# Proper Tourniquet Application



## JANES (14 Apr 2006)

Sorry, but I have removed this post


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## kj_gully (14 Apr 2006)

Great stuff Janes as usual. The biggest problem I have with all these tidbits of info you pass on is folks look @ me sideways when I use Army.ca as my reference when I regurgitate this stuff @ work!

Keep it up, you may drag CFMS into the lifesaving business.


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## Armymedic (14 Apr 2006)

JANES said:
			
		

> I'm amazed at the ignorance in the CF and specifically the medical field about tourniquets.



I say...Pardon Me? You wanna qualify that statement a bit? Take that statement out and you would have one of the best posts on the site.

I also say almost everything you said is exactly how I teach the use of a TK.



> An effective tourniquet should be applied to life threatening hemorrhage approx 1 to 2 inches above the wound.  Too close to the wound and it risks slipping in, to high above and you are starving good tissue of perfusion.  Don't put the tk over top of the wound, it will cause more tissue damage and may not stop the bleed if an artery has been completely severed and has retracted.  Also dont place them on joints, if you must go above the joint.  Try to smooth out clothing to avoid pressure points on the skin.



I used hand measurement for placement....no closer the a handwith of the wound, and not closer then 2 fingers above or below the joints.



> Packing wounds, especially large shrapnel wounds with sterile gauze is also an effective suppliment to hemorrhae control, especially torso bleeds where tk's are useless.


I teach this in my theory lecture. Direct pressure mean pressure directly on where the bleeding is. That means pushing material right into the wound, fill the wound with the white part of the old fd dressing or gauze, and then cover over with the Israeli dressing.  It is not sufficient to put the pressure dressing flat over large gaping wounds. I enjoy watching everyones eyes widen in surprise when I say that...

One thing for everyone:


> If you have the time, write it on the casualty's forehead.



No. Do it. If you do not have a pen or marker, use the casualty's blood and mark a T or at least a "T" like cross on the forehead.

edit to add: 





> A tk should be applied in the Care Under Fire phase to all unmanageable bleeding.


No. In Care under Fire, a TK is applied immediately to all penetrating trauma to the arms and legs, regardless of the severity. You may have quite literally minutes left to live if you do not. And this has been proven in cbt. Once it is applied, return to the fight if able.

JANES, 
Great post. Please refrain from the broad statements that may get you into trouble, esp as MM and I and others are really trying to enlighten people. I am more tolerent of insult then most


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## JANES (14 Apr 2006)

"Isn’t the standard to loosen it q10min?"

"My understanding from the docs in ER is it is on 10min and then off and a short time (based on the status of the bleed) and then back for another 10min...is it not necrosis that sets in after an extended period of lose of blood flow? Which kind of defeats the purpose of the tourniquet if you are supposed to be preserving life and limb.
Although if you have to choose life over limb you know how that story goes...
As well a complete amp (as per St. John Ambulance) is not supposed to bleed in excess..."


It was these statements that caused me to write that.  I didnt mean to stereotype, my point was that there is still a lot of resistance and misunderstandings.  I applaud your efforts to educate the CF on this topic.  It is desperately needed.  You said it yourself.  Its trying to enlighten everyone.  There is no doubt that there are a lot of compitent medics out there that know all about tourniquets.  But when there are still medics that are asking if you should ventilate tourniqueted limb every 10 minutes then there still exists a problem.  I'll say the controlversial statement again, because I stand by it, and maybe try to clarify it.  I am amazed at the [lack of education] in the CF and specifically the medical field [meaning those that resist teaching everyone, not just deploying troops] all the information that exists on tourniquets.  There are medics out there, and of course not you AM and MM and who ever else, that believe the old St Johns heave ho that tourniquets bad and do not use, and when you put on a tourniquet you have lost that limb and the soaking up the blood is "controling the bleeding", and if the dressing bleeds through just place another on top, an another and another.  What I am saying is keep teaching, because we are in a paradym shift.  And all truth will go through the phases.  We want everyone to accept the information as self evident, and we are not there yet.


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## Armymedic (14 Apr 2006)

Aye, seen...
The person you quote isn't in the CF yet, but yes, good example.


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## Big Red (14 Apr 2006)

Great post JANES.  I had completely forgot about this: 

"Tk aren't that great at stopping lower leg and forearm bleeds as the vessels travel between two bones.  That doesnt mean you don't attempt to apply them there.  A way to add advantage when placing them distal to an extremity joint is to pad underneith the tk between the bones (with a traingular, vacuum gauze or something similiar) to help force more point pressure in between the two bones.  Instead of causing circumferencial pressure around the limb, now you are forcing pressure in between the bones where the vessels are."

Thanks for the refresher.


