I was having a good day, during a bad week. Then Kelly Grayson – everybody’s favorite Ambulance Driver – directed me to a discussion of tourniquets.
We believe all sorts of scare stories about lawyers.
Why?
Ignorance and repetition. Too often, these are our teachers in EMS.
The discussion was based on a good question and does include some good comments, but too many are suggesting that use of tourniquets carries some sort of greater legal liability than other EMS care.
That is nonsense.
it’s called Civil Liability… not an issue in the Armed Forces ( thankfully ) and thank you for your service !!!!!!!
As in – Thank you for your service, but don’t get an extremity injury with severe bleeding when I am on duty?
A tourniquet, when indicated, is good patient care.
Withholding a tourniquet, when a tourniquet is indicated, is bad patient care.
Not knowing how and when to use our equipment is bad patient care.
Bad patient care IS a liability.
We can be sued for anything. Most nonsense will probably not be accepted by a plaintiff’s lawyer, or will probably be thrown out by the judge. For the rest, the best defense should be that we provided the best care we could.
Gene Gandy has stated this many times. He is both a lawyer and a paramedic. Skip Kirkwood has expressed similar sentiments. He is also both a lawyer and a paramedic.
Should we learn from wannabe lawyers on FaceBook, or should we learn from real lawyers?
Some more of the FaceBook advice –
you can’t get sued in the military. civilians love to earn a buck on our behalf, even if it was life threatening.
One word…lawyers. aside from civi medic I’m a Red Cross pro rescue 1 aid n cpr instructor. Lawyers and arm chair docs dictate civilian EMS. Military has no such hinderance. Lots more operational liberty in the military where civi ambulance chasers have no power
I have to agree with the above poster. Military medic is totally different then city ems. Totally different protocols. Seems to me city ems has to constantly walk on egg shells with their patient’s because people are lying and saying thing’s that never happened to try and make a quick buck. I think tourniquets are better then applying pressure but sad to say civilians won’t see it that way. Civilian world will never be like military world and that’s that.
Using a TQ may result in the loss of an arm or leg.
According to the people commenting, this patient’s amputations are the result of the tourniquets (TQs).
They are not pretty prepackaged tourniquets, but what matters is whether they work.
The tourniquets are the problem?
No.
Incorrectly Using a TQ may result in the loss of an arm or leg.
Tourniquets do not sneak up and steal our patients’ limbs. We generally have to screw up in a big way.
I treated a patient with a BTK amputation and did not use a TQ. As a result, the team at the University of Cincinnati Trauma Center Hospital was able to reattach the patients leg.
Would the outcome have been worse if a tourniquet had been used?
Based on what?
It seems as if this person does not understand that tourniquets are not amputations. They aren’t even spelled the same way.
Competent tourniquet use does NOT cause amputations.
Civilians aren’t trained for war zone injuries, military are……….
Civilians are not trained to treat for shootings, stabbings, or explosions?
What about farming accidents? Farming equipment can be just as nasty as any military weapon.
Risk management. The military doesn’t have as much risk of being sued if used improperly. So, in this case, the safest bet is to not use it.
What?
I am not competent, so I will let my patient die. That will prevent me from being sued!
No.
That might even encourage an aggressive attorney to try to bring manslaughter charges against you.
Is that negligence any more responsible than driving while extremely drunk and on bath salts and texting about it at the same time?
because tactical medicine is different than civilian medicine. Tactical focuses mote on saving lives in a fast environment and there’s no time to try to save the limb. civilian world = save life, and hopefully limb also. if there’s time to stop bleeding with an alternate method then why TQ and cause loss of a limb? makes sense huh? thanks. – civilian paramedic!
For all those tunnel visioned by “MAJOR INJURIES/BLEEDS” and say TQ first…i have personally seen an amputated leg, above knee, and even with femoral being severed…direct pressure and pressure point stopped bleeding. no TQ needed. theres a reason for the difference in medicine tactical vs civilian ….learn them, and use common sense to understand why, before criticizing!
Another one mistakenly claiming that tourniquet equals amputation and that because he once saw bad bleeding controlled without a tourniquet, that tourniquets are unnecessary and very bad. The back to back comments are by the same person.
This guy needs to provide evidence to support his criticism of tourniquets.
Making irrelevant comments is not evidence.
His confused attempt at logic does not demonstrate that tourniquets are a bad idea.
Litigation is the way “I” rationalised between being a PAARNG Medic and an EMT.
Wow!
He won’t become a medic, because he is afraid of being sued?
Don’t worry. Basic EMTs get sued, too.
when theyre used people tend to loose limbs. In the civilian world that can mean ones lively hood.
No evidence, just another uninformed opinion.
We see these comments enough and some of us may start to believe that these people actually know what they are writing about.
