First Aid - My recent "Quick Clot" re-evaluation.

[Oklahoma]

Okay. Here is the situation.

Four years ago my first daughter was born. This spurred me to evaluate my home, vehicle, work, and pack first aid capabilities.

In doing so, I upgraded to carrying several "Israeli Badages" (6" w/ sliding pad) along with "Quick Clot" blood coagulant in an effort to be all high speed low drag when or if it ever came to a major blood spilling injury.

My first aid training is limited to US Army combat life saver, basic Red Cross first aid / CPR (Infant to adult), and some additional bio hazard / blood born pathagen protection training.

Anyway, I have been carrying the "Quick Clot" stuff for 4 years now and while at work I was recently provided information from one of the local paramedics. He informed me that they (local ambulance service) had received information that "Quick Clot" was causing burns, and other complications such as post injury infections on patients. I believe these reports are from current military after action reports.

I had read in the past that "Quick Clot" did "Heat Up" but I did not know about any "Burns". The paramedic basically said the "Quick Clot" actually was cauterizing the blood vessels, thus stopping bleeding.

Once applied to a casualty, the pain from the "Quick Clot" is suppose to be very intense causing the patient to be un able to focus on self aid or any other task that may aid in the situation they are in.

So I conducted an experiment. I opened a package of "Quick Clot" and added "some" (1/4 cup ish) of water. The "Quick Clot" IMMEDIATLY began to pop and make noise and got VERY HOT. I would guess it reached 300 to 400 degrees within five seconds. I was only able to hold the package by its laminated edges. You could not hold the main portion of the package with your hands.

Needless to say, after demonstrating the same "experiment" to several friends and co workers, I have removed all "Quick Clot" from my first aid kits.

I could not imagine the result of putting that burining stuff on one of my girls.

I understand there is a "Cooler" version of "Quick Clot" on the market now. I recomend anyone carrying such a product conduct an evaluation of its "Burning" capabilities prior to shoving it on or in a major wound.

Its going to be tourniquets and Israeli Bandages for my worst case first aid kits.

What's in your first aid kit????????

[towheadedmule]

Dont forget an occulsive dressing for open pneumos (sucking chest wound). You need at least two, things that go in tend to come out. Bullets usually go completely thru.

My first aid also has IV supplies, but then again, i work with the stuff daily.

In most settings direct pressure and/or a pressure dressing work best. If you are really bad, what you need is a surgeon, not quick clot.

Russell

[docw]

unless you live on a farm or something, if your daughters injure themselves bad enough that good first aid won't stop the bleeding, then you have bigger problems. i've only ever used quick clot once and it wasn't because i couldn't stop the bleeding. it was because with all the rounds coming in i didn't take the time to do it. it did cause some burns but the pt didn't seem to mind all that much, after all we were dodging rounds. sometimes, i worry that people get these new wonder items and think that they replace good first aid. direct pressure, elevation, pressure bandage, pressure points, splinting, and so on should work on almost everything. as far as the infections, it's probably from the environment the injuries are happening in than the quick clot. hope this helps.

[Brotzie]

Sorry, I just can't ever endorse tourniquets as routine carry items. The ONLY time they're indicated is if someone is going to die if you don't employ one; the casualty WILL end up with massive necrosis distal from the application, huge metabolic toxin buildup in the same region and almost certainly will require amputation - as a result of the tourniquet even if not of the original trauma.

QuikClot burns, yes, (superficially, or 'first degree' in old money) but it is less traumatic overall than a tourniquet. It WILL stop the bleeding; it WILL NOT interact with blood flowing through uncompromised vessels near the injury - unlike a tourniquet which will just shut down everything. This means that far more tissue distal to the injury remains intact and viable.

In the case of a traumatic amputation, there's probably not much practical difference between the two treatments. If you're dealing with, say, a femoral artery wound, QuikClot may well save your leg. It's only intended for MAJOR wounds, and it's recognised as being a pretty last-ditch item - its own protocols say direct and indirect pressure first, before you even think of breaking the stuff out.

THM - absolutely, pack a couple of ACSs in your med kit. This is not something you want to try to improvise a dressing for on the spot.

[towheadedmule]

<div class="ubbcode-block"><div class="ubbcode-header">Originally Posted By: Brotzie</div><div class="ubbcode-body">
THM - absolutely, pack a couple of ACSs in your med kit. This is not something you want to try to improvise a dressing for on the spot. </div></div>


Unless your Ambulance was not stocked correctly by the materials people. Our rigs are pre stocked for us, and the bins are sealed. Supposedly this helps to turn the trucks around quicker. Last week I had a guy with a stab wound to his back that punctured the lung. Three of us on the truck could not find the ACS, turns out the wrong bin had been placed on the rig. I ended up making one. 4 Minute return to the hospital, and the "gentleman" lived.

Russell

[docw]

the ability to improvise is a must in ems whether civilian or military. the nature of the job is that sometimes, things go wrong, don't work, are missing and you don't have teh hosptial supply room to turn to. i've come up with missing or malfuntioning equipment in both arenas of the job and you have to make it work or your patients die or at best just get worse. at our service we stock our own rigs so can't blame anyone but ourselves.

[straps]

Quik-Clot is a great solution for TRAINED RESPONDERS in a position to treat GRAVELY WOUNDED INDIVIDUALS suffering from ARTERIAL BLEEDING who DON'T HAVE A TIME CERTAIN FOR ATLS/HOSPITAL CARE.