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## JANES (14 Apr 2006)

Armymedic said:
			
		

> No. In Care under Fire, a TK is applied immediately to all penetrating trauma to the arms and legs, regardless of the severity. You may have quite literally minutes left to live if you do not. And this has been proven in cbt. Once it is applied, return to the fight if able.



I'm a little on the fence about applying a tourniquet to all penetrating trauma during CUF.  Not every GSW is life threatening, and yes you cant tell so you treat the worst case scenario.  So lets look at a worst case scenario.  GSW to the thigh.  You can bleed as fast as i liter per minute.  There should be a significant amount of blood coming out, then you apply a tk.  If there isn't, lets look at the worst case scenario again - complete femoral artery disection and by some chance the permanent cavity the projectile created has seal.  The bleed should tamponade after about 1.5 liters.  What I'm trying to get at is that if the bleed is life threatening, in most circumstances you will know.  You will see a lot of blood.  If you get a wound with little or no bleeding (on the EXTREMITIES), it wil most likely have no great vasculat damage and great circulatory compromise, a tk is going to be more of a tactical hindrance.  I would say that it is very important to stress life threatening bleeding vs non-life threatening bleeding.  Butler states one of the five bigest mistakes WRT tk's coming back from the deserts are that they are being applied when they should not be.  The other issue is that when someone is in combat they are very vasoconstricted due to catecholamines from stress.  They aren't going to bleed as much in the CUF phase as they will when things settle down and the situation transitions to the TFC phase.  Then they will start to bleed more.  If you teach to put it on everything, I won't say thats wrong, but it can be better.  Not every GSW deserves a tk, the key is getting good enough to diferentiate which one do and which ones don't.


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## Armymedic (14 Apr 2006)

For the blood flow in the lower limbs, (if I recollect correct) 60% in the lower arm and 40% between in the lower leg flow between betwen the bones.

I am not sure about padding the TK on the distal portions limbs (not sure enough to dispute what JANES wrote), but you must accept at least 50% reduction in effectivenss if applied below the joints. But, direct and indirect pressure is also more effective below the joints, so it is almost an even trade off. And there is always Quickclot if you have it.


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## JANES (14 Apr 2006)

This concept is a little hard to grasp.  I'll try to explain it a bit further.  Its not padding proximally or distally.  You actually place padding under the tourniquet where there is the soft spaces between the two bones.  For example, you dont place the padding on the tidia, you place it in the grove between the tib and fib.  Then when the tk is tighened it forces the pad in between the bones.  The theory is that this will apply more pressure to the vessels in there as opposed to circumferential pressure where the vessels are protected by the bones.  Does that make sense?

And I think its actually 70% in the lower legs  

And yes thats the first little yellow head I have ever used...I think


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## Armymedic (14 Apr 2006)

JANES said:
			
		

> If you teach to put it on everything, I won't say thats wrong, but it can be better.  Not every GSW deserves a tk, the key is getting good enough to diferentiate which one do and which ones don't.



"They" have found what you said to be true. At the time of injury, you may not be able to tell how bad you are hit. So this protocol removes all doubt. People have died with the TK in thier hands, realizing too late they should have applied it to themself.

We also teach that if you put it one in CUF, then once in the CCP or area of realitive safety where you can take care of your wounds: 
Apply direct pressure to your wounds, loosen the TK to assess how bad you are bleeding. If bleeding is severe (spurting, blood soaks thru first dressing, etc), retighten the TK, etc etc.



			
				JANES said:
			
		

> The theory is that this will apply more pressure to the vessels in there as opposed to circumferential pressure where the vessels are protected by the bones.  Does that make sense?


Yes, makes perfect sense in theory, as padding under any TK does make them more effective. I not sure of the practical application, and also for instruction of non med pers. Placement for added pressure between the bones would need to be almost perfect to increase effectiveness. (I'll admit, I never read or heard of distal padding for the commercial TKs)



			
				JANES said:
			
		

> And I think its actually 70% in the lower legs



Ok then, I do have the percentages backwards.


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## JANES (14 Apr 2006)

Keep it simple for the troops.  Don't worry about giving them more crap like padding the tk on distal extremities.  They are trying to digest enough as it is.  It should be taught to medics as another tool in the box (or out of the box!).  

Medics sould have an Emergency and Military Tourniquet.  This is the best tk for the casualty if they are going to be monitored because its pneumatic and if it rips or malfunctions or altitude change (helo) may deflate.  Its not a good idea for the troops to carry these for those reasons.  This one shouldn't need padding as the bladder will conform a little better the the bones.  The strap tk's you CAN pad undernieth.  Ideally the CAT gets applied CUF, then EMT applied during the reassess in TFC.  

Everything regarding application in CUF and reassessing in TFC you mentioned last is great.  Good to keep it simple and tell everyone to put it on.  If I get shot in the arm, and its not bleeding too bad though...I think I'll defer a tk and keep fighting!  But thats my perogative.


