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When Do We Apply the TQ "High and Tight?"

      There is a lot of discussion on whether to place a tourniquet (TQ) "high and tight" on an arm or leg,  or place 2-3 inches above the wound, even if on the forearm or lower leg, sometimes called a  "double bone compartment. " There is also those who say a tourniquet can be on for 1 hour, or for 8+, so which is it? 

The short answer is, it depends on the wound, who you are, and where you are.

 "When do we do high-and-tight? "

High-and-tight is a "catch all" for most situations and non-medical professionals. It's easy to remember and unlikely to be placed distal (away from the injury, not between injury and heart) or be placed over a joint which would make it ineffective. High and tight also accounts for blast wounds where the wound may be more extensive or deeper than it appears, and when placing over clothes during "Care Under Fire" where the wound and location of bleeding may not be easily apparent.

For non-medics and Tactical Combat Casualty Care (TCCC) trained individuals, high-and-tight is for care-under-fire.

For those close to a hospital, within 1-2 hours, high-and-tight is also fine. We will discuss why if farther away from care you may want to consider other options.

 

 

 

Myth: Tourniquets do not work on Double Bone Compartments

  [caption id="attachment_3670" align="alignnone" width="950"]2418-pb2-r1 Anatomy of arteries along forearm, leading some to incorrectly believe they run too deep to be properly occluded. [/caption]

      The placement of the tourniquet in the picture above would have some believe that it is ineffective due to it being over a " double bone compartment."    This post purpose is to address and dispel the common myth to avoid placing a tourniquet(TQ) on the forearm or lower leg because it might be less efficient at total arterial occlusion due to the anatomy of a double bone compartment, or might cause further harm due to a certain wound set.   If you have basic medical training and were taught "high and tight" is the only way to go, this is not saying don't go high and tight during Care under Fire or when hospitals are nearby, this is more a consideration for medical professionals in an austere environment where medical care is hours away and is not as applicable for the layman. Medical professionals have a higher level of care to deliver to their patients than just doing high and tight for every situation. Multiple sources are posted at the end of the article because I believe in evidence based medicine, not "I do it this way because my instructor told me." A study by Dr. John F. Kragh (US Army Institute of Surgical Research) who is a renowned tourniquet expert, found that not only is it not effective, it can be more effective and the benefits of proper tourniquet placement are key (Cited below.) Take into account that often times meaty thighs take two or more tourniquets and it can be easier to understand why a tourniquet would work better when there is a smaller circumference to compress. Why does this even matter?

 Tourniquets don't cause permanent damage until they are on for about 6-8 hours if done correctly, as early as 2 hours if done incorrectly in the case of venous tourniquets causing compartment syndrome. The body will physiologically loosen (even when applied properly) so re-assess your TQ's and expect them to come loose and need to turn the windlass again.. If tissue will be lost because this tourniquet will be on for over 8 hours, the TQ should be 2-4" above the wound to salvage as much tissue and save complications as possible. Optimally, if not an amputation, the tourniquet has not been on too long and the patient is hemodynamically stable, you will want to convert to a pressure dressing directly on the source of bleeding so you can have perfusion back in the limb, but only if you can monitor for re-bleeding. If you already have a "High and tight" placed by a non-medical provider such as a TCCC or First Responder, you can consider  at least approximate the tourniquet by placing a second 2-4" above the wound and loosening the high and tight. Your actions during initial treatment during your TCCC phases can come to bite you later, so consider not going high and tight if the situation is tactically safe. High and tight is for care under fire and non-medical professionals, but when tactically feasible the medical provider should strongly consider deliberately placing the tourniquet 2-4" above the wound,  converting it to a pressure dressing if the criteria is met, and at least approximating the TQ.Even if TQ's needed another revolution or two with the windlass when placed in these areas, the benefits of proximal placing are worth it.  Such is the standard put out by the Committee of Tactical Combat Casualty Care and taught in U.S. Army Combat Medic School and Special Operations Combat Medic School. Sources,  Evidence:

Austere Guide to Gauze

Hemostatic Gauze Vs. Non-Hemostatic Gauze... There are many types of gauze on the market to choose, from standard gauze rolls to different types of "Hemostatic gauze", which are impregnated in substances to help stop bleeding. Without understanding the differences between a package of compressed gauze, to Combat gauze, Celox-gauze and Chito-gauze, how they work, or even if they work, it can be difficult to decide which one is right for you and your medical kits. Here's the breakdown:

Our Special Forces medics are discussing trauma on CAG NET!

