Tag Archives: ITLS

Rescue Task Force Skill. Tourniquets: Where the science stands

DWK Fraser, CD, BA, PCP @DWKF
Views are my own, and do not represent my employers in any way.

If you asked any researcher to name some prehospital interventions that truly proved their worth during the recent conflicts in Iraq and Afghanistan they would, almost universally, include  tourniquets and TXA on their list.  Yet there is still, despite a huge volume of well documented research, widespread resistance and misinformation  about these two interventions.

During an EMA Licensing Exam I recently watched someone take a tourniquet off a complete amputation.   He looked at his watch, said “Ten minutes, time to loosen the tourniquet”, and proceeded to remove it from his patient.  Looking at me he asked “Is it bleeding again?” “Of course it’s bleeding again!” was my reply.

I looked at his instructor, and I was floored.  This is what the first aid groups are teaching people about tourniquets? Something very important has been lost in the knowledge translation.

Here are several published studies which look at tourniquet use in the modern context.

The first one we’ll look at was conducted at a US Army Combat Support Hospital (CSH) outside Baghdad over a 7 month period in 2006.  232 patients had 428 tourniquets applied on 309 injured limbs.  194 patients had tourniquets applied in the prehospital setting.  The remainder had them applied in the CSH.  “The 5 casualties indicated for tourniquets but had none used had a survival rate of 0% versus 87% for those casualties with tourniquets used.” The most common complication (less than 2% of patient) suffered a transient nerve palsy. Let me say that again.  Less than 2% of patients had complications, and the most common one was that their limb hurt or felt funny from the tourniquet compressing a nerve. And it went away.  There were no amputations associated with tourniquet use in this study.  

While this study isn’t without some problems, most glaringly the use of the quality & presence or absence of a radial pulse as the determinant of shock, it is very noteworthy that early tourniquet placement was associated with a better outcome and such a low complication rate makes it THE prehospital intervention for hemorrhage that can be tourniqueted.

LEO Applied TK

Law Enforcement Applied Tk to upper extremity due to arterial bleeding post stabbing. This required an additional full rotation of torsion bar to achieve hemorrhage control by EMS

The second is a follow up to the first, and when we add another 267 patients we get virtually identical data: an overall 87% survival rate, higher in those who received tourniquets early and lower in those who didn’t receive one at all or until the CSH, with a <2% complication rate and no amputations.

This is not to say that any intervention is without risk.  The use of improvised tourniquets and prolonged application times are associated with worse outcomes, and there are some documented cases, with improvised tourniquets, that DID result in amputations after long (17 hour) application.

It is critical that medical providers train with their tourniquet of choice under all potential conditions.  Application effectiveness does not improve under real world conditions! Lower extremity application continues to have the highest failure rate, likely due to the higher occlusion pressures needed (300mmHg!).

The inherent efficacy of tourniquet products contributes to high failure rates under combat conditions, pointing to the need for superior tourniquets and for rigorous deployment preparation training

What is the objective to loosening a tourniquet? To prevent loss of limb? To decrease complications like transient nerve palsies?  If those are your objectives, relax, the tourniquets have this one. Put it on, and don’t take it off.  We’ve got the EMS evidence to back this up.

Tac Tool Tuesday! Junctional Compression!

The AAT is now the AAJT! This device has been shown to reduce hemorrhage in junctional trauma with lower tissue pressures than other devices.

AAJT

Exciting emerging applications for this device include it’s prospective use in pelvic fractures! Rather than worry about stopping multiple fracture sources of blood loss, just stop blood flow to the affected area altogether until timely surgical repair or embolization.

Here’s a link to the abstract from the research at Madigan Army Medical Centre

Tactical & Medical Decision Making

Not all tactical tools are tangible, some are cognitive.

This runs to 20 pages including bibliography, but it describes several essential skills that any emergency medical provider needs to have.

The OODA loop is something that we use in the classroom in order to give students a model of constant reevaluation of the patient condition, the conditions they’re operating under, the courses of action open to them, and the most efficient treatment, movement, or evac options.

To truly master Emergency Medicine, much less the tactical environment, you need to understand the OODA Loop. Yours should be tight and fast. But sometimes you need a far quicker response, and only training and simulation can build instant RPD through what this author calls tactical decision games (TDG) or decision making exercises (DME).