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## old medic (14 Apr 2006)

Janes,

Armymedic beat me to the first four points, so I won't repeat the first three.
I want to re-enforce his fourth:



> One thing for everyone:
> 
> 
> 
> ...



Marking it has to be done.  This is both an MSI for CF Medics, and a NATO STANAG (2350-Ed2) for everybody who
would apply a tourniquet.


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## JANES (14 Apr 2006)

Theres books and regs and then theres reality.  If rounds are flying past my head, I'm not going to dig for a pen.  The time on their forehead can wait until the TFC phase.  The blood with the finger is reasonable, but finger painting with a sauage finger on a guys forehead when he's got a helmet on isnt going to be very legible.

If you've got a problem with my post, please let me know and I will gladly remove it, or by all means remove it yourself, but if you do I fully expect that you don't save a copy for yourself.  If you're going to focuss on the negative then there is no reason it should stay up.  After all you are in charge not me.  I'm just trying to help some people out.  If it's not up to your standard, I'll take my info and go home and provide the info through a different medium where people can appreciate it.  And if you're going to warn or ban me again for standing up for myself, then let me know ahead of time so I can erase my info myself.


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## medicineman (14 Apr 2006)

Padding TK`s - oddly enough, when I first learned to put one on a hundred odd years ago, it was just whatever you were using and a stick or whatever you were using to wind your windlass with.  Every American combat medical reference I`ve read says to pad them regardless - the bulk gives extra pressure and it causes somewhat less gross damage to nerves travelling close to the arteries concerned.  They also help out with the problem inherent with the low leg and forearm.  When I teach TK`s they get the C.A.T. and improvised, and I always teach to use the padding on the improvised ones.  I also always teach the guys to have at least 2 TK`s - whatever commercial one they are issued (C.A.T. at the moment) and something for an improvised one - and a triangular bandage does well for that, as long as they have something to wind the windlass up with, it works quite well.  And in the Stan, most everyone has a scarf of some sort as well.

Removal - there will be a protocol for removal.  Essentially, it`s don`t actually remove it, but loosen it under control with a pressure dressing =/- QC in place in place first and after about an hour.  It stays on though, as something might happen that blows the clot and it starts again, and therefore it can be tightened quickly.

Marking - I see where you`re coming from Janes - crack crack by your ear is a bit of a deterrent to getting the head marked, but I think something should be done and sooner than later - if the poor slob goes unconscious, someone needs to know it`s there, especially if it`s gotten itself hidden.

Packing wounds - the new kit list for the TCCC bags is going to include a PriMed dressing.  It`s vaccum compressed Kerlix for packing wounds and will be taught as part of the bleeding control package.

Lastly, I don`t take too much offence to the paint brush over the CFHS (you should hear me some days), however, as our first aid courses at the moment are essentially off the shelf what is taught to civvies, that happens.  There are alot more people out there than you think though, that are closing the TK circle and alot of them are in fact physicians.  Problem is getting the first aid instructors out there to think outside the box and not by their rote learning - alot of them know only what they are taught on their courses and they aren`t given alot of leeway as to what they are allowed to teach.  Also, there are some medics that are either set in their ways or have had so much civvy paramedicine shoved down their necks they forget they are in the military and the environments are quite different.

Phew.

MM


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## old medic (14 Apr 2006)

JANES said:
			
		

> Theres books and regs and then theres reality.  If rounds are flying past my head, I'm not going to dig for a pen.  The time on their forehead can wait until the TFC phase.  The blood with the finger is reasonable, but finger painting with a sauage finger on a guys forehead when he's got a helmet on isnt going to be very legible.



You didn't mention anything about rounds flying, just tourniquet application.  There are role 1, 2, and 3 personnel reading 
this, so we should be clear on proper doctrine before shortcuts. Not every tourniquet will be at the FEBA.



> If you've got a problem with my post, please let me know and I will gladly remove it, or by all means remove it yourself, but if you do I fully expect that you don't save a copy for yourself.  If you're going to focuss on the negative then there is no reason it should stay up.  After all you are in charge not me.  I'm just trying to help some people out.  If it's not up to your standard, I'll take my info and go home and provide the info through a different medium where people can appreciate it.  And if you're going to warn or ban me again for standing up for myself, then let me know ahead of time so I can erase my info myself.



Had there been a problem, this thread wouldn't be here. I can assure you that all the staff here are capable of 
putting together their own thoughts without copying your post.   If you like, we can discuss the rest of this via 
private mail. Alternately, you are free to discuss your concern with any of the staff here.

OM


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## JANES (14 Apr 2006)

PLEASE tell me where the FEBA is in Afghanistan right now?

Thats pretty old school.  We work in a 360 degree environment now!