If you're a CAPITALIZED PERSON who helps CAPITALIZED PEOPLE with CAPITALIZED INJURIES then Quick Clot is a potentially useful tool, and has its place in the TCCC (or alternative cool life-saver/heart-breaker acronym) toolbox. Conversely...

Quik Clot has undergone refinement (based almost entirely on feedback from the field). The chance that Quik Clot is primarily (or even partially) responsible for infection is low; Iraq and Afghanistan have MUCH higher percentages of what I'll describe simply as "icky stuff" in the topsoil, introduced ballistically and traumatically, that has caused devastating infections in people treated with Quik Clot, HemCon or just good applications of fundamentals.

And if you're carrying an ACS, why not also carry a 14 GA needle for tension pneumothorax?

If you want to help, by all means help. As others have said, let your training (not your income, or even your desire to help) dictate your tools.

[Aimless]

I'm not a TRAINED PERSON /images/%%GRAEMLIN_URL%%/wink.gif but they did talk about this stuff in a couple of firearms classes I took. Actually it's kind of surprising for the amount of civilian classes I have attended how few addressed actually getting shot.

That quickclot stuff supposedly does a lot of damage to the surrounding flesh. I was told that the military is restricting it's use. Supposedly quickclot is "reformulating" it to make it "cooler" I also saw another quickclot product that is some kind of dressing with sea shells or something that promotes clotting and does not cause burning.

As far as tourniquets I have heard recommendations of having them, beats being dead and the danger of having it on long enough to lose a limb as a result of most shootings in the us is small because of the relatively fast response time of paramedics in most areas.

[Brotzie]

Is there any medical professional out there who would advocate use of a tourniquet in anything other than a last-ditch life-or-death situation?

Is there any published civilian first aid protocol which says 'use a tourniquet'?

Employing a tourniquet is functionally equivalent to inducing a crush injury ona limb. It doesn't take very long (minutes!) for metabolic toxins to build up distal of the tourniquet. If you then take that tourniquet off, these will flow back into the casualty's system and cause serious renal damage and greatly aggravate his undoubtedly already-bad shock.

Couldn't agree more with Straps' post. Work to your training levels. If you don't fully understand the implications of employing a tourniquet then don't use one.

If the paramedics can get there that fast, then direct pressure is indicated - as indeed it always is for a wound. In those circumstances, your most likely outcome as the person giving aid is that you'll have doctors etc. testifying that the tourniquet was NOT necessary for the preservation of life and was the cause of them needing to partially amputate. That testimony will be against you, in the lawsuit brought by the guy in the wheelchair you put him in. Hope your third-party insurance is good.

[mb]

"One of the differences in the new first aid training from the former training is that there is an emphasis on using the tourniquet to stop bleeding when dealing with amputations or partial amputations."

http://www.usmedicine.com/article.cfm?articleID=1074&issueID=74

[Vet Medic]

Brotzie,
Ischemic damage actually takes 2+ hours to set in from the application of a TQ. Most TQ's are not put on tight enough anyways so they don't fully stop circulation. The idea though is to use the TQ to dam the flood upstream and pack the wound downstream allowing the pressure to be opened up and the TQ loosened once the wound has been packed and bleeding controlled. This is not civilian protocal. This is Military Medicine. But the items dicusssed in this thread Quick Clot, Isreali Dressings, ETC. are all designed for Military use and pressed into use on the civilian side of the house.

Cheers

[Brotzie]

Absolutely agreed in a military environment; it's kinda unfortunate this topic - which is of general significance - is on the military board.

I have relatively little issue with the use of tourniquets in the case of amputations - see my post #115380 above - but, in the case of other major wounds, they can easily be more of a hazard than a benefit.

Also from the article MB cites above:

"The first-aid training that soldiers are given differs from civilian first-aid training because of the types of scenarios that soldiers encounter on the battlefield.

If ... you either had a partial or complete amputation of an arm or a leg, chances are the EMTs that showed up and responded to that call probably would not put a tourniquet on you. They would probably put trauma dressings on it, apply direct pressure ... That's all they would need to do until they got you to the emergency room." Beyond that, they've got a lot of options that are far less traumatic than a tourniquet - IVs, MAST gear (or whatever we call that these days), etc.

Every casualty is different, every situation is different. All I'm asking is that, before your reach for that tourniquet, be sure (1) you understand the consequences and (2) you've run out of other options.

To drag this thread back to the original subject, I've yet to be convinced that - in the circumstances its use is indicated (see Straps' post above) - QuikClot is a Bad Thing. Given the choice, I'd rather take the burn than have a tourniquet applied; less extensive damage to me, less long-term damage to me. Alternatively, as a responder giving aid, lower litigation risk for me.

But let's be clear that BOTH treatments are appropriate in dire emergencies only.

[towheadedmule]

<div class="ubbcode-block"><div class="ubbcode-header">Originally Posted By: Brotzie</div><div class="ubbcode-body">
- IVs, MAST gear (or whatever we call that these days), etc.

</div></div>

MAST or PASG is basically out here.

Russell

[MitsosOSougias]

Obviously my training is different than your training ... mine is mostly tactical AND austere (there is a lot of common ground as of the lack of recourses). I am not being confrontational just trying to offer another point of view.