They do not know what they are writing about.
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Skip Kirkwood writes –
This is old news. The civilian world has been teaching and using tourniquets for years. Litigation has nothing to do with it – try to find any case law involving the use of the big T – you won’t find any.
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And there is this excellent comment –
As a former Army medic, I can’t help but agree. I always said it’s easier to replace air than blood…priorities…and ensured everyone had three CAT’s on them at once.
The alphabet has A before B and B before C, but our patients will die (and stay dead) if we let them bleed out while we are messing with A or B.
We can deal with Airway and Breathing after we control major bleeding. Using a tourniquet makes it more likely that we will be able to deal with the bleeding and the airway/breathing problems and save a life that would not be saved without a tourniquet.
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Practical use of emergency tourniquets to stop bleeding in major limb trauma.
Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB.
J Trauma. 2008 Feb;64(2 Suppl):S38-49; discussion S49-50.
PMID: 18376170 [PubMed – indexed for MEDLINE]
CONCLUSIONS:
Morbidity risk was low, and there was a positive risk benefit ratio in light of the survival benefit. No limbs were lost because of tourniquet use, and tourniquet duration was not associated with increased morbidity. Education for early military tourniquet use should continue.
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Minor morbidity with emergency tourniquet use to stop bleeding in severe limb trauma: research, history, and reconciling advocates and abolitionists.
Kragh JF Jr, O’Neill ML, Walters TJ, Jones JA, Baer DG, Gershman LK, Wade CE, Holcomb JB.
Mil Med. 2011 Jul;176(7):817-23.
PMID: 22128725 [PubMed – indexed for MEDLINE]
RESULTS:
After comparable methods were verified for both the first and current studies, we report the results of 499 patients who had 862 tourniquets applied on 651 limbs. The clinical results were consistent. No limbs were lost from tourniquet use.CONCLUSION:
We found that morbidity was minor in light of major survival benefits consistent with prior reports.
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Complications associated with prolonged tourniquet application on the battlefield.
Dayan L, Zinmann C, Stahl S, Norman D.
Mil Med. 2008 Jan;173(1):63-6.
PMID: 18251333 [PubMed – indexed for MEDLINE]
The use of a tourniquet to control bleeding is a necessity in both surgical and prehospital settings. Tourniquet application, if performed properly, can be a lifesaving procedure, particularly in a traumatic setting such as the battlefield. A tourniquet is easily applied and requires the use of a relatively uncomplicated piece of equipment. However, improper or prolonged placement of a tourniquet because of poor medical training can lead to serious injuries, such as nerve paralysis and limb ischemia. Here we present five case reports of improper tourniquet applications on the battlefield that resulted in nerve damage. We conclude that there is a need for improved training among medical personnel in the use of tourniquets,
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Tourniquets are not that complicated, but they do require that we know how to use them and that we know how to reassess our patients.
If we don’t know how to use our equipment and we do not know how to reassess our patients, we are not safe with anything.
.
As an EMS Coordinator who is trying to get purpose–made tourniquets put in my local EMS protocols (PD can use them for self-rescue, approved by our medical director, but not yet EMTs and Medics) I shudder at the arguments presented on that facebook page.
While the discussion here focuses on tourniquets, I think that the underlying issue is the lack of critical thinking skills holding back our profession. While we may not always agree, I will always applaud you (and Kelly’s) promotion of critical thinking for Emergency Medical Services.
It is extremely unfortunate that in an age where a search of Google Scholar or the Cochrane Reviews will produce years worth of scientific research in about 0.02 seconds, that people who are motivated enough to publicly express their opinions don’t bother to perform even a cursory review of the research and evidence. We may not all come to the same conclusions after evaluating that research, but at least we won’t be throwing around the old “I was on a call one time and this thing happened.”
Likewise a bit of informed, expert opinion (as in actual trained lawyer) goes a long way over “They” say you can’t and “You might get sued”.
A little bit of critical thinking may not eliminate the arguments, but at least it would raise their level to a degree that we can be proud to call ourselves a profession of pre-hospital medicine.
If your medical director is hesitant to step out of the dark ages and allow you to use commercial tourniquets, a $5 carabiner and 50 cent 2″ split key ring can secure a cravat in nearly as little time as a commercial TQ. Slip the keyring over the cravat, and tie it around the extremity with a simple overhand knot. Tie in the carabiner with another overhand knot. Use the carabiner as your windlass. Once proper tension is applied, slip the key ring through the gate on the carabiner and it will lock it into place.
No sense letting people bleed while your EMT’s break their pens trying to fruitlessly improvise a windlass or half-ass it with a leaky BP cuff. Just pair a couple carabiner/keyrings with some cravats and show your guys how to whip up a TQ with them.