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## kj_gully (14 Apr 2006)

speaking of old school, isn't writing on the forehead a little old school? If you feel that strongly about it, why not create a sticker or tag, or fluorencent pink tape that can be quickly, effectively and positively applied where it will be seen, make space for the time maybe even punch/cut outs, ever seen a Deer tag?Issue one in the same packaging as the TK? My pen never works when I need it most. grease pencil melts, not everyone has a sugical marker. Pencil works if you press hard enough, but the scar will be there for a LONG time


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## old medic (15 Apr 2006)

JANES said:
			
		

> PLEASE tell me where the FEBA is in Afghanistan right now?
> 
> Thats pretty old school.  We work in a 360 degree environment now!



I'm not sure what your arguing here.  We're discussing tourniquets, not 
Afghanistan, not just tourniquets on a current operation or TCCC. 

I only mentioned FEBA because you seem to be blinded by TCCC and 
care under fire.  If your going to claim 





> I'm amazed at the ignorance
> in the CF and specifically the medical field about tourniquets.


,
then your discussing full spectrum. As I mentioned, all roles. If your 
going to train, train correctly.


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## old medic (15 Apr 2006)

kj_gully said:
			
		

> speaking of old school, isn't writing on the forehead a little old school? If you feel that strongly about it, why not create a sticker or tag, or fluorencent pink tape that can be quickly, effectively and positively applied where it will be seen, make space for the time maybe even punch/cut outs, ever seen a Deer tag?Issue one in the same packaging as the TK? My pen never works when I need it most. grease pencil melts, not everyone has a sugical marker. Pencil works if you press hard enough, but the scar will be there for a LONG time



Those already exist, however they become seperated or never make it on initially. 
Thus the NATO agreement on casualty marking.


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## kj_gully (15 Apr 2006)

sounds like the same thing that happens with the written TK. Issue them, and you will end up with some written, some tagged, and overall more compliance


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## the 48th regulator (15 Apr 2006)

JANES said:
			
		

> If you've got a problem with my post, please let me know and I will gladly remove it, or by all means remove it yourself, but if you do I fully expect that you don't save a copy for yourself.  If you're going to focuss on the negative then there is no reason it should stay up.  After all you are in charge not me.  I'm just trying to help some people out.  If it's not up to your standard, I'll take my info and go home and provide the info through a different medium where people can appreciate it.  And if you're going to warn or ban me again for standing up for myself, then let me know ahead of time so I can erase my info myself.



hmm,

interesting statement, perhaps freudian slip ....

dileas

tess


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## JANES (15 Apr 2006)

old medic said:
			
		

> I'm not sure what your arguing here.  We're discussing tourniquets, not
> Afghanistan, not just tourniquets on a current operation or TCCC.
> 
> I only mentioned FEBA because you seem to be blinded by TCCC and
> ...



I guess I am the one mistaken then (as you always seem to have to manipulate your understanding of my posts to try and prove that I am wrong, and of course you are always right because you are DS).  *I was discussing tk WRT TCCC as they dont really have any application anywhere else.*  St Johns's first aid, BTLS, PHTLS, ATLS is the standard everywhere else (non-tactical, non-combat), and they discourage them very strongly.  When I started the thread it was under the presumption that everyone would understand that it was for use during TCCC.  I guess I should have clarfied that for those that can't see the big picture and realize where a tk is and isn't appropriate.  It's seems like you're going out of your way try and find a fault in my postings. 

I'm not sure I understand the second part of your statement.  I used Afghanistan as an example.  We don't fight 180 degree FEBA style warfare anymore.  We are involved in 4th generation warefare.  There is no FEBA.  

I'm discussing tourniquet use by soldiers and military medics, using them in the context of their job, i.e. tactical and combat environments.  During TCCC.  Not in garrison or the clinic or "full spectrum" as you claim I have stated.  They just don't get used there.  Why does the DS always seem to turn forums that I post in, into defamation attempts.  Conversations always run so smoothly until they get involved.  

If I'm going to train, train correctly?  I can assure you that I train correctly.  More correctly than you will ever be privy to know!



			
				Recorded Lad said:
			
		

> hmm,
> 
> interesting statement, perhaps freudian slip ....
> 
> ...



What does that mean?  How does this apply to tourniquets???


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## the 48th regulator (15 Apr 2006)

My Job is to Moderate the site, on behalf of Mike B.

You make a statement, challenging a Mod to ban you _again_, and that piques my interest.



> What does that mean?  How does this apply to tourniquets???



Maybe a simile to who you are and how I am seeing things....

dileas

tess


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## JANES (15 Apr 2006)

Recorded Lad said:
			
		

> My Job is to Moderate the site, on behalf of Mike B.
> 
> You make a statement, challenging a Mod to ban you _again_, piques my interest.
> 
> ...



