# Need clarification on few techniques



## kaja (Feb 3, 2015)

Hi


I'm sorry if this topic wouldn't prove valuable for others or is off the line (and if that's the situation, feel free to delete it), but I'm in quite peculiar situation and need help from more experienced guys than I am.


For short, I'm just in process of training with one SOF medic, who, to my knowledge, is vell educated in tactical medicine and have lots of tours in sandbox/ a-stan. We ran few drills today, and few techniques were explained by him. My problem is, that they are sometimes in conflict with what I had learned during my previous medical career (3-year military paramedic school, civilian practice, BARTS, TCCC courses and so on....). I tried to find some studies/ guidelines/... regarding these techniques, but to no result.


So I'd like to ask you about your opinion on following practices:


All of Tq application process is a drill (like weapon malfunction drill,...) done always the same way. When deploying Tq use fast "whip" to un-fold it. In arm application after positioning it on landmark use 2-3 quick and violent tugs/jerks to tighten it and then using windlass. After securing windlass the loose end is run around windlass and back to the bracket and secured with velcro. When used on leg, always remove strap (SOFTT or CAT) from buckle, put it under knee and use "saw-motion" to get it up, then again using tugs and then secure as usual. Not much deviation from this procedure is allowed.

I'm specially concerned about "whipping", tugging and "sawing" velcro portion under leg.


Next is emergency trauma bandage/ any other bandage use. He really emphasizes covering edges of the "pressure pad" with wrap. Also after 2-3 the loose end (still rolled) is just secured under last wrap which is considered enough for ground transport to not waste time.
I see a potential risk in loosening of dressing, and don't see that much of a problem with uncovered edges of a pad.


For vitals check we're told to check breathing (breath sounds and chest rise), radial and carotic pulse at the same time to "get at least something" and again save time.

Also he doesn't recommend using pressure points and rather use limb elevation for arm bleeding (looks quite like some restraining technique with cas arm held in armpit and locked against knee, thus flexing extremity/muscles and reducing the bleeding).



Given his background, I'm worried that lots of principles I perceived as right are wrong, but I couldn't find any backing to his teaching other than his claims. And they doesn't make sense to me, which might be because of my limited anatomy/physiology/pathology knowledge...



So, if you can give me your opinion on mentioned procedures, I'll be very glad.



Thanks guys!


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## Ranger Psych (Feb 3, 2015)

Have you been through PHTLS?

One thing I don't think you're paying attention to is MOI and what that MOI actually does in terms of effects. Doing a Z-saw motion to get the TQ there on a bleed is going to be faster than trying to be all fucking ginger about it. You're putting a TQ on for a reason, it needs to get put there.  You have a natural gap at the knee to allow you to work up or down as necessary provided that you're dealing with penetrating and not blast trauma. If it's a stump you're working with, your job just got easier unless it's partially attached.  I personally put a knee in the femoral (and was hated for it) if it was training for a GSW TQ app since a good bit of weight there will provide pressure point as well as give me leverage to get it good and tight right off before applying windlass (or Ratchet, if you're old school). That way you're not playing the rotating game for 10 minutes taking up slack that didn't need to be there in the first place. Using proper method of bracing while getting your tightening down, you aren't going to do anything bad to the patient even if they have long bone involvement because you've got the leg somewhat immobilized when you do that.

Covering the edges of a dressing helps keep the wound clean, as well as increases the area that the dressing is applying pressure therefore making the dressing more effective due to the fact that you're restricting further capillary action through the compression. Not using the entire roll is a technique given that true heat of the moment you're going to be putting that shit on tight, and at least in Regiment we were finding our casualties that got treated by Ranger First Responders let alone squad EMT's and even Platoon medics were having dressings we'd have to loosen at the company or battalion CCP due to being too constrictive. Not an issue for a short haul but if you're spending a long time waiting for casevac then it's an issue, especially if you're in a tactical situation where removal of all of their gear to check nailbed cap refill etc is a NOGO due to that being inherent environmental protection as well as injury protection from terrain if on a skedco or anything else for that matter.

Pressure points are fine and dandy, but you're doing care in an emergent, military, environment. You want that pressure point maintained, it either means it screws with your ability to render aid for the patient or you take someone who's good off of security to apply that pressure point.  Which goes against fire superiority being the best medicine in a military situation. Prevent more people from getting hurt by being able to kill enemy deader quicker, etc.


In closing, instruction value regardless of who's teaching it can vary.  I'm not in the course, and it looks like you're more civ-med oriented which does a ton of shit for prevention of litigation moreso than actual necessity for proper care of patient's issues... you're in the army now, son, etc.


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## Muppet (Feb 4, 2015)

Tagged for later on...

F.M.


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## policemedic (Feb 4, 2015)

Very quickly...

The TQ should be stored ready for one-handed application to the arm so I'm not sure what you mean by whipping it.  If you're being told to crack it like a bullwhip, that's counterproductive as it would seem likely to close the loop. 