Whenever there is severe blood loss from an extremity, I would put a TQ first then pack the wound. Then do the reassess etc.
This is not only for partial amputations and the tactical environment; it should also be used for open fractures etc. and in austere environments. I know at least two MDs and many medical professionals that advocate the use of a tq by people that have the training that enables them to judge the situation.

Tqs got to become a big “no-no” because people (without any formal training) were over using them incorrectly! Slapped one on for minor things and then forgot to pack wounds, re-evaluate, loosen etc. and kept them on for many hours ... they got over used and they got taboo.

Just like the initial burns with the “magic dusts”, they got overused and then people freaked because of the side-effects. Quickclot (and other magic dusts) is just another tool in the toolbox.

[docw]

another good use of a tq in a MILITARY environment is to slow the bleeding to a manageable rate, find the source, clamp with 2 hemastats, pack tight, place pressure dressing and release the tq slowly while monitoring the pt's stats. if you don't have a background in minor emergency field surgery though i would not try it. you need to fully understand hemodynamic principles and the infection risk. There is a reason why every military casualty brought in gets iv antibiotics hung. even in training we hang out in very dirty conditions.

on the other hand, surgeons have been using modified tq's for decades in surgeries that take anywhere from 4-10 hours. the way they wrap a leg for a hip replacement surgery does the same thing as a tq-to prevent undue blood loss. however they wrap the limb very tightly from the foot up wish prevents compartment syndrome and the resulting acidosis/necrosis in the limb.

for the highly trained responder, the use of tq's is a good tool when properly utilized. if i respond in the civilian world to a farm accident where a person has a severely cut up or partially amputated arm, i probably will go to a tq fairly quickly knowing that- 1 the limb may not be salvagable and 2 he will be in surgery withing 45 min -1 hr. in that time a full tq can be undone and with the proper after care, no damaging effects.

[Hutch]

The latest med training we received (SOF) was to not fear the tourniquet (incidentilly, the same training I have recieved for the last 7-8 years in the SOF world). The briefing trauma surgeons (all were/are Iraq or A-Stan vets) stated that they had little or no problem with the after effects of tourniquets. Of course this is after sufficient attempts with direct pressure, packing the wound and pressure dressings were unsuccesful. Applying a TQ, packing and applying P-dressings, reassessing and gently loosening is basically SOP. Others have described the method I'm talking about far more eloquently above /images/%%GRAEMLIN_URL%%/smile.gif

Additionally the newest form of Quickclot that we are being issued is n "teabag" form. It is now all contained in a bag that is packed into the wound. I would also like to add that it seems that the civilian world is viewing Quickclot as some majic formula that you sprinkle on a wound to stop bleeding, when in fact it is to be forced deep into the wound after identifying the "leak." Additionally, we were instructed to really only use it as the last resort and especially for wounds which could not be affected by a TQ such as a deep femoral etc. I'm no 18D, so I'm only relaying what the battlefield trauma types are saying, so take that for what it's worth.

[Brotzie]

I'm grateful for all the combat medics and others sharing their experience with me.

I have now had an opportunity to look at my latest protocol references to confirm my recollection. Bear in mind these protocols are (1) first aid rather than more advanced techniques (2) civilian and (3) British. All that said,

<ul> Tourniquets are NOT IN PROTOCOL at all, and In a situation where limb circulation has been compromised for more than 15 MINUTES it should not be restored without advanced care being available.[/list]
That's for the benefit of interested lay readers; U.S. or other protocols may differ, military situations are different and individuals may well have further training which allows them to go beyond the safe limits of first aid described above (can you tell I'm a lawyer in my day-job? /images/%%GRAEMLIN_URL%%/smile.gif ).

Mitsos said it well above:

"Tqs got to become a big “no-no” because people (without any formal training) were over using them incorrectly!"

Like him, I'm not trying to be confrontational. I just want people to be clear about what they're embarking on when they decide to use one. That's me done - end of crusade! /images/%%GRAEMLIN_URL%%/smile.gif

All the best, Ian

[towheadedmule]

Our protocols allow us to use TQ, but I havent heard of one being used in several year at this service. We are mainly a urban service, but do cover a wide area of rural zone. We have a few places where if the conditions are right (i.e. the helicopters are not flying for weather) that chance of using one goes up. Still low tho. I would use one with a exsanguinating wound in a multisystem trauma, long transport, no helicopter. But I would have to on top of the case. If its a long time to the hospital, its a long time to the call. In that case, it probalby going to be a traumatic death.

Of course, TEMS is whole other story, see above post for the military medics (and Corpsman).

Russell NREMT-P, HM3-8404, FMF ret.

[docw]

no worries brotzie, just an informational discussion. it's good to throw ideas around. the only problem i have with you isthat you're a lawyer. /images/%%GRAEMLIN_URL%%/smile.gif

[Brotzie]

http://forums.kifaru.net/ubbthreads.php?ubb=showflat&Number=115500&page=0#Post115500

[docw]

maybe a med forum would be useful.