FYI I was never banned.  I I never challenged anyone to ban me.  But it wouldnt surprise me if they did as some people get threatened by information very easily here.   Now why is this conversation taking place in a public forum on tourniquets???


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## the 48th regulator (15 Apr 2006)

So You were _never banned_, yet state you were.

Yes I will take this up in a "Public thread" on tourniquets.

Very serious subject, and I find an oddity to your creditability pertinent to your statements....

see the reason for me posting in this Public forum.....

Oh and by the way, just because I am "DS", don't try to use that as a way to skirt the issue....pretend a I am a just like one of the other people here who has found it odd in what you have said...

dileas

tess


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## old medic (15 Apr 2006)

JANES said:
			
		

> FYI I was never banned.  I I never challenged anyone to ban me.  But it wouldnt surprise me if they did as some people get threatened by information very easily here.   Now why is this conversation taking place in a public forum on tourniquets???



This is where it came up.


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## JANES (15 Apr 2006)

You know what says a lot about credibility, is making issues when none exist to trying and look important.  

Banned, warned, whatever, is semanitcs.  

I'm not skirting any issue.  I will deal with every issue head on.  And I can't pretend you're NOT DS because as soon as you loose face or feel threatened, all you have to do is give me a warning.  So Im going into this discussion at a disadvantage.  And funny enough, the only people that found what I have said odd is two DS staff.  Everyone else was here was engaged strictly in informative discussion about tourniquets and found my post benificial.


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## the 48th regulator (15 Apr 2006)

I don't feel threatened at all...

You sound like you are, wouldn't you agree?

Why is that?  Hey your information may be Phenomenally correct, or it can be sugar coated to sound like it is.

Why do you choose to point out the fact that the only people questioning you are DS.

You see, to me that is an example of some hidden reason for your posts....You are quick to take digs at the CF, and then at the staff here.  Then you try to play the victim as being the one that is picked on in a viable thread about medical aid.


But you see, that is where the truth must be found.  As if you are spouting insulting statements, expect it in return. And if you are doing that in a thread that can cause harm to troops, I will not put up with it. 

So Janes, what is your agenda?  To help the average soldier, or to goad us DS into proving a point....

My Spidey senses are tingling.....

dileas

tess


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## DartmouthDave (15 Apr 2006)

Hello,

There are many ways of doing things.  Doing things one way dose not exclude the fact that an other way isn't correct as well?  
Lots of gray areas.  When I asked, "Is the standard to loosen q10min?"   I just wanted to see what the current thinking was.  JANES gave his , fine.  I just think his antagonistic tone is counter productive.

David


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## the 48th regulator (15 Apr 2006)

Cheers Dave,

Will be interestin g to hear what our fellow poster has to say...

I am off to bed, Oh five hundred, and I am still up.

dileas

tess


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## JANES (15 Apr 2006)

Recorded Lad said:
			
		

> You see, to me that is an example of some hidden reason for your posts....You are quick to take digs at the CF, and then at the staff here.  Then you try to play the victim as being the one that is picked on in a viable thread about medical aid.
> 
> But you see, that is where the truth must be found.  As if you are spouting insulting statements, expect it in return. And if you are doing that in a thread that can cause harm to troops, I will not put up with it.
> 
> ...



You're digging for something you will never find.  All my intension was, was to, in your words "help the average soldier".   "goad us DS into proving a point" was an issue that was fabricated by DS.  Spiderman you are definitely not!

I took no digs at the CF, I simply stated I was surprised how some medics don't know proper tk guidelines.  Maybe you should read my second post in this thread before you get your blood pressure up. 

This all started because someone doesnt know that the word "ignorance" simply means lack of education, and it's just been proven again



			
				DartmouthDave said:
			
		

> There are many ways of doing things.  Doing things one way dose not exclude the fact that an other way isn't correct as well?
> Lots of gray areas.  When I asked, "Is the standard to loosen q10min?"   I just wanted to see what the current thinking was.  JANES gave his , fine.  I just think his antagonistic tone is counter productive.



There are medics out there with a lack of education on tourniquets.

The antagonistic tone I may point out started with here:



			
				old medic said:
			
		

> Janes,
> Armymedic beat me to the first four points, so I won't repeat the first three.
> I want to re-enforce his fourth:
> No. Do it. If you do not have a pen or marker, use the casualty's blood and mark a T or at least a "T" like cross on the forehead.
> ...



There are much less "antagonistic" and finger pointing ways of stating this information.   

You want to talk about Freud?  A statement worded like this shows me an insecurity because he has to address it specifically to me instead of providing a general informative addition, then let everyone know that he's a very smart guy and very informed by saying he would have stated all that information if someone hadn't beaten him to it.  Then he feels he has to has to point out very clearly, because it makes him feel good about himself, (point out anothers fault to relatively make your own standing look better) why a little tiny statement in a very large post was wrong (actually misinterpreted out of context).  Now sit there and call this last statement BS and a figment of my imagination, but I can sit here and say the same about all your bold theories about me.  Theres no difference.  Mine's backed up by psychology, your's are based on assumptions.

