When Dr. Jeff Rea attended medical school, tourniquets were regarded as outmoded and dangerous, “Civil War medicine.”
“We were taught never to use tourniquets,” said Rea, who works in the emergency department and surgical intensive care unit at Albany Medical Center.
But over the past decade, tourniquets have made a comeback, and Rea used them while serving as a flight surgeon in Iraq.
“They are absolute lifesavers,” he said.
Medical experts said that without tourniquets, many of the people injured at the Boston Marathon bombing last week would not have survived. Three people were killed and more than 170 injured when two bombs packed with pellets, nails and metal shards exploded near the finish line. The force of the blast blew off people’s limbs, broke bones and shredded muscle. Rea said that the scene in Boston was like what he saw during his deployment.
“Tragically, the frightening scene in Boston is reminiscent of what you see in Iraq and Afghanistan,” Rea said.
A tourniquet is a device, such as a tight bandage, used to temporarily constrict an artery of the arm or the leg. They are generally used as a last resort, in situations where a patient would otherwise bleed to death, because cutting off the flow of blood can kill body tissue and cause the limb to die, necessitating amputation.
Rea said that the military began to reconsider the use of tourniquets after the failed 1993 “Black Hawk Down” military operation in Somalia, in which 18 U.S. soldiers died. A review determined that many of the deaths were a result of injuries to the arms and legs and could have been prevented had tourniquets been used to stop bleeding.
Today the Army instructs soldiers to use them on the battlefield, and the use of modern tourniquets has been widespread in Iraq and Afghanistan. These tourniquets are not hastily made out of belts or found materials as in bygone eras. Rather, they are ready-made devices distributed to soldiers.
Rea served in Iraq from 2006 to 2007 and treated a high volume of blast injuries at the combat support hospital in Baghdad after the suicide bombing of the Iraqi parliament building. He described the tourniquet he used there as “a strap of webbing that’s beefier than the webbing that makes up a seat belt. It was relatively inexpensive, about $30. People can be trained to use them in short order, in a typical combat first-aid course.”
The military’s success with tourniquets has made them a popular tool stateside.
The Schenectady Fire Department is trained in the use of tourniquets and uses them fairly regularly, said Capt. Donald Mareno, who oversees the department’s EMS division. Firefighters use tourniquets to aid shooting and stabbing victims, often in conjunction with clotting agents.
“Tourniquets are another tool in our toolbox,” he said. “They have their place. They’re another thing at our disposal to help someone.”
Capt. Anthony Helstowski of the Schenectady Fire Department spent four months in Iraq in 2010 with a National Guard unit out of Florida, working special operations. He serves as a self-aid buddy care instructor at Stratton Air National Guard Base. The work involves teaching people how to use the individual first aid kits that include tourniquets and clotting agents, and he has also trained members of the Schenectady Fire Department’s tactical EMS unit.
“In Vietnam, there were over 2,500 deaths from bleeding out through the extremities,” Helstowski said. “There was this misconception that if you put on a tourniquet, you’d lose an arm.” But he said that research and experience has shown that tourniquets can be applied for a much longer period of time than previously thought — about six hours — and that losing a limb is preferable to death.
“When people in Iraq are wounded, you have about 90 seconds to decide whether to put on a tourniquet or bleed to death,” he said. “We say put the tourniquet on first, and don’t take it off until you receive medical attention.”
The Schenectady Fire Department has been using triangular bandages as tourniquets but will soon be using a type of tourniquet popular with the military known as the combat application tourniquet, or CAT. These military-style tourniquets are on order. Helstowski said that the Schenectady Police Department already uses the CAT.
Help close by
Medical experts said that the close proximity of so many doctors and emergency personnel to the blast site at the Boston Marathon saved lives. The medical tent that provides care to exhausted and injured runners was located near the finish line, where the bombs went off. Immediately after the explosions, the tent was transformed into a trauma unit of the sort found in a war zone.
The types of injuries sustained in the marathon bombing are unusual in the United States.
“Blast injuries are rare in the civilian world,” said Dr. Michael Dailey, who serves as director of prehospital care and education at Albany Medical Center. “Something like this, where there’s an IED, creates a huge surge in patients.”
Dailey said that patients occasionally arrive at the emergency department with tourniquets. “Some have been placed by well-meaning bystanders incorrectly,” he said. “Some have been used very effectively.”
One of the first uses of a tourniquet that he saw, several years ago, was on a young man who had punched a plate-glass window, which sliced his arm “like a guillotine.” Gunshot wounds and injuries sustained in motorcycle crashes can also be extremely damaging to the extremities, he said.
Dr. Jeffrey Lozman, an orthopedic surgeon at Albany Medical Center, said that the first thing medical personnel at the scene of a mass casualty event do is determine whose injuries are life-threatening and whose are not and treat those with the life-threatening injuries first. Treating life-threatening injuries involves asking and answering questions, such as “Do they need intubation?” “Do they need a tourniquet?” “Is their airway intact?” The goal is to make good use of resources.
“You want to restore normal limb function, but that is not always possible,” Lozman said. “Limb salvage is important, but patient survival is the most important thing.”
A blast injury, he added, can cause immediate amputation, necessitating the use of tourniquets.
Lozman said that everybody should take a first responder course and learn how to aid patients in emergency situations.
Dailey and Rea instruct local EMS units and law enforcement agencies in tactical combat casualty care — life-saving techniques and strategies for battlefield-like conditions. Rea said that this sort of training helped save lives after the Arizona shooting in 2011 that injured former U.S. Rep. Gabrielle Giffords and left six people dead.
“I was impressed with every facet of the response,” Dailey said. “I don’t think they could have done a better job.”
Dailey said he would study what happened in Boston and see what lessons and improvements he could draw from it. Though a terrorist attack in the Capital Region remains highly unlikely, there are events that could produce a surge in badly injured patients, such as a bus crash on the Northway.