This is the core of current EMS education.

Simulation creates an experiential learning environment where the students can develop that mental database of Action : Response for everything from snoring respiration : jaw thrust or massive extremity bleed : tourniquet intuitively, not just academically. Where they can find themselves suddenly on the ground applying a tourniquet to their own leg intuitively knowing that placing the tourniquet chasis This way instead of that way will give them a better initial pull on the strap.  The same repetition that has someone doing a tap, rack, and engage on one stoppage but a reload just from the feel of the recoil.  That’s recognition primed decision making.

Klein says “…Their experience let them identify a reasonable reaction as the first one they
considered, so they did not bother thinking of others. They were not being perverse. They
were being skillful. We now call this strategy recognition-primed decision making.”2

Always with the paperwork, or get a textbook early if you’re taking ITLS!

We’ve wrapped our NSR ITLS Provider Course, and it’s all over even the paperwork.  ITLS is a great organization to work with, and they try hard to make the administration pretty seamless.

I sent it off yesterday morning, got a reply yesterday afternoon, and someone at Int’l is hard at work in the CMS getting our cards ready for printing a distribution to our friends at North Shore Rescue.

There’s the course roster, which we try hard to get done before hand.  The practical evaluation results, the student info forms, and the written “celebration of learning” answer forms all get scanned, and all the data goes into ITLS Course Management System.  We also keep copies of every course feedback form in our database; it’s nice to make sure we’re not making the same mistake three or four times!

The number one comment that we get is some variation on “I wish I’d gotten the textbook sooner!” and this has been consistent throughout the 15 years I’ve been teaching ITLS.  There’s a huge amount of info crammed into a 2-day provider course, and the more thoroughly you do a pre-read, the better your experience in the course will be!

Yesterday was a good day

Devon, Ian and I spent the day with 10 NSR members working our way through day one of ITLS.  We covered the ITLS Primary Survey and Ongoing Exam. Airway management, hemorrhage control, chest and abdominal injuries.

One of the best things we do in ITLS is almost insidious.  We get people talking the same language.  We take students with qualifications ranging from Wilderness First Aid through to EMR (in this case) who have been trained by the Red Cross, St John’s, JIBC, AET and other training providers, and we get them all using the same terminology.  This means that when teams are communicating and collaborating on scene, the transfer of information is fast, efficient, and leads to shorter scene times and better care.

North Shore Rescue 2 TK

We also try to introduce new equipment, procedures, and techniques to our classes. Comfortable with a CAT? Let’s look at a SOFT too.  Use the SAM Pelvic Sling? Have you looked at the TPOD for your agency?  Asherman Seals work, but how about Hyfin?

We don’t expect our clientele to stay on top of the latest science behind EMS.  That’s what we do.

Our second NSR course!

Tomorrow we start our second contract course, another ITLS for North Shore Rescue.  We’d originally planned this to be our ITLS Site Visit for sign-off as a ITLS Training Centre, but due to scheduling conflicts we won’t be getting our visit done this time around.

Ian’s packing up a his jumpbags, AV kit, and airway mannequins. I’ve got a briefcase full of admin and paperwork, and I’m answering questions from students already. Devon’s looking over his material.

Faculty at the CF SAR School in Comox, BC practice ITLS Rapid Trauma Surveys.

Faculty at the CF SAR School in Comox, BC practice ITLS Rapid Trauma Surveys.

Working with SAR groups is always a bit different than working with EMS or other health care providers.  Medicine is only a small part of the mission, whether you’re a CF SARTECH or a community volunteer, and amidst all of the other critical skills that they work hard to keep sharp, the more difficult it can be to keep the finer nuances of patient care.

Regular review of the material is great, but team based training helps to ensure that the collective knowledge of the team is maintained.  Not every team member needs to be an expert prehospital care provider; every team member does need to know what the goals and fundamentals of care are. That’s what makes a team efficient and effective, that they’re all working towards the same greater goal.

One of the great things about ITLS is it’s focus on a team based approach to caring for the HMMVW Amb on the flight line, KAFinjured.  Concurrent activity and clearly defined and communicated goals keeps scene times to a minimum and allows for superb care even under very austere conditions.