And then, this is my favorite part, lock the topic.  (maybe you feel like you're fighting a loosing battle?  Are you afraid of what the other posters might say?


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## JANES (15 Apr 2006)

Recorded Lad said:
			
		

> You see, to me that is an example of some hidden reason for your posts....You are quick to take digs at the CF, and then at the staff here.  Then you try to play the victim as being the one that is picked on in a viable thread about medical aid.
> 
> But you see, that is where the truth must be found.  As if you are spouting insulting statements, expect it in return. And if you are doing that in a thread that can cause harm to troops, I will not put up with it.
> 
> ...



You're digging for something you will never find.  All my intension was, was to, in your words "help the average soldier".   "goad us DS into proving a point" was an issue that was fabricated by DS.  Spiderman you are definitely not!

I took no digs at the CF, I simply stated I was surprised how some medics don't know proper tk guidelines.  Maybe you should read my second post in this thread before you get your blood pressure up. 

This all started because someone doesnt know that the word "ignorance" simply means lack of education, and it's just been proven again



			
				DartmouthDave said:
			
		

> There are many ways of doing things.  Doing things one way dose not exclude the fact that an other way isn't correct as well?
> Lots of gray areas.  When I asked, "Is the standard to loosen q10min?"   I just wanted to see what the current thinking was.  JANES gave his , fine.  I just think his antagonistic tone is counter productive.



There are medics out there with a lack of education on tourniquets.

The antagonistic tone I may point out started with here:



			
				old medic said:
			
		

> Janes,
> Armymedic beat me to the first four points, so I won't repeat the first three.
> I want to re-enforce his fourth:
> No. Do it. If you do not have a pen or marker, use the casualty's blood and mark a T or at least a "T" like cross on the forehead.
> ...



There are much less "antagonistic" and finger pointing ways of stating this information.   

You want to talk about Freud?  A statement worded like this shows me an insecurity because he has to address it specifically to me instead of providing a general informative addition, then let everyone know that he's a very smart guy and very informed by saying he would have stated all that information if someone hadn't beaten him to it.  Then he feels he has to has to point out very clearly, because it makes him feel good about himself, (point out anothers fault to relatively make your own standing look better) why a little tiny statement in a very large post was wrong (actually misinterpreted out of context).  Now sit there and call this last statement BS and a figment of my imagination, but I can sit here and say the same about all your bold theories about me.  Theres no difference.  Mine's backed up by psychology, your's are based on assumptions.

And then, this is my favorite part, lock the topic.  (maybe you feel like you're fighting a loosing battle?  Are you afraid of what the other posters might say?


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## old medic (15 Apr 2006)

JANES said:
			
		

> I guess I am the one mistaken then (as you always seem to have to manipulate your understanding of my posts to try and prove that I am wrong, and of course you are always right because you are DS).



Upon review of your posts, I have only replied once to anything you have posted. That was in June 2005. 



> The antagonistic tone I may point out started with here:
> .....
> There are much less "antagonistic" and finger pointing ways of stating this information.



Ah.... Lets review them:



			
				JANES said:
			
		

> So what is this tactical combat casualty care?  Whats wrong with the what we have?





			
				JANES said:
			
		

> It's inspiring to see such interest in the topic, especially from the Combat Arms.  It's also very scary to see all these self proclaimed experts on the topic.  It's important to realize, just because you're a medic or nurse or whatever in the Army, doesn't mean you're a TCCC SME.





			
				JANES said:
			
		

> This is a bad medium to learn in gents, I dont recommend it.  You cant verify any info as being true.
> I'm gone boys, nice chatting, but no one would give me the right answer to my questions, Whats 500ml of NS going to do for anyone?
> 
> Good luck!





			
				JANES said:
			
		

> ......  You can read all the slideshows and books you want, but to truely understand it you need the experience.  So I'll ask again, who will develope the standards and who will teach it?





			
				JANES said:
			
		

> Everybody sure does a good job of letting everybody else know how smart they think they are.....





			
				JANES said:
			
		

> Good thing you Canadianized it, I don't speak American.  .....





			
				JANES said:
			
		

> Seems this thread has gone dead,
> kinda like the topic in the CF - no implimentation, no standardization, everyone teaching their own version.  Brass doesnt know what or how to address it, so they ignore it.  Seems like TCCC is a swear word to cbt arms cmdrs.  First Aid all the way!!!!  DCDS directive!!!  No staffing, no money no time, no subject matter experts.  To proud to look south for advice?  Gonna bite the CF in the bum.  Hows that First Aid workin out for ya?





