Having a Tourniquet (TQ) in your gear but not knowing how to use it is both pointless and dangerous. The only positive thing you can do in that scenario is hand your TQ over to someone like me (and soon you) to put it on properly. In the military we call those people LTC (Liability to Command). You don’t want to be a LTC.
All images and tips will assume you are using a NAR Combat Application TQ (CAT). If you don’t have one get one! Check out my review of all available TQs LINK
Sometimes tourniquets (TQ) don’t work. Sometimes you could apply it to the optimum place with the optimum technique and still it won’t work. The rest of this article assumes you have put your TQ on correct first time.
I know you thought it was your last most definitive tool you had in you tool box to stop bleeding. Well that is true but it is not the last thing you can do…
Why didn’t it work?
To know what to do now you must first know why the TQ didn’t work. So….how does a TQ stop bleeding?
Simply, all a TQ does is provide pressure to the blood vessels distal (above) to the site of injury. However at no point does the TQ actually directly contact the artery nor does it compress it from both directions.
So how does it work then…?
Well the best anatomical advantage we have is that all major blood vessels run along the inside of long bones (In your legs the femur. In your arm the humerus). When I say run along I mean that in the most literal sense. The vessels are also generally surrounded by a large muscle mass (In the leg the thigh. In the arm the bicep). The TQ uses both of these facts to stop bleeding. A properly applied TQ compresses the large muscle groups against the blood vessel which in turn is pressed against the hard surface of the long bone.
This is why you will have less success with your TQ on the fore arm or lower leg. The fore arm and lower leg have two bones running parallel with the blood vessel protected inside. That makes it incredibly hard to compress the muscle groups onto the artery and then onto a long bone. In reality you just end up squeezing the two bones together and never truly effecting the artery.
So what can we do…?
Add a second or third TQ
Well the obvious choice is to add a second or third TQ right? Yes, right but why?
In the last 16 years of modern combat a lot of study has been done around the use of TQs in the combat setting. Interestingly 17% of all lower limb massive bleeds were stopped by a single TQ. So what does that tell us? We will most likely need a second TQ regardless of how well we put the first on. In the same study it continues on to say that massive bleeding in the lower leg was only stopped by double TQs ~80% of the time. So that tells us? We may need x2 TQs and something else 20% of the time….that’s a lot of the time!
So what does adding a second TQ do anatomically?
We know that one TQ compresses the muscle against the artery which in turn pushes against the flat, hard surface of the long bone. If that TQ doesn’t provide enough compression to overcome the Blood Pressure (BP), the bleeding will continue. However it will do something. It will reduce the local BP on the proximal (lower) side of the TQ. A second TQ would only have to overcome this local blood pressure to stop the bleeding. It’s like adding a sand trap before the tire wall. The sand will slow the car and the tire wall will stop it.
So who of you only carries one TQ? I get that they are expensive but so is a funeral. If you are looking to add to your Individual First Aid Kit (IFAK) I always recommend these TQs LINK
Packing the wound
Right so now both your TQs haven’t worked or you only had one or whatever…we find ourselves having to get a bit more direct, and I mean direct.
Packing a wound has been twisted in movies. From putting dirt in the wound (Lone Survivor) to using Tampons (She’s the Man). That’s just not true. I want to get across one thing, Packing a wound is not glamourous. It is physically demanding, extremely precise and incredibly aggressive. It is not like a magician hiding a ribbon in his hand but more like getting the last Pringles out of the can when you haven’t eaten in weeks.
Firstly, we need some packing gauze. I recommend this stuff LINK.
Secondly, we need to understand what we are trying to achieve. There is no point giving a step by step diagram of how to do it. Every wound is a different shape and has different variables. If you know concepts you will be able to pack any wound. For a more comprehensive guide to Packing go here.
- Do a thorough search for the site of bleeding, both visually and by feel. Scoop blood away or get your hands in the wound. I recommend both.
- You are not just filling a hole with stuff. You are finding the exact location of bleeding and packing pressure against it
- Once your finger has found the site of bleeding, never remove it.
- Pack as hard and as tight as you can
Indirect Pressure
Multiple TQs haven’t worked and now the packing has failed for whatever reason. I would start calling the Padre over….but not for why you think, we don’t need the grace of God yet. Generally the Padre is the most sedentary, therefore heaviest soldier around and we are going to need his weight for this next move.
Indirect pressure, in my mind this is underrated or I guess more specifically taught wrong. It is taught to be used at the wrong time and in the wrong way. For me indirect pressure is that last ditch effort to control bleeding and it works often. I am going to list the cons of indirect pressure which is a weird way to sell the idea to you I know. All you need to know for the Pro side is that, if done correctly it is the best way (besides surgery) to control a massive bleed.
So why don’t we do it all the time before TQs and Packing (cons):
- It is hard physically…you have to be strong or heavy to keep good indirect pressure.
- It is hard technically…if your knee is in the wrong place at all for a second the bleed will restart and your clot formation will blow
- It is painful…A heavy man kneeling in your grown sucks, especially for as long as it takes to get to surgery. If the casualty moves at all the pressure is lost.
- It is a manpower drain…It takes a whole first responder out of the picture. This becomes their sole purpose in life. Maintain that pressure. Make sure you put the least experienced person on this role. If it’s just you, well good luck