[towheadedmule]

+1 on the med forum


(and the gear pics forum)

[straps]

Great point about liability. There is a guy in my office we call "Heart Attack Jack" because he's had multiple cardiac episodes (from ischemias to infarctions) at the job site. As the bug-eyed freak in the corner with the rigger's belt and the GSW kit in his E&E, they call me when this guy starts hyperventilating. Every time this happens I say a little prayer because his wife (who is the cause of most of his stress) is involved in civil litigation against our employer, her former employer, a mortgage lender and a major retailer. Unfortunately for this guy, the best I will EVER be able to do for him is offer a kind word or two, dial 911, and have some vitals ready for the bonded, insured EMS provider.

The aversion in the professional medical community to tourniquets is largely American in origin. As late as 2000, the tourniquest was trained as a measure of last resort for military personnel, many of whom if asked would probably wait until too late. The Israelis began publishing findings that endorsed the use of tourniquets as the last stop on the care continuum, and went on to describe courses of treatment in Trauma and ICU environments (designed to overcome the dangers Brotzie mentioned) that allowed the patient to keep the limb and retain some level of function (Motor nerves die first and don't regenerate; muscle is far more resilient--most tourniquets don't completely eliminate the flow of blood)--in some cases after as long as 6 hours had passed after application of the tourniquet.

Does this make the tourniquet an initial course of action? Absolutely not. Does it make it acceptable for use in a dense urban environment with easy access to trauma care? Probably not. In a situation when someone's bleeding from an artery and you're a 15 minute sprint from the last place you got a cell signal? Hmmmm...

Again, goes back to your training and your conditions.

Time to look for more X-Ray pics...

[straps]

Yup, +1 on the Med Forum. Looks to be some talent 'round here...

[Brotzie]

OK, really final word on QuikClot etc., courtesy of Anthracitic: http://www.tacmed.dk/new_page_6.htm

Thanks, A! What a mine of information you are!

[Vet Medic]

+1 on Med forums.

I would have to say that Med protocals are very different in the civilian world, especially Europe. I would also make the Statement that Medicine is a Practice and an Art. Different means to the same end, ETC. There have been lots of studies on Hemcon, and Quick-clot. I have talked to lots of the Doc's in the 86th CSH (Field Hospital, from "Baghdad ER") and will tell you that the Surgeons all agree that Quick-clot is the most effective when used propperly. The exothermic effect is something that as a company they have worked to try and limit. The thing that I find scary is that there are some very important steps in the safe application of this stuff but in the US it can be bought OTC, for aorund $30.00 (roughly a third+ of the price of Hemcon).

I agree that a forum to discuss these matters is important, but also implore people to seek out propper training and work to there limitations. The other important thing to remember is that Medecine is growing by leaps and bounds, and while the basics always work some times you need to update or add to the toolbox.

Cheers

[eggroll]

<div class="ubbcode-block"><div class="ubbcode-header">Originally Posted By: Aimless</div><div class="ubbcode-body">I also saw another quickclot product that is some kind of dressing with sea shells or something that promotes clotting and does not cause burning.</div></div>

That would be HEMCON, markedly more expensive than Quikclot.

there is however another product called CELOX which is also derived from shellfish chitin, that is commensurate with the QC price points

[BiTMAP]

How is this product for people who have allergies to shellfish??

(oh hai, first post, i registered for this one :O!)

[docw]

i don't know for sure but if you're bleeding bad enough to consider using it then you probably have to weigh the risk to benefit ratio.

[BigSky]

Quick Clot has been removed from our CLS bags. It is my understanding that this was done because soldiers were using it too much. Specifically, they were using it where it wasn't necessary. For those of us who have been in combat, there is something to the saying, 'better safe than sorry'. During our CLS recert last year we poured Quick Clot on a steak and it cooked it before our eyes. Very interesting stuff. As has been said herein, it does have its use and purpose.

[Phridum]

When I was "over there", we all pulled out our Quick Clot. My buddy took a round through his calf and they used Quick Clot on it simply because it was the first time they were able to. He said it hurt worse than the bullet did.

Tourniquets were frowned upon in the past because of people leaving them on too long and causing damage to the whole limb. However, with combat medicine gaining the recent experience it has, that's our first reaction now. Direct pressure on the wound, determine if you need a tourniquet, and apply it. Simple. They can put little sticks in veins to hold them open but can't repair tourniquet damage? C'mon...especially for a stateside medical emergency, I would have no qualms about throwing a tourniquet on anyone.

[HM2]

Actually, the response time for major trauma in current US active combat theaters might be considerably better than that found in much, if not most, of the United States right now. But I agree with your potential use of a tourniquet. I have never viewed bleeding to death as an acceptable alternative to loss of a limb. The warnings about tourniquets are correct, but you have to apply common sense (a very uncommon property) along with any first aid treatment.

[one-eyed Bob]

If you can't stop the bleeding, use the tourniquet. Amputated limbs have been reattached after having no blood flow for hours and we use tourniquets in surgery daily up to 2 hours or so. It seems if you are in such a position you would be more worried about saving the patient's life by reaching civilization and sending help. Perhaps an injury from a broadhead or ax is the closest thing I can imagine. I would hope a medical man would get a tie on the vessel and then use pressure.

[William Clunie]

Hello HM2,
I'm an ancient HM2 also, and I'm from Maine. I was stationed at Camp Pendleton from 1980 until 1985.
I would use a tourniquet before letting someone bleed to death.