			
				JANES said:
			
		

> You are so stuck in the hospital.  .....  Thats what they're using, so go tell Butler your concerns, his address is Surgeon General, USSOFCOM.  I don't make this stuff up.





			
				JANES said:
			
		

> Sounds like a personal problems.  .....





			
				JANES said:
			
		

> You know, I dont take kindly to threats.  I simply say things the way I see them.  I also provide a lot of good information that some people must feel threatened by.  I assure you, I don't make anything up and only post facts.  As for my blank profile, I believe it keeps people honest.  It prevents bullying and brown nosing.  Regardless if I'm a 12 year old kid or a trauma surgeon, you can take my posts or leave them.  ....  By turning me off of this forum, you will loose a valuable information asset.  So for now, I will sit back and watch from a distance.  Good bye!


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## JANES (15 Apr 2006)

Seems I have to reply in here as DS is posting in a locked thread and I dont have that luxery.

I'd have to say thats all those statments are taken out of context.  Some of it was a devils advocate approach.  Why did you lock it?  And then why would you post in it after it is locked?  One would almost think you are afraid of replys to your posts!  Or afraid of public opinion.


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## George Wallace (15 Apr 2006)

I don't know?  It seems to me that you have been asked questions and have chosen to ignore them.  You have made some very antagonistic statements and claims and when someone questions you, you've become extremely defensive or retreated from the forums for days.  It seems like you have a very thin skin in the debating circles and a very high esteem for your own abilities and knowledge, pumping up you ego at every chance you can take.  This topic is an example of 'some poor little kid going off to his corner to sulk.'  Seems like you are a borderline Troll to me.  If your claims on these forums are anyway flawed, they could have damaging effects on soldiers lives and wellbeing.  If you can't take the heat from Medics and Medical Staff, and as you have no profile, I guess you don't have any leg to stand on.


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## the 48th regulator (15 Apr 2006)

> You're digging for something you will never find.  All my intension was, was to, in your words "help the average soldier".   "goad us DS into proving a point" was an issue that was fabricated by DS.  Spiderman you are definitely not!



We shall see.  I have been right before.

dileas

tess


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## the 48th regulator (15 Apr 2006)

And once again I will say,



> You're digging for something you will never find.  All my intension was, was to, in your words "help the average soldier".   "goad us DS into proving a point" was an issue that was fabricated by DS.  Spiderman you are definitely not!



We shall see.  I have been right before.

dileas

tess


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## JANES (15 Apr 2006)

And probably never wrong!


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## Centurian1985 (15 Apr 2006)

Getting back to the point, I am intrigued by what the current policy is for tourniquets:

Formerly, the only people who were legally allowed to apply a tourniquet (wait wait, dont get mad yet) was, as of 2002, CF doctors, CF medics,and St John First Aid qualified instructors.  The last group was because St. John First Aid did not want to take responsibility for anyone in the armed forces using their medical techniques who incorrectly applied a tourniquet.  (They did not recognize the need for field-expedient medical aid techniques)

I bring this up because on one refresher mine-training course I took in 2001 some older ranks verily snottily claimed that no one was allowed to apply a tourniquet to another CF member, upon which I informed him of his incorrect information (thus leading to more snottiness, but I rant on...).  My point is, are our guys in the field now allowed to apply tourniquets to injured comrades without some rear area pencil-pusher saying "hey, youre not allowed to do that you know, I could have you charged!".  In other words, has it finally gotten through that this is a required training need and a battlefield requirement regardles of St. Johns?


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## Armymedic (16 Apr 2006)

Oh how times have changed...Charge me for saving the guys life because I used a tourniquet? You go ahead and try.

I am not sure if there is a CF policy per say. I can safely say though that there was no official policy against using a tourniquet, except that it was discouraged by St Johns Ambulance FA tng because of the loss of limb issue. In the case of losing life vs not using TK, common sense says TK every time.

Also Standard FA is a civilian oriented course. TK have always had relevence in military medicine (severe wounds, long transport times, etc). That is why a proper Mil FA course still taught about TK, just told you to use it as a very last resort, as you would/could cause the person to lose the limb.

As for someone properly applying a TK...we have a case already. I do not think he will get in any trouble for saving the medic's life.

There are no absolutes without reason in medicine. If someone tells you must do X, or can not do X, without a reason beyond "thats the way the book says"...then ignore them. Everything we do has a reason. And if you read through this thread reasons for doing and not doing things change all the time.

So, in a nut shell:
If you are in uniform and someone is injured and bleeding to the point where the dressing is soaked through with blood, apply a TK as tight as you can, no closer then 1 handwidth above the wound. Make a T on thier forehead and get / go to medical care as fast as you can.


