Recently, we had a visitor to site send in a great question about the placement of tourniquets over a single-bone structure versus a two-bone structure. Our medical director, Pat O’Neil, responded with some excellent information that should be kept in mind when you find yourself in a situation where you must apply a tourniquet to a friend, loved one, or stranger to stop life-threatening hemorrhage and save their life, and as much of the limb as possible.
Regarding your video on SOFTT application on a lower extremity, as a retired surgical RN, my impression is you apply it up on the thigh. The tibia and fibula interfere with compression of BK arterial flow. Any thoughts?
This is Pat O'Neil from Prepper Skills. Great to hear from you and your question is one that would come up frequently is some of the trauma courses I taught to deploying Docs and PA's going to Iraq and Afghanistan.
In a wartime scenario, when the medic is in a rush and possibly under fire, we teach them to apply all tourniquets in a "high hasty" manner. Placing the SOFTT or CAT as high on the thigh as possible. This is because many times they see a bloody uniform from a blast and there may be multiple injuries both above and below the knee. They aren't really sure where the injuries are and compression over a single bone is always better that over a two-bone structure.
Once the medic gets the patient to a safe location, such as a building with thick walls and overhead protection, the medic now has time to place a "deliberate tourniquet" on the patient. The injured leg or arm will be fully exposed to see if we can move that tourniquet down to the preferred location. We want to place the tourniquet two inches above the wound to try and save as much of the extremity as possible in case the leg needs amputation. The difference between a Below-the-knee amputation (BKA) and Above-the-knee amputation (AKA) is huge. BKA's will walk with only a slightly noticeable limp and may even return to running again. We have had several BKA's return to A-teams and deploy to combat again.
Now, to your question about compressing the arteries between the two bone structures of the fibula and tibia (and the radius and ulna) with a tourniquet. If the bones are still intact structurally and have not suffered a fracture, it may be extremely difficult to stop the bleeding. However, what we have noticed with arterial bleeding from the distal extremities is that the structures are not normally intact. usually one, or both, of the bones will have been fractured by a blast, bullet, or injury from a fall. The arteries are normally pretty well protected by these bones and for an arterial bleed to occur, many times those bones have been fractured. Once fractured, they are very easy to compress distally and you can get a very good tourniquet effect on a lower extremity. When you see a veteran with a BKA or distal Forearm amputation, their tourniquet was most like placed below the elbow or knee joint.
I have had multiple patients overseas where I put CAT and SOFTT tourniquets on a forearm or lower leg and they worked well.
The main thought is this: Try to save as much of the extremity as possible...without risking life.
On the other hand, I did have had a patient that took a bullet through the gastroc and was bleeding profusely. I put the tourniquet on and when I evaluated it a couple minutes later (he also had other injuries I was dealing with) the gastroc was still bleeding. Not as profusely, but at a rate I didn't feel comfortable transporting him in that condition. I applied another half-turn of the windlass and evaluated again a minute or so later. It was still bleeding so I put the tourniquet above the knee at that point. Life over limb. It was the right choice for that particular patient.
So the bottom line here is: Try to save as much of the extremity as possible for future functionality, without risking the patient's life. Attempt the tourniquet two inches above the wound, but if it is not successful on the first attempt, try a little more compression with another 1/2 turn of the Windlass. If still bleeding, place the tourniquet above the knee or elbow.
This is the current technique we are teaching the Combat Medics and in our Pre-Deployment courses for trauma refresher.
I hope this answered your question and please feel free to let me know if you have any other questions or concerns.
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Pat O'Neil, PA