William Clunie

[Brotzie]

As de facto leader of the anti-tourniquet brigade, let me just be clear that I would too - but only when it was the last option available. My concern is that people will use them too readily, when direct pressure, elevation and indirect pressure would otherwise manage the situation.

I believe that QuikClot is a better option than a tourniquet, but again I can see that people get carried away with the shiny new toys in their medkits and use that inappropriately too.

[HM2]

Brotzie,

I'm with you 100%! I guess my concern is the acceptance of any course of action in a dogmatic fashion which doesn't leave wiggle room and allow for the application of common sense. I get the impression that you have all of your feces in one place and tightly wrapped, so I don't worry about you. I suspect that you also have enough experience to know when to wiggle and when to fall in line.

My fear is that a lot of folks with no experience are being taught that tournequets, MAST Trousers, etc are 'BAD' and shouldn't be used, kind of a baby/bath water scenario. I hate to admit it, as a health professional, but medicine tends to be a little trendy; some treatments go away for cause and some just go away for no better reason than another treatment has come into vogue. Just my opinion.

[XOGA]

HM2: I completely agree about the problem of trends in medicine and first aid.

The current version of the Combat Casualty Care manual is very well thought out compared to most of its predecessors.


1. The current recommendation is utilize a tourniquet whenever you are confronted with bleeding from a major artery that you cannot control. I would broaden this to include almost all traumatic amputations and near amputations - situations in which direct pressure is more difficult to apply and less likely to be successful.

2. Consider them for the transport of casualties under less than ideal conditions - even if you have previously obtained control of bleeding with direct pressure. Under fire, this is anyone who is going to walk out (typically less than 1km) assistance. For the purposes of this forum, it is worth considering for lower extremity injuries involving major arteries in remote locations. It's difficult to imagine an instance where I would feel the urge to do this with an upper extremity injury that was anything less severe than a near amputation. Almost no one exsanguinates (bleeds to death) from an arm injury.

3. Just because you applied a tourniquet doesn't mean you have to leave it on. Well trained rescuers will sometimes apply a tourniquet, cut off the clothing, and apply a pressure dressing that conforms to the contours of the wound. It can be difficult to get a good fit when blood is spraying all over you, and much easier if the bleeding has been slowed or stopped. Apply your pressure dressing - make sure it's going to apply pressure as you require, and let down your tourniquet. The benefit of being able to position your dressing in the absence of significant bleeding is self evident to everyone who has BTDT. If you care, I find that a bandanna, rolled up on top of the gauze, works well with those new-fangled Israeli bandages, and will generate the kind of pressure that you will require in these situations.

4. Survival from major trauma has been improved through the more appropriate use of tourniquets by appropriately trained providers. I'm gratified that the ability and expertise our first responders possess has finally been matched with guidelines that take full advantage of them.

5. The time that it takes to sustain a devastating injury from a tourniquet varies. As others have pointed out, patients are routinely subject to tourniquet times of 2-3 hours during knee surgery. What most people don't realize is that these legs are usually exsanguinated with a very large rubber band....(they literally squeeze all of the blood out of it). Why? So their blood vessels don't clot from the blood just sitting there. Patients with vascular disease tolerate only short tourniquet times. Previously healthy people tolerate an hour easily, and most will tolerate a few. Some experts advocate a strategy of intermittent 'holiday' or release of a tourniquet to allow blood flow to the injured extremity. In the absence of a major arterial injury (e.g. a crush bleeding everywhere), this approach is very reasonable. In the setting of a major arterial injury, the blood you are letting flow is more than likely going into your bandage and not into the leg distal to the injury. Tourniquet holidays obviously make less sense in this scenario. All of this is important to understanding this: even when a tourniquet is applied under questionable circumstances, it is almost certain to cause minimal harm relative to the original injury.

6. If you understand all of the above then you'll understand this: Tourniquets are most likely to be required in instances where there is an obvious major injury to a major artery in the thigh or around the knee. Casualties can bleed to death in a few minutes from these injuries. Injuries to the arm (especially the forearm) and leg below the knee are much less likely to require a tourniquet.

7. Monday morning quarterbacking is easy given the leisure of time, a more perfect assessment of the injury, and the absence of stress. It's why there's so much litigation arising from emergency care. My view is this: it is the duty of the instructor to teach their students about the appropriate use of tourniquets, and to pass only those who have mastered the material. In the field, it is the duty of the first responder to do their best, whatever that may be. The vast majority of casualties derive far more benefit than sustain harm from those who render first aid to them. We should be loathe to second guess the judgement of any care provider who has obviously been sprayed with arterial blood.

[cog]

XOGA,

+1 and two thumbs up on your comment about Monday morning quarterbacks. What a PITA to work your tail off for twelve hours on a patient and have someone come in on the morning shift and point out everything that you did 'wrong' and then to 'diagnose' the problem and come up with an all inclusive treatment plan after having been with the patient for all of five minutes. Only rarely does that vunderkind recognize that the bulk of his or her conclusion rest solidly on the results of your last twelve hours of successes and failures. Ah well . . .

You bring up a very good point about patient transport. It is difficult to maintain adequate direct pressure on a moving gurney or wheeled stretcher. It's almost impossible on a carried litter or a patient being carried out by rescuers over uneven ground. Under fire? Fuh'ged aboudit!