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## Centurian1985 (16 Apr 2006)

That part of why I asked, because it apparently WAS an official CF policy. I was informed of this first in 1996 by the man who at that tiem was head of military St. Johns training for BC.  It was the first I'd heard of it.  As a qualified instructor i was forbiden to teach application of tourniquets and was to onofmr students that they were not allowed to aplplya toruniquet.  However, after sveral incidents of life-threatening injuries in Bosnia I though a silly thing like that would have been eliminated, but no, again in 2001 senior officers were still saying it was against CF policies (in other words it wasnt a queen's reg, but it was a policy that was enforceable).  

I think such a ruling is ridiculous and as of 2005 I know the policy has still not been rescinded in domestic operations.  So Im still wondering, are our boys still being told not to and then the policy-makers turn a blind eye? This does not solve the problem!


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## Armymedic (16 Apr 2006)

Let me rephrase..I am not aware of any official CFMG policy against the use of tourniquets, nor am I aware of any official CF policy IRT the use or nonuse of tourniquets.
I believe that was a St Johns ambulance policy to not teach it, not a military one. As FAIs, they would have to follow the guidelines set down by the regulating agency. I remember having to teach avoiding using TK when we instructed predeployment FA tng, but I do not recall ever hearing it was a CF policy.

I am certain (as I just showed the MND how tourniquets are taught and used) that currently there would be no problem with the proper use of a TK in military medicine, esp in an operational environment like Afghanistan.


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## Centurian1985 (16 Apr 2006)

Gotcha, thats what I was trying to figure out... if you show the MND thats pretty much a 'blessing through precedent'.


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## the 48th regulator (16 Apr 2006)

JANES said:
			
		

> And probably never wrong!



Yep,

You are finally learning....or you will...

dileas

tess


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## medicineman (16 Apr 2006)

Illegal to teach tourniquets??!!  I`ve been an instructor since 1992 and a FAIT for 3 years and have never seen hide nor hair of anything in the militray first aid manual about it being something that is not allowed to be taught.  Nor have I seen any regulations prohibiting there use in the military.  They were however always taught as a last resort - some people wouldn`t teach them because they thought that, since it was a last resort, they didn`t need to be taught.  In fact, I used to teach them as a first resort when dealing with mass cas situations as a quick fix for a bad bleed when there are other casualties around that need tending to.

Whoever told you it was categorically illegal was smoking something that should be shared with the rest of us so that we`re on the same wave length.

MM


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## jmackenzie_15 (16 Apr 2006)

medicineman said:
			
		

> Illegal to teach tourniquets??!!  I`ve been an instructor since 1992 and a FAIT for 3 years and have never seen hide nor hair of anything in the militray first aid manual about it being something that is not allowed to be taught.  Nor have I seen any regulations prohibiting there use in the military.  They were however always taught as a last resort - some people wouldn`t teach them because they thought that, since it was a last resort, they didn`t need to be taught.  In fact, I used to teach them as a first resort when dealing with mass cas situations as a quick fix for a bad bleed when there are other casualties around that need tending to.
> 
> Whoever told you it was categorically illegal was smoking something that should be shared with the rest of us so that we`re on the same wave length.
> 
> MM



When a tourniquet is "properly" applied, (im not positive anymore on how that is anyway) is it most times that you will lose the limb? Or am I under the wrong impression.... I always thought if you had to apply a tourniquet you had like a 90% chance of losing the limb.


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## medicineman (16 Apr 2006)

If the TK is left on too long and no reperfusion has been attempted, it`s a probability.  However, they are often left on in surgery for some time without untoward effects to keep surgical fields clear of blood.  The general rule of thumb is longer than 6 hours, you`ll end up losing tissue below the site.

MM


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## Armymedic (16 Apr 2006)

Let me put some perspective on the loss of limb thoughts that prevent the use of TKs.

When you apply a tourniquet it is to save life. People who bleed (as little as 1 L) go into hypovolemic or hemorrhagic shock and *DIE* if the bleeding is not stopped. It takes 5-10 mins for clotting with direct pressure. The Femoral Artery in your upper leg bleeds out at 1 L/min, the Brachial Artery in your upper arm, .75 L/min. You have an average of 5L of blood in your body...do the math.

Stop Bleeding. Prevent Shock. Keep your buddy alive.

Would you like have your buddy alive and be able to kick your ass with his one good leg, or would you rather go to his funeral?

Think about it.


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## Franko (16 Apr 2006)

Well said Ash....straight and to the point as always.

Thanks for keeping this thread on topic.    

Regards


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## kj_gully (17 Apr 2006)

Let's not forget who started this thread, one of the best current threads in the whole forum, and maybe put up with a little to get a lot, instead of being so...petty is a bit much ,but keeps coming to mind... thanks all for the posts to now, although I could do without most of pg 3


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## Armymedic (17 Apr 2006)

Yep.


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