Plain (Non-Hemostatic) Gauze:  Often called Kerlix, and coming in "Z-fold" or "S-rolled", or even compressed to take up less space, This is a must and a minimum. While this gauze certainly is not as good as the hemostatic gauzes in terms of controlling severe hemorrhage , It's inexpensive and versatile use make it a must. This isn't just for packing a bleeding wound that a tourniquet can't reach, it can be used as simple bandaging, dressings, stabilizing such as a sling and swathe and so much more. For the low-cost, it's a stepping stone towards hemostatic gauze. I recommend at least 2-3, and more in your house/truck kit, for those areas on your body where a tourniquet can't stop the bleeding, or for a little pressure in an extremity that is not a severe enough bleed to warrant a tourniquet. [gallery size="medium" type="rectangular" link="none" orderby="rand" ids="2327,2328,2329"] Hemostatic Gauzes - For arterial bleeding, don't risk having a non-hemostatic gauze as your Primary choice, you and your loved ones deserve the best shot at survival. What you do for bleeding control for the first few minutes is similar whether you are in an austere environment or 911 is just a few minutes away... If you don't get this bleeding stopped, it will eventually stop when the patient runs out of blood. Unlike previous generations of hemostatic gauze, these do not generate heat or burn.  Here's your choices, and how they work:

  1. Combat Gauze:  Combat Gauze is the #1 choice of the U.S. Army Institute of Surgical Research and Committee of T.C.C.C and has earned it's place. It is impregnated with kaolin, which helps the bodies clotting along much greater than using standard gauze. It's got a hefty price tag, but would you rather have a wallet with more money or a heart with enough blood to keep pumping? For a bare minimum medical pack I'd recommend at least 2, because if the first one does not work, you will have to be more aggressive your second time.
  2. Celox Gauze - Unlike Combat Gauze, Celox does not help your body itself clot but creates one. This is because when the it comes into contact with blood it creates a gel. What this means in basic terms is if your patient does not have good clotting factors ( Hypothermia, Medications such as Aspirin, etc.) this is a good choice because it works by itself instead of supporting the bodies clotting process. 3.   Chito Gauze - Chito Gauze does not rely on the bodies clotting process, as well. Instead of a gel, it uses the chitosan and dressing to slow down and stick the blood and platelets to create a clot. Again, for those with poor clotting factors, this is a good choice.

[gallery type="rectangular" size="medium" ids="2338,2339,2340"] These are in no particular order, and I'd recommend all 3 as a good decision. While the Military recommends Combat Gauze as #1, their demographic is healthy young soldiers who likely don't have poor clotting factors. Even then, blood loss can cause hypothermia and ruin their clotting factors, making Celox or Chito-gauze an option as well. Now that you know why and how, you can make an educated purchase. Personally im a fan of Chito-Gauze, but I'm also a reasonably trained medic...

All of these products can be found at shop CAG!

A product is only as good as your training, so if you leave it on the shelf, it won't live up to it's potential in a stressful situation. Have a couple non-hemostatic gauze as "trainers" to practice wraps and packing wounds as free drills to keep sharp. You do dry Fits in a cargo pocket

Knock-off medical supplies: Is saving your wallet worth risking your life? 

This warning fully understands that many who seek self sufficiency are not made of money and may be on a fixed income. It's always nice to get a deal on something by finding it online for cheaper, but when does the expression "You get what you pay for" come into play? When does quality become priority over price?  bogusCAT Medical Supplies should be that line in the sand. In  CATS eat RATS: Tourniquet Comparison Article we addressed the difference between tried and true and unproven medical interventions, but now we're talking Knock-Offs and copy cats from trying to save a dime by going through unreliable vendors. Some may justify buying a cheaper tourniquet on non-reputable dealers because the differences aren't obvious to the untrained eye. Would you do that on medical supplies, such as heart or cancer meds? I've seen many post pictures of their medical gear and I've caught fakes, knockoffs and at a minimum outdated gear. For instance, China has a terrible problem with infringing upon patents and not caring about which products they make look-alike. While it can often be harmless stuff such as clothing, there is simply no cheap way to go about quality medical supplies. If there is one thing to not be frugal about, I'd recommend it to be what you have to use on the worst day(s) of your life. I've noticed no explanation needed for people to drop hundreds and hundreds of dollars into weapon accessories, just to turn around and relentlessly search Ebay or auction sites for used or knock off medical supplies. While I'm not denying the effectiveness of firearms and self defense, I will rebuttal with frequency of medical emergencies. How many times in your life have you needed to use your firearm in relation to times you've needed medical intervention? Nobody is immune to this, and you can't always trust "How to spot a fake" guides. Some are nearly identical and it is a fact that even the U.S. Military has bought batches of fake CAT tourniquets that have made their way into the battlefield, where they have failed when needed most. They are frequently used by "Military Simulation" (MILSIM) / Airsoft Operators to match their Plate Carriers to what the SOF uses without the cost. Their game is not life or death, but ours is. [caption id="attachment_1229" align="aligncenter" width="620"]The Boston Bombing is a testament to the proof of tourniquets in civilian, especially mass casualty incidents. The Boston Bombing is a testament to the proof of tourniquets in civilian, especially mass casualty incidents.[/caption] You may get lucky when you roll the dice, but I'll stack the odds in my favor and go into a situation with superior training and equipment. Use a reputable dealer to negate the risks associated with subpar products that you, your loved ones and your patients will need in the most common factor of emergencies: Medical Injuries and Illness. References: CAT Knock-Off - http://www.scribd.com/doc/31121665/Combat-Application-Tourniquet-GEN-III-vs-E-CAT

What is the first Antibiotic, or even Medication, that one should stockpile for Survival? 