If you have any questions or require a demonstration, reply to this comment with your contact info and I’ll get in touch with you. Your patients shouldn’t have to suffer because your medical director isn’t up on his literature.
Marc,
Any chance you could post a youtube video for us all to see?
I’ll see if I can get on posted tonight. If not, tomorrow for sure.
https://www.youtube.com/watch?v=m4pUfV20o3s&feature=youtube_gdata_player
Here you go fellas. Shot this with my cameraphone at work so excuse the quality.
I was taking my time and talking through it, but as you can see it could be applied nearly as quick as a commercial tourniquet. It’s also nearly as idiot proof.
Excellent! Love it. I’m going to give it try at work tomorrow. I have a couple extra carabiners and a slipring on hand. Thanks for posting that… improvised solutions really get the brain moving.
Cool. If you have any questions just ask here.
For the record, Lamar’s leg still hasn’t required amputation following my reckless tourniquet application. It must be a miracle or something. 😉
Marc, that’s pretty slick.
If you’re willing, I’d like to feature that trick on my next month’s clinical tip on EMS1.com, with proper attribution to you, of course.
Shoot me an email if you’re interested.
email sent to your EMS1 address. I am all about having good tips like this disseminated to a wider audience. Let me know need me to do anything like write a blurb or something. If you want to post the video I’m planning on making a more rehearsed HD video of this shortly since this isn’t the first time I’ve been asked to demonstrate this technique,
Marc- I’m missing how the ring locks the “windlass” in place, maybe I’m just a bad spatial reasoner, but I can’t figure it out.
Thanks!
Larry Torrey does an excellent lecture on tourniquets. In it, he points out that much of the negative data comes from their use in the war.
The Civil War.
When are EMT’s going to stop just blindly accepting dogma and living in fear of a legal boogeyman that doesn’t exist?
I served in the Army from 1992 until 2005. I’m an EMT in a medium sized east coast city and a paramedic student. I think that the tourniquet myth that you discuss above originates from the early 20th century, or even earlier. Soldiers in WW1 and WW2 were thought to use the TQ to save their own lives, and the lives of their buddies. These were the days before helicopters and MEDEVAC. Transport times to definitive care behind the lines was long. Hours, sometimes days. Placement of of TQ on a limb was a life or death decision… There was no question that the soldier would lose the limb.
As late as 1992, when I went through Basic Training at Fort Knox, KY, I was taught that a TQ was only to be used if pressure dressings failed. The TQ was a last line of defense to control a hemorrhage. We were told to mark the patient on the forehead with a “T”, and note the time the TQ was placed. The “T” was an insurence policy that should the effected limb be covered be a blanket, the TQ patient would be identified during triage at the aid station and recieve care in the appropriate order. The Army has since updated the task of applying a tourniquet, and it is directed use is much more liberal. Experience in Iraq and Afghanistan have informed how soldiers are trained.
I have no issues using a TQ in the city. Our transport times are short, under 8 minutes usually. I do not have any real fear that a tourniquet would cause the loss of a limb in that short amount of time. I’m also confident that I know when and when not to use a tourniquet, having applied them in the desert and in the city.
I do not live (or work, or treat patients) in fear of being sued. I make sure I follow established protocols, SOG/SOPs, and other rules. I stay inside my scope of practice. That is my first, and best defense against litigation. My advice to others- trust your training and don’t listen to the “stationhouse lawyer”.
Fantastic post Rogue Medic. Keep up the good work.
As an EMT I use a tourniquet on nearly every patient that I encounter. It’s also referred to a BP cuff. On my patients I completely cut off circulation to one of their limbs. Sometimes multiple times and multiple limbs, even. To my knowledge, I’ve yet to have a patient lose a limb from this frequent use of the tourniquet.
Why? Because applying one for 0-5 minutes doesn’t appear to cause limb loss. I’ve read/heard somewhere (stuff-I-remembered-from-the-Internet-based medicine) that you don’t generally seem to have permanent limb damage until after 2 hours.
We know that severe uncontrolled bleeding will cause death. We know that tourniquets are a way of controlling certain types of severe bleeding. The goal isn’t to leave a tourniquet on a patient permanently – it’s to get them to an advanced medical facility (say, one with vascular surgeons) where more advanced treatment can be provided. In the ideal case, if a tourniquet is used, it helps keep the patient alive until they get to the hospital where, because he’s in much better condition, can now undergo emergency surgery to repair the damaged arteries, restore blood flow and save the limb (and life). This is in contrast to letting the patient bleed out all over your ambulance, which is both a lot more paperwork and requires a lot more scrubbing. Understanding what we’re doing and why we’re doing it is a much better way of practicing medicine than “I heard a boy scout once screwed this up somewhere and Bad Things happened”.