[Doc]

Both Brotzie and XOGA have raised many valid points about primary care.
The main point though, is and always has been, get training in what kit you are using and stay current.
Example: While in the military I was a AAMC (approx level 6 ALS) qualified medic. During that time, I delivered children, performed minor surgery, installed chest drains, trachies, NTs, whatever was required to keep people alive (mostly without guidance from higher) until evac to a treatment facility.
Would I do any of that on some guy I happen across in the course of my travels now that I am out?
Not a chance. Anyone that I help is getting basic first aid only.
That is all that is covered by our "Good Samaritan act" and is usually all that is required.
Fortunately for us, the use of TQs is covered in our protocols. Last resort use only.

For the Military side of the house, the sky is the limit. Do what you have to.
Two reasons.
1: Your patient is unlikely to sue you for saving them, despite hurting them in the process. They are much more likely to thank you.
2: The chances are, after 2 or 3 years working together, he's your friend. You do what you have to for your friends.
Any BTDT would.

[Repoman]

I would add to the comments about trends and beliefs in medicine that once some ideas become established for whatever reason, they can't be changed no matter what data is available.

I'm a Navy Emergency Medicine physician, and teach tactical/wilderness medicine classes. I've deployed three times since the war started. My colleagues and I have experience with many thousands of patients between us since 9/11.

Quik Clot was always a useful product if used correctly, and saved many lives. Hardly anyone was taught how to use it. I watched Marine Generals tell Marines it was magic and they had to use it, but no instruction was given. It was designed to be used PACKED INSIDE a deep wound with arterial bleeding. These are wounds that don't stop bleeding with direct pressure alone, and the artery can't be clamped or oversewn, or a TQ used. If the wound was a bullet tract, it had to be sliced open with scissors or a knife to make a "bowl" to pack the QC in and hold it there under pressure. When used that way it does work miraculously, and in that setting it doesn't reach high temps or cause tissue damage. It's a moot point now anyway because the new low temp "tea bag" formulation solves that problem. CELOX costs the same and on first look seems to work as well. HEMCON is almost 10X more expensive, and is much more difficult to use technically, requiring good surgical technique. But when it works, it is fantastic as well.

I don't mean to be confrontational, but the advice given against tourniquets in this forum will kill a patient in the wrong situation. I've seen and personally used hundreds of them over a 30 year career. I have NEVER seen a damaged limb from them (although lately much of the time I've used them there wasn't a lot of limb left). For serious extremity bleeding when the patient is a long way away from a blood transfusion to replace what is spilled on the ground, the TQ should be the next response after direct pressure. Then while you are trying different techniques and bandages to control the bleeding, the TQ keeps the patient from pouring more into the soil. You can keep loosening the TQ to assess whether or not your bandage is working. If you can't stop the bleeding any other way, leave the TQ on. The entire protocol can be found in the last chapter of the PreHospital Trauma Life Support text, which is on military medicine. It is approved by every trauma group in the US, including the American College of Surgeons. You can also Google Tactical Combat Casualty Care and come up with several other references.

The stories about QC and chest catheters and whatever being taken out of medical kits to avoid problems drive me crazy. The answer is to get the right training, not to throw the tools away. In the military, the boneheads who give orders like that would rather have a patient die without the right treatment, because they think they can't be blamed for that, than deal with the problems of keeping everyone trained up.

[cog]

<div class="ubbcode-block"><div class="ubbcode-header">Originally Posted By: Repoman</div><div class="ubbcode-body"> The answer is to get the right training, not to throw the tools away. In the military, the boneheads who give orders like that would rather have a patient die without the right treatment, because they think they can't be blamed for that, than deal with the problems of keeping everyone trained up. </div></div>

It's sad to see that some things in the Big Canoe Club haven't changed in the 35 years since I got out. Even then we worked with some pretty phenomenal docs, nurses and corpsmen under some pretty extreme conditions and achieved amazing results most of the time. From what I can hear and see, that is also something that hasn't changed too much in the interim. Now if we could only do something with the VA, it remains spotty, brilliant in some places and a throwback to the fifties in others. Our wounded deserve better.

[cdnkelly]

We used OB Tampons for bullet holes. The Navy surgeons in TQ (by Fallujah) got a good laugh until they tried to get them out! From the surgeons own advice, they work great. Quikclot and touriquets are just tools in the tool bag. I saw alot people blown up and shot over in Iraq, you need to rely on knowledge and training. Case in point, touriquets do not cause a crushing injury and "metabolic toxins" do not take minutes to build up. (the majority of "toxins" are byproducts lactic acid and CO2) Does Anarobic or the Krebs cycle ring a bell? Did you not take into account the lungs and kidneys functions during the Krebs cycle? A basic college course in Anatomy and physiology would go a long way in disspelling alot of medical myths out there. Anyone ever had knee or hand surgery? They use a touriquet for the entire time they are working on the limbs to minimize blood flow. This can take many, many hours. My last knee surgery took two hours, with most of the time being in a touriquet. So, if you cut your finger tip, it's ok to "touricate" your finger with the other hand, until the bleeding has stopped and blood vessels and caps have clotted or shut down. It's also "OK" to use a TK on the limbs to stop the arterial or veins bleeding and pack the wound with hemcon, gauze, quikclot, MRE crackers (was done in 04)or a tampon. Leave it on, loosen or tighten, what ever it takes. Best advice, "Be careful out there...."