Easy question to answer! Self sufficient personnel often ask Austere Medical Professionals which medications, especially antibiotics they should stockpile to treat themselves or others in preparation of a time where the medical system may have collapsed, from geographical instability such as a Katrina like event to an economic event mirroring or worse than what Greece is currently going through.antibiotics Easy question to answer! Self sufficient personnel often ask Austere Medical Professionals which medications, especially antibiotics they should stockpile to treat themselves or others in preparation of a time where the medical system may have collapsed, from geographical instability such as a Katrina like event to an economic event mirroring or worse than what Greece is currently going through. My answer for which antibiotics/meds one should stockpile for that situation is none, maybe over-the-counter meds.  You're going to have to work hard to get from "None" to "Some."  Give me a second to explain myself.

Green Beret moderated forum only $1 a month!

You can do a lot of harm by taking or giving medications, even the right ones. Best case scenario it didn't help at all, it could make it worse, and worst case be fatal. There is a reason why medical professionals are the only ones who can give certain medications. I'm not saying you need to rush out and go to Med School, but I am saying you're going to have to study and learn. While Medical Professionals have the foundation of schooling, that is not where knowledge is gained, it's where it just begins: What separates successful medical providers from the rest is studying and continuing to learn. So if a Doctor studies medications, why aren't you? Let's put it this way, You owe your patients, including yourself, the best possible treatment they could receive. Truly understanding why you're doing something is different from, "I'll buy Medication 'A' incase they have Sickness 'A'." Knowing which medication to give for which illness or injury is a knee-jerk reaction that does not account for obstacles and makes clinical judgment lazy. That's right, lazy. Medications are not just to be acquired and then left on a shelf. You don't treat by asking them to open their mouth, then throwing pills at them and whatever lands in there is good to go. You need to put some serious study hours in.

Join the Crisis Application Group!

It's the same concept as your Concealed Carry Weapon, you don't (or I hope you do not) buy it, slap a magazine in it and never touch it again; You do dry fire drills, go to the range, have spare parts, maintain and clean it. Weapons often get all the glamour, but the truth is you're far more likely to face a medical scenario, so why would you neglect the tools of the medical world? If you're going to use a medication you should know how it works, how much to give, side effects, alternate medications, and why you are giving it, etc. etc. Before that, you should know the patients history, especially medications, allergies. If they are allergic to cephalosporins, is Keflex good to give, or would you rather give Cefalexin? Is it used for gram positive or gram negative bacteria? Which antibiotics do you give for viruses? Will they survive without antibiotics? Why would you want to treat a teenager with strep throat? Now, The first antibiotic, the first medication someone should stockpile is a pharmacopeia as well as other references such as a Nursing Drug Handbook. [caption id="attachment_1968" align="aligncenter" width="600"]The good news is knowledge weighs nothing and you can take it with you everywhere! It's never hurts to have a few books on hand to double check, though. The good news is knowledge weighs nothing and you can take it with you everywhere! It's never hurts to have a few books on hand, though. There is a lot to remember and reference.[/caption]

"What if medicine is not my thing?"

If you're not that dedicated or medicine is not your forte, that is understandable. A minimum option that I wholeheartedly recommend for medical basics is the book, "When There Is No Doctor." It's used in countries as a medical reference for places that are much too far away to get help and casualty evacuation can be a voyage, much like what you and I prepare for. In addition, You can still benefit from keeping your stocks of medication, they are great to barter but may not be your level to administer care. Learning the chemistry and effects of medications takes YEARS of education and practice. Don't be in a hurry and don't settle for Google. Locate and learn how to use the references that the professionals use! CAG runs a forum called CAG NET, join and ask questions!

Firearms, Tactical & Defense Training

( Long term, after Tier 1 & 2 established? ) Which medical kits are right for you: First Aid Kits, Pouches, Aid Bags or more?

