Tourniquets have returned to favor after saving lives in Iraq and Afghanistan:
The mass use of Improvised Explosive Devices (IED) by enemy fighters, and the use of body armor by US troops, meant a wounding pattern which primarily affected the extremities. This is where treatment with a tourniquet is the ideal solution, and why the numbers backing the use of tourniquets are so high.
The wounding patterns in active shooter incidents (ASI) don’t lend themselves to tourniquets:
The Profile of Wounding in Civilian Public Mass Shooting Fatalities is a study published in the Journal of Trauma and Acute Care Surgery on February 16, 2016.
The study examines 371 wounds from a total number of 139 fatal casualties of 12 separate ASI’s.
Each victim had an average of 2.7 gunshot wounds (GSW) and,
“Overall, 58% of victims had gunshots to the head and chest, and only 20% had extremity wounds. The probable site of fatal wounding was the head or chest in 77% of cases. Only 7% of victims had potentially survivable wounds. The most common site of potentially survivable injury was the chest (89%). No head injury was potentially survivable. There were no deaths due to exsanguination (severe loss of blood) from an extremity (arms and legs).”
The most common preventable way to die from penetrating trauma to the chest is by Tension Pneumothorax:
Tension Pneumothorax develops after a bullet (for our purposes) punctures a lung, allowing air to enter from the wound into the chest cavity, but unable to escape. Over time, air builds up pressure to the point where it begins to restrict blood flow of the heart and other nearby vital arteries.
This can cause what is known as Obstructive Shock. The heart and arteries are unable to function properly due to being compressed or obstructed, in a similar fashion to how a tourniquet works. Additionally, pressure is placed on the injured lung making it unable to stay inflated or function.
[...]
The solution is more chest seals.
A chest seal is what is called an “occlusive dressing.” ‘To occlude’ means ‘to stop, close up or obstruct an opening.’ It refers to any non-porous material (plastic) affixed in place to prevent more air from entering the chest cavity.
While there are of course many professionally manufactured chest seals designed to function as required, occlusive dressings can be made from just about any plastic packaging or bag, and tape.
[...]
After discovering a penetrating wound on the trunk of a patient, “From belly button to collar bone,” the giver of first aid immediately clamps a hand over the wound site to prevent additional air from entering into the chest cavity.
Using their teeth and other hand, or instructing a bystander to do it, the first responder removes the chest seal packaging. The first responder then tells the patient to take a deep breath and exhale. At the end of the exhalation, any blood present on the skin is wiped away and then the sticky side of the chest seal is applied over the wound, ensuring adhesion.
Once the exit wound (if any) is found, the steps are repeated. (Always search for an exit wound. It won’t do your patient any good to have only one hole patched.)
The patient is then placed in the sitting position, or on their affected side (recovery position).
[...]
Many trauma, or “blow out” bags, include a needle decompression kit for treating patients with Tension Pneumothorax. This is only necessary after the condition has worsened to the point where it has become life-threatening. The timely and correct application of a chest seal could prevent the need for needle decompression.
There’s a mistake here, surely; you’re only looking at fatalities, it appears, not total wounded. Yes, compared to all wounded the fatalities are going to have;
a) More wounds
b) More central torso wounds.
But you can’t from that infer that tourniquets aren’t useful for all those unobserved wounded cases with femoral injuries….
Now, it’s true that mass-shooter incidents are closer to a 1:1 Killed/Wounded ratio than the modern battlefield at 1:4 or whatever (shooter has closer range and ability to coup de grace), but there’s still a lot of wounded out there. This study is a crushingly obvious case of censored data.
Cleverness could work with this data, partially.
Take the multiple injury cases only: take away the single lethal head or torso wound that got them into your data set. Look at the distribution of the remaining wounds.
Not perfect, but a better estimator…
I think it’s interesting that the tourniquet is getting a second shot at things, considering that throughout my early years and the first half or so of my military career, the tourniquet was universally despised by all right-thinking medical authorities–It was only to be used as a last resort, and then reluctantly.
Part of the success of the things in recent combat comes from the prevalence of body armor–You’re seeing a lot more peripheral injuries vs. torso hits, so the tourniquet is much more dramatically visible and successful. It’s also an artifact of the generally younger male population they’re getting used on–You have the same injuries in an elderly out-of-shape sort of victim, and they’re not likely to survive. Young guy? No problem…
It is interesting to see how these things shift; time was, you’d fail the practical tests for first aid in the military if you went to a tourniquet right off; now, it’s quite the opposite. Evolving practice, I suppose, but it’s disturbing to recognize the faddishness and the sheer amount of error in the old ways… At least, from the perspective of today. Makes you wonder what’s going to be seen as stupid and fallacious in the coming years that we think is the absolute right way, today.
One of the big things I think has made a difference in combat survival rates for the wounded these days is the training of what the US Army refers to as “Combat Lifesavers”, along with the provision of medical supplies for them. Time was, you basically abandoned your wounded to the ministrations of the medics, and if they weren’t there, well… Too bad.
Now? PFC Snuffy had better get his ass in gear, and get his buddy stabilized before the medic can get to him, or there’s gonna be hell to pay. And, God help the poor bastard that’s squeamish about blood. He’s gonna be hating life…
Evolving standards, I suppose. One does wonder what the actual effect is on the pace of operations, and if perhaps that might result in more casualties than simply abandoning the wounded to self-care and fate. However, the costs to morale would need to be weighed in, with all that.
Which is more grist to the mill for my assertions that we simply do not know what the ever-loving hell is really going on in combat. On either side–We think we know, but we really don’t. Does it make more sense to sacrifice a few badly wounded men today, to keep up the optempo in order to defeat the enemy more quickly…?
These are the kinds of questions that essentially remain unknowable, so long as we don’t have good data to work from. It’s not just the weapons, folks–All of this applies and has influence. The whole question of how to make war is interwoven into all of this–You select for a caliber and cartridge that requires quick-and-dirty close-in assault, and you’d better have a package of medical support for the wounded built into your doctrine that takes that all into account, or any advantage you might gain in terms of lightweight weaponry is going to get pissed away when CPL Smith decides to slow or stop the attack in order to get his wounded (caused by that up-close-and-personal thing…) properly dealt with.
Every decision you make in this realm is influential, and you’d best be sure you understand what pushing in on the balloon here is going to do, over there…
This is what they called a sucking chest wound in 1966? Taught us in basic to prevent death by placing plastic over the wound first and then bandage.
Yep… Exactly what a sucking chest wound is. Today’s dressings include valves for letting the air out, and enable longer timespan before getting to an aid station and a real doctor.
Agree about body armour. I got to do some stats on this using Afghan data back in the day. Effects were entirely predictable:
a) Slight increase in WIA/KIA ratio.
b) Increase in survivability of thoracic hits (Duh! But also survivability of thoracic injuries as lethal hits turned into sub-lethal hits and sub-lethal hits turned into “ouch!”)
c) Increase in proportion of limb injuries and headshots in the treatment chain.
But Walter Reed has done some excellent stuff over the years on this but never seemed to publish in one piece.