The first time I placed a tourniquet onto a patient, I was driving for the day. My partner and I responded to report of “bleeding.” The cops were on scene of a crash for 30 minutes or so, before they called for an emergency ambulance. Bleeding, huh? That is a call type that could mean anything.
The scene began as a non-injury grinder. One of the damaged cars was being towed away and the tow truck driver had to sweep up broken glass from the street. He had a new, unassembled push broom where the bristle part was zip-tied to the handle part. The tow driver popped open his Spiderco and sliced the zip tie. The knife slipped and he stabbed his offhand wrist, opening his ulnar artery. The driver couldn’t get it to stop bleeding, so he mentioned it to the police officer on scene. The police officer couldn’t get it to stop bleeding, so he called for an ambulance.
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| The patient was stabbed right about where the illustration labels the "Deep volar branch of ulnar." Public domain image. Via Wikimedia Commons. |
My partner and I were a little slow getting on top of it. I mean, it was a dinky little 2-centimeter lac in the ulnar side of the wrist – pinky side, not thumb side. If the guy’s hand was chopped off, we would have been all over it. As it was, we tried and tried to get this dumb little lac to stop spraying blood everywhere. I couldn’t get pressure onto it properly to get it to stop. We couldn’t really get the bleeding to even slow down. My partner and I shared a look: I can’t believe this! Do we actually need a tourniquet for this little thing?!?Yes. Yes, we did need a tourniquet. I pulled the TQ off my belt, placed it, and stopped the bleeding. All in all, it wasn’t a big deal to do it once the decision was made. That is like a lot of medical decisions: the hard part is deciding, not doing.
I learned two lessons. First, pull the strap as tight as you can before you velcro it down and start twisting the windlass. Take all the slack out of the system before cranking. I didn't pull it especially tight, so I had to twist way more than otherwise. If I would have put a grunt into the first placement, I wouldn’t have had to twist the windlass what felt like fifty times. Second, it hurts the patient a lot. Like, a lot. Make ready with the analgesia.
After the bleeding was controlled, my partner started an IV and pushed some fentanyl into it. Then we had to debate whether we were going to transport emergent or nonemergent. On one hand it was a teeny little two-centimeter lac and the bleeding was now controlled. Emergent transport, for that? But on the other hand, a tourniquet was placed on the patient’s upper arm. Does it make sense to transport nonemergent with a tourniquet? I think we did a “paperwork 10”*.
We arrived to the trauma center and they assigned up a big room, with the whole trauma team, surgical residents, and such waiting. My partner gave the big room report and I could feel the surgical team’s skepticism as they examined the wound in the patient’s wrist. It was like they were saying: This?!? You placed a tourniquet for this little lac?!? One of them helpfully pointed out that a tourniquet should be placed only if other methods of bleeding control failed. (Thanks, buddy.) The team quickly came to the decision that the tourniquet should be taken down. One resident took it off. Spurting blood sprayed her surprised face and across her gown. That got everyone to believe the tourniquet was a good plan. Just like as happened with me, they could not get proper pressure onto the lac to stop the bleeding. They couldn’t even get the bleeding to slow enough to clamp or sew off the bleeding vessel. After a few minutes, they tried to put the tourniquet back on. Just like with me, they didn’t pull the strap tight before velcroing it down, so they had to spin and spin the windlass until the bleeding slowed.
The final lesson is that even with the TQ placed, the guy didn’t lose his arm. With the bleeding controlled, they could get into the lac and tie off the bleeding vessels. Not a big deal, all in all. Better than needing to top the guy off with a transfusion or something.