Preparing for medical intervention can range from a band-aid in the medicine cabinet to extensive medical kits. Deciding on medical equipment when expecting to be in an austere, survival, disaster or other situation depends on what you know how to use as well as how much you can carry on foot. For situations that involve a vehicle or close to home, the weight and bulk is not as much of an issue. On that basis I will address the variations of medical kits in a tiered system from small first aid kits and everyday carries, to Aid bags, to large Truck bags or cases in the house. 1.) Basics - Every Day Carry, Minimalist, Clandestine Medical Supplies: This is the easiest level for all skill and financial levels, with little to no weight, while offering some medical capability in any and all situations. In a former article we discuss Every Day Carry of a tourniquet added for extremity bleeding.  A hemostatic gauze could also be added to account for non-compressible hemorrhage, or areas where tourniquets can't control the bleeding. For those at risk of a severe allergic reaction, an Epi-pen is a must ( link article) 2.) First Aid Kits (IFAK) and Pouches: The next step up, an IFAK or medical pouch on yourself or nearby means being able to handle more during your Trauma Patient Assessment (MARCH-E). This moves on from just tourniquets and gauze to Nasopharyngeal Airways, Vented or Occlusive Chest Seal(s) , 14G Needle's for Needle Chest Decompression, and a few other items your situation may warrant. Epi-pens, Gloves and a few others items can easily be added to the kit, as well as duplicates of the basics. The C.A.G. Tier 1 MedPack offers all the essentials to care for an emergency. 3.) Aid Bags - The Aid Bags go multiple different ways. You must tailor it to your situation, which may change. For examples I will list the different roles battlefield medics fulfill. No two medics are alike, even if their job is the same. If your aid bag will be in a truck or vehicle nearby, it can be filled to the brim and you can enjoy more medical capabilities. If you are wearing your aid bag, whatever you have on your back is what you and your Emergency Action Group have. If you are staying out for extended periods of time, you need to bring a lot with you to account for everything that may go wrong when you can't seek medical help. If you plan on going through urban situations or in tight spaces after a disaster, you'll want a bag with a small silhouette and to add some high visibility markings, panels, chemlights and maybe whistle. Tips:
  • "Hot-wire" your Aid-Bag to save time. Placing Labels provides easier access. Putting tape where the openings of medical equipment are save time when motor skills are impaired by adrenaline.
  • You should train your Emergency Action Group on where everything is in your bag. If they need to grab it for you, or get something inside, perhaps even treating you, you'll be thankful that they are not lost in the many pouches an Aid bag can have.

Hypothermia's Deadly Role in the Trauma Patient

hypothermia It's 120 degrees on a hot summer day and your patient is dying of...hypothermia. You've controlled hemorrhage, have a patent airway and your patients respiration is stable. Why would you be worried about hypothermia? You don't need to be treating your patient on an iceberg for hypothermia to effect them. It's the 4th leading cause of death in Afghanistan and nearly 2/3 of all patients admitted to the Emergency Department have some form of hypothermia. It only takes a patients core going under 95' degrees to be considered hypothermic, which can happen even in 120' weather, especially if you've lost enough blood that your body is unable to stabilize itself.  There is a reason hypothermia has earned it's place in the algorithm "MARCH" and needs to be addressed in your austere medical considerations.  If you haven't got it by now, I'd recommend adding a survival blanket as a minimum, or an Hypothermia Prevention and Management Kit or HPMK. We will go over the benefits and how to use them because a proper wrap will save heat and it's more than just putting a blanket on them. Survival Blanket / "Space Blanket" Hypothermia Prevention and Management Kit (HPMK)

(draft, need Al + Jays insight) Low-Light Treatment of Trauma Casualties

Low light patient treatment is not only for the warfighter on a night mission. In emergency situations where one may sift through rubble after a natural disaster or through buildings in an urban jungle without electricity, it can be difficult to even manuever in no/low-light conditions, especially if you lack night vision capabilities, do not have light, or the tactical situation does not permit you having heavy illumination. Points to write about:
  • Chemlights ( cut package for directional lighting )
  • Headlamps (when tactical situation permits. L-shaped flashlights is a cheaper alternative)
  • Advanced: Cost of night vision 
  • Either way, treatment of the patient will require clinical decision making. Are you able to use light or no? Is the scene safe (the lights are off), is time of the essence (structural instability) and do you know the Mechanism of Injury (how he got hurt.) 

(Draft ) Welcome to Thoracic Park: Austere Respiratory Management of the Trauma Patient

This article will be addressing the "R" in MARCH-E. Massive Bleeding Airway Respirations Circulation Hypothermia / Head Injury Evacuation
  1. Before we know what we're doing, we should know "Why"      (Basic anatomy)
  2. How-to exam and what you're looking for
  3. Injuries and how to treat (flail chest, pneumo/hemo, etc.)
(Insert occlusive vs vented article) Video of a Needle Chest Decompression from the inside: ( Note during the video expansion of the lung before needle entry and after) [youtube https://www.youtube.com/watch?v=co9_RLN78IY&w=560&h=315]
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