressed.

I graduated from 300F1 in 1979. At this point, I feel comfortable in saying, I've forgotten more tramua treatment techniques and procedures than this "seasoned medic" has ever learned. 30+ years later, I'm still better trained, more experienced and decidely capable than any basic skilled medic.

You know, "Doc" one of the first principles I learned was, "First, Do No Harm." That meant I spent a great deal of my time seeking and heeding knowledge whenever available. I'm known some really capable medics in my time but I'd take even a partial school trained 18D over any of them or you any time or any where to treat me or someone I care about. I know and trust their capability and competence while distrusting your arrogance and need to demonstrate how much you think you know to everyone else.

BTW, I doubt you'd have to spend a year learning your job all over again. I don't think you'd make it thru 3 complete weeks of S&A with your sorry attitude and inability to listen.

[MTN Medic]

than willing to go if t weren't for having to learn my job all over again for a year, because I'm sry but a seasoned medic with deployment experience on not only the line but in the aidstation side of he house as well is going to be just as good if not better than a 18D straight outta the school house. I met and worked guys straight outta the school house and I can't say I'm too impressed.

Boy, I really hope you are kidding. I just know if I found out who your COC/COR was, they would be happy to regale me with stories of the one upper, braggart, loner and generally piss poor soldier.

Don't you ever talk about my fellow 18D again this way. It is clear you have no idea what you are talking about. You wouldn't last an hour in selections or a day in a team room.

Have you been to selections? Have you been to JSOMTC? No? The keep your mouth shut. My previous offer from my last post still stands.

[Sonic03svtCobra]

Hit him with the BANNED stick.

[longrange1947]

Doc Robalt - You really are full of yourself and you really have no idea what you are talking about do you? I doubt seriously you have any idea what an 18D is trained in or what are all his quals. I hope that you learn, but I seriously doubt you will learn anything, but I am sure you are great at shifting blame for your short comings.

Have a nice day and see if the "18D wannabe" may possibly teach you something, you need as much help as you can get.

[greenberetTFS]

Stay safe.

Hey Doc in case you couldn't read Guys post let me help you.........:rolleyes::eek::mad:

Unless they put the TQ around their patient's neck, they aren't going to kill someone by "incorrect" placement. The book isn't wrong YOU ARE..........

Big Teddy :munchin

[gits]

And one more thing WTF!!! Why post stuff your selling in "The Cache" if you don't respond to PM's!!!

[PSM]

Damn, I need earplugs in this thread. :D

Pat

[Old Dog New Trick]

Doc-Rabalt hope you are still able to read this and have not been sent packing or just gave up because the heat was turned up in a kitchen of your choosing.

Some 23-years ago I wanted to be an SF Weapons Sgt (for reasons not important to this discussion.) After selection they saw more potential and requested that I change to an SF Commo Sgt...guess I had something called "aptitude." I replied back with I'm not really interested in that MOS (no practical use outside SF), can I become an SF Medical Sgt? Their reply was..."So you wanna be an 18D, you've got the scores and motivation, sure we'll send you down there (Ft Sam) but if you fail...commo school is back here and you'll be a recycle so no more chances to fail again."

Guess I had something else called, "fortitude."

I successfully completed the 91A/91B before heading into 300F1 (SOFMED) course and I don't remember ever having to relearn something from those two other schools. In fact, nothing about 300F1 comes from the Army enlisted medical program. If you were a PA or MD I could see your conundrum but you are not...

Something else I learned down there was humility and humbleness, I also came away with a capability very few other enlisted folks will ever know in life. I have forgotten more about how to save a life under fire or extreme duress than most people will ever learn, but there is this etched in my mind. "Do no further harm, but do something."

If you are attempting to put a tourniquet on yourself so tight as to completely cut off circulation for no other reason to see how it works you have failed rule number one...do no further harm. The tissue under a properly applied TQ is permanently crushed - soft tissue fills in around hard tissue (bones) and blood clotting will take care of the rest that's how it works. Placement is secondary only to survivable tissue proximal to the wound - too close to the end and they fall (squeeze) off, or are ineffective at stopping blood flow. About the only known contraindication is never place a TQ over a joint because of inadequate compression of arterial passage. While the best is certainly over/around large round bones, applying a TQ to the thigh of a comrade who's lost a foot below the ankle will certainly remember you for having his knee amputated down the road.

Signed, 18D wanna be, but I are graduate. It wouldn't have made a difference if I did not make it to the end or not, I was there for the training along the way. Give that "civilian trainer" a bit more respect, he might make a medic out of you someday...maybe you could ask him at what point he failed because we don't pass people on the last day if they are not capable of operating independent sans MD on the battlefield or remote location with nothing more than a sharp knife, a Leatherman and some dental floss.

[x SF med]

Doc Rabalt.... haven't you left other military boards because you got pissed off that people didn't kow-tow to your godliness.... OH Yeah, you D-bag, that was me... Hi, you arrogant little POS... guess what this time there are other (and more) Doctors and 18D's you are pissing on.

Hmmmm... let me think - I would guess that at least one of these guys also had some of the same instructors as I did... one of whom is now the friggin SOCOM Surgeon (who used to be an 18D, oh sorry, no he wasn't he was a 91B3SVyadayada...).

Remember your training - you need to keep them alive until they get to the hospital; and think about the 18D training - Keep them alive, you are the hospital.

You need to take a good long look at yourself in the mirror, then apologize to yourself, and apologize to the ER docs, PAs and 18Ds you think are less educated and know less medicine than you - Hey Guy, Eagle, Chief, Crip, Richard, et al... he was depoyed as a medic, ever done that?

and as a final word on this post.... Wow.... just .... WOW....

[Richard]

OK - we're done here. This guy suffers an incurable case of SA insufficiency syndrome. Nothing to see here, ffolkes. Move along now.

Richard

[swatsurgeon]

OK - we're done here. This guy suffers an incurable case of SA insufficiency syndrome. Nothing to see here, ffolkes. Move along now.

Richard

Agreed....thread closed since his ignorance has trumped the reality.

ss