[pigslayer]

I am not an expert on quick clot, but I have done field trials in urban trauma setting (shootings). We found that it performs as stated. The trouble with it is, it causes clots. good to stop the bleeding but when the clots break free and travel through the blood stream it cuses problems. for this reason quick clot is a last ditch option.

[MWCAMP7]

THIS IS MY FIRST TIME EVER LOGGING INTO A FORUM SO FORGIVE ANY ETIQUETTE VIOLATIONS. FIRST, LIKE SOMEONE ELSE SAID, EVERY TOOL HAS ITS PLACE. QUICK CLOT IS NO DIFFERENT. HAVING BEEN THROUGH THE USMC FIELD MEDICAL SERVICE SCHOOL AND CURRENTLY ASSIGNED TO THE USMC AS A "DOC", QUICK CLOT HAS ITS LIMITIATIONS. HOWEVER IT IS AN EXCELLENT TOOL WHEN USED CORRECTLY. DO THE RESEARCH, AND KNOW WHEN TO USE IT. AS FOR ME I WILL CARRY IT UNTIL SOMEONE COMES ALONG AND PROVES TO ME IT DOESN'T WORK. AS FAR AS THE TEMP, ABOUT A 180 DEG F, IS ABOUT AS HOT AS IT GETS. I WOULD RATHER HAVE A SECOND, OR HECK, LOCALIZED 3RD DEGREE BURN, THAN BLEED TO DEATH. THAT'S JUST ME THOUGH. ALSO, QUICK CLOT DOES NOT CAUTERIZE A WOUND. IT REACTS WITH THE LIQUID IN THE BLOOD, AND EVAPORATES IT, IE. CAUSES AN EXOTHERMIC REACTION. A BIG WORD THAT MEANS IT HEATS UP ENOUGH TO EVAPORATE THE LIQUID. WHAT YOU ARE LEFT WITH IS THE SOLID PRODUCTS IN THE BLOOD THAT FORMS A CLOT. THIS CLOT CAN ONLY BE REMOVED BY SURGERY AND THAT IS THE DESIGN OF THE PRODUCT. CONTACT QUICK CLOT AND HAVE THEM GIVE YOU THE NEEDED INFORMATION. I HAVE NEVER HEARD OF THE CLOT BREAKING OFF AND CAUSING ANY TYPE OF BLOCKAGE.

TOURNIQUETS. THEY HAVE THEIR PLACE. REMEMBER LIFE OVER LIMB. AS FAR AS HOW LONG THEY CAN STAY ON? ASK AN ORTHAPEDIC SURGEON HOW THEY KEEP PT'S WHO ARE HAVING KNEE REPLACEMENTS FROM BLEEDING TO DEATH. HMMMM? THAT'S RIGHT TQ'S. NAVY CORPSMAN ARE TOLD THAT UP TO 90 MINUTES WITHOUT MAJOR DAMAGE. REMEMBER EVERY SITUATION IS DIFFERENT AND WHAT I AM SAYING MAY NOT APPLY TO EVERY INJURY/SITUATION. YOU HAVE TO ASK YOURSELF, HOW LONG ARE YOU GOING TO TRY AND STOP EXTREMITY BLEEDING THROUGH THE NORMAL DIRECT PRESSURE, ELEVEATION ETC WITHOUT RESULTS BEFORE APPLYING A TQ? YOU CAN BLEED OUT IN 90 SECONDS. THE NUMBER ONE CAUSE OF PREVENTABLE DEATHS ON THE BATTLEFIELD ARE FROM BLEEDING TO DEATH FROM EXTREMITY WOUNDS THAT COULD HAVE BEEN PREVENTED BY RAPID INTERVENTION. NOT ALL OF THEM MAY HAVE NEEDED A TQ, BUT I AM SURE IT WOULD HAVE SAVED A LOT OF LIVES. ALSO, THE FIELD MEDICS ARE ON THE CUTTING EDGE OF WHAT WORKS AND WHAT DOESN'T. I SPOKE WITH A NAVY DOC WHO TOLD ME HIS TQ OF CHOICE WERE BUNGEE CORDS HE BOUGHT AT COSTCO. GO FIGURE. CIVILIAN MEDICS/ER DOCS HAVE RESOURCES AT THEIR FINGER TIPS THAT YOU MAY NOT HAVE IN THE WOODS. DIFFERENT SITUATIONS CALL FOR DIFFERENT APPROACHES. I RECENTLY BOUGHT A BOOK DURING A RECENT TRIP TO YOSEMITE CALLED MEDICINE FOR MOUNTAINEERING BY JAMES WILKERSON. IT HAS GREAT INFO, ALSO, CHECK OUT PHTLS (PRE HOSPITAL TRAUMA LIFE SUPPORT) THERE IS A MILITARY AND CIVILIAN VERSION, YOU PICK WHICH ONE IS BEST FOR YOU. I HOPE THIS HELPS, SORRY FOR BEING SO LONG WINDED.

[Ralph]

As a suggestion, typing in all upper case makes it look like you are shouting at us. Try using upper and lower, it looks better snd is easier to read. Welcome to the board.

[cdnkelly]

Straps, DOC, HM2 and all others, thanks for the good discussion, maybe someone should get a medical forum going. The medical protocols for us military folks are changing rapidly. Good men and women are out there on the front finding better and better ways to save the men and women who are serving our country and helping those who cannot help themselves.