Most TQ failures are due to not properly tightening the constricting band before using the windlass.  That may be why he's advocating the tugs you describe.  The TQ has to be as tight as possible before tightening the windlass or hemorrhage control likely won't be achieved.  That said, I don't do it that way but whatever works. 

Pressure points are a waste of time, with the exception of kneeling on the femoral artery in the manner the very large Ranger described. 

As to the bandaging, leg TQs, etc., I agree with @Ranger Psych.


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## kaja (Feb 4, 2015)

First, let me thank you guys.

Of course, I had a discussion with instructor after the class, but some of his replies were "I was taught it that way, and it worked for me". Nothing necessarily wrong with that, but I like to have some backing to techniques I'm gonna use if possible.

Ranger Psych:
Never was through PHTLS.

Regarding MOI- it's always important, but these drills were run without any scenario/ MOI to work with and were treated as universal tool. The Z-saw wasn't really faster for me than routing TQ under extremity, and I would be worried about ruining CAT's velcro (IIRC some study showed that 30% of CATs on lover extremity were routed just through one slit, thus relying on velcro, and it's now recommended to use it single-slit during CUF to save time...) or shifting stuff in pockets way up where they may interfere with proper application. But as an option I'm OK with it, just I don't like it as a "A" option.

Agree with the knee to groin, and with importance of removing any slack. I just disliked "tugging" for the reason you mentioned. Could you describe the proper brace method please?


Dressings- thanks for pointing out the issue of overtightening. That didn't come to my mind, and is valid concern. Restriction of capillary action shouldn't be that much of a concern when used as a method of fixing packing material in the wound, but for larger abrasions- another good point. And making it "pretty" in training should help with applying it better in actual emergency situation at least.


By pressure points I meant the groin/brachial which could be pressed by knee while preparing Tq. Of course wasting manpower on holding pressure point for longer time is stupid, and colateralization of blood supply might start to make it ineffective.

And you're point on with me being more civ-oriented. Only real world experience I have if from ambulance or ER. Military medicine is all moulage/ scenarios so far...


policemedic:
By whipping I/ instructor meant way of disengaging the velcro holding it in folded shape ( maybe different way to fold it...). Do you have any pictures of proper storage method, because I'm confused now.


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## Muppet (Feb 5, 2015)

All that has been covered by @Ranger Psych and @policemedic. I cannot add anymore....

F.M.


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## amlove21 (Feb 11, 2015)

policemedic said:


> Pressure points are a waste of time, with the exception of kneeling on the femoral artery in the manner the very large Ranger described.


First of all, the answers out there in the thread are dead on. Well played.

I will only address the quoted- there are at least 2 Med AAR's floating around SOCOM specifically talking about this (knee inguinally to tamp femoral bleed), and they both involve the patient dying due to severe manipulation of an undiagnosed pelvic fracture. 

Rule of thumb- if there is an injury close to the pelvis containing enough energy to insult the largest, strongest artery in your body (femoral), you have to assume that the pelvis may also be unstable. Kneeling on that pelvis could quite possible injure and/or kill your patient. 

This obviously doesn't play if you're trying to gain inguinal control of a lower-leg type bleed (mid thigh down), but anything close to the pelvis I get very, very worried about kneeling on someone. 

I can tell you from treating 3 serious femoral bleeds, one of which I lost- you have to get aggressive. Way, way aggressive. However, if you miss a pelvic injury and fully separate the pelvic girdle, you are not going to save that patient. Putting a knee in some dudes groin when you're amped up is a pretty sure way to do that, so you better be sure that you can rule out the pelvic fracture before you do.


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## policemedic (Feb 11, 2015)

amlove21 said:


> First of all, the answers out there in the thread are dead on. Well played.
> 
> I will only address the quoted- there are at least 2 Med AAR's floating around SOCOM specifically talking about this (knee inguinally to tamp femoral bleed), and they both involve the patient dying due to severe manipulation of an undiagnosed pelvic fracture.
> 
> ...


 
Agreed, and good info.


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## Ranger Psych (Feb 11, 2015)

amlove21 said:


> First of all, the answers out there in the thread are dead on. Well played.
> 
> I will only address the quoted- there are at least 2 Med AAR's floating around SOCOM specifically talking about this (knee inguinally to tamp femoral bleed), and they both involve the patient dying due to severe manipulation of an undiagnosed pelvic fracture.
> 
> ...



Yep. My primary utilization of that technique was for a GSW to anything below mid-thigh and no additional trauma is noted... blast trauma I would be rather hesitant and while not ginger with anything I'd be taking additional precautions reducing my "use of force" on the patient specifically due to any skeletal instabilities that might be something not easily noticed. Fucking decepticon injuries (more than meets the eye, nyuk nyuk), etc.


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## policemedic (Feb 11, 2015)

Decepticon injuries. I am SO stealing that.


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## Muppet (Feb 11, 2015)

F.M.


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