Remember what Teddy Roosevelt said about the man in the arena.

[Repoman]

As an update, QuikClot is now releasing a new form: a gauze bandage impregnated with the material. It sounds like something I will definitely want in my bag. One of the other clotting agents, Celox, is also being sold in a "tampon-like" applicator for injection into bullet tracts. I just got an email from Chinook Medical about it. I haven't seen studies or heard reports of its use, but it appears to be a reasonable alternative to trying to stop bullet wound bleeding.

[theotherphil]

I'm a Paramedic in the UK and we can use tourniquet's as a last ditch attempt or in some cases, the first response. We are also looking at haemostatic agents (more than likely quikclot for it's price).

I've never been in a situation where I needed the above as direct/ indirect pressure and elevation works great in most cases. I am not taking incoming rounds though so I can safely work on the patient in my own time.

[Doc]

<div class="ubbcode-block"><div class="ubbcode-header">Originally Posted By: cdnkelly</div><div class="ubbcode-body">
The medical protocols for us military folks are changing rapidly. Good men and women are out there on the front finding better and better ways to save the men and women who are serving our country and helping those who cannot help themselves.

</div></div>

Quite true. As an example, I recently chatted to a guy just returned from the sandbox, and the advice now is "use tourniquets early and often, in cases where indicated."

[modustollens]

I viewed a recent documentary of a convoy in Iraq; just prior to its departure the officer in charge told his drivers to pre-apply a tourniquet to upper thigh, though without tightening it - before they began the convoy - for a common injury for drivers is a severe upper leg wound, and a tourniquet could save their life or their limb.

I have seen people die of exanguination during 911 calls when working EMS up here in Canada - believe me: its not pretty when all your blood is spilled about haphazardly for whatever reason - its only worse during war time under the duress of combat.

Tourniquets are certainly reasonable under the proper circumstances.

[StillHuntin]

HM2,WmC,Repo etc,
Another HM2 (Balboa 55-FMF 1st Div 56-59)
Good to see y'all.
IMO While medicine is trendy in some respects, common sense has always been the hallmark of good medicine.
The use of tourniquets 50 years ago was determined and limited as described above.
I attended a bow-ed class a few years ago that was presented by some fellows who were very knowledgable, and dedicated, ski-patroler/mtn responders. My aid kit would have put them in a panic.
The "(not so)Good Sam" protection has me protecting ONLY those I know and love dearly; as we were (rightly) instructed many decades ago.
Semper Fi & Protect Those Now Serving
"Doc" T

[HM2]

Semper Fi, Brother, and welcome.

[Smackdaddyj]

I have been in Iraq for about 6 months now, and since we are in a similar situation to SF teams, we recieved more "first aid/first responder" training than most of the guys coming over here. Most of it was from some very high speed SF medics that had definately BTDT. During our very realistic PE I discovered something very important. Attempting to provide enough pressure to stop a femoral artery from bleeding out is almost impossible with your hands (at least my hands) but very easy to accomplish with my knee (i.e. kneel on the inner thigh). Is it painful? You betcha! Does it stop th bleeding? Yup! In the case of serious injury, pain is already present, so I wouldn't be as worried about adding a little to save a life. Here is basically what we are being taught:

Facts - 80%(ish) of preventable battlefield deaths occur from bleeding out. 10% (ish) are from blocked airway due primarily to face trauma (i.e. explosion close to your face). 10% (ish) Circulation, head injury, hypothermia.

Recommend that you use the MARCH method of treatment:
M - Massive Hemorage
A - Airway Compromise
R - Respiration
C - Circulation
H - Hypothermia/Head Injury

Bottom line, look for red stuff and stop it. If it is on the extremities far enough down to apply a TQ, then that is first step after evaluation. As you are evaluating, lets say you see bleeding from the lower leg, pretty bad, first you place your knee in the groin portion of that leg and bear down, stopping the bleeding. Now finish the evaluation, make sure no other serious bleeding, and then come back and place a TQ before moving on. If you can't do a TQ, then use CQ.

Then move on to the other areas. Pirmary tool we are given for Airway is that Nose tube (can't think of the name). Respiration is needle chest decompression. Circulation and Hypothermia/Head Injury, get them off the battlefield and to a facility as quick as mission allows. But the important thing to take away from this is that everyone on these teams that I am a part of gets this training. I am pretty impressed and have been very pleased with our overall medical training. No more, give an IV and your a CLS. We also do saline locks now and not just starting IVs. Love giving them, hate getting them, but that's just how it works.

I am by no means a "trained medic" but would feel comfortable assisting those I love with life threatening injuries and will be teaching my family these methods when I return home.

It also seems that with the media hyped soldier deaths (not to belittle them, they are just fairly low for the levels of conflict encountered) the brass has authorized a lot more options.

Smackdaddyj

[Smackdaddyj]

For some reason it is not letting me edit now. Above, my line that reads "If you can't do a TQ, then use CQ." is supposed to read QC (Quick Clot). Also for respiration, we are taught to use the occlusive dressing for sucking chest wounds. Once that is done and bleeding is stopped, we just go ahead and do a needle chest decomression to make sure that there is no pressure against the lung...assuming there is a sucking chest wound, of course.

Sorry for the confusion.

Smackdaddyj