Page 62 - Journal of Special Operations Medicine - Summer 2015

a mean civilian age of 37.2 years, with 49.1% of the care often preclude a complete documentation of the
population being male. Despite these differences, we circumstances surrounding procedures or clinical deci-
20
have shown the tourniquet and hemostatic gauze were sion-making rationale. Thus, explanations as to why a
both safe and effective within this population. tourniquet was placed first or why a wound was aug-
mented with hemostatic dressings are sometimes un-
Based on our experience, with 11.2% of cases (14 of clear. Also, in the majority of cases, the patients’ medical
125) requiring multiple tourniquets or hemostatic histories were unknown and thus undocumented. For
agents, each prehospital vehicle in our system currently example, the anticoagulation status was only known in
carries two tourniquets and two hemostatic dressings. 7.3% of patients (11 of 150), which could impact mor-
The cost for one CAT is $33.25 and for one QuikClot bidity and mortality in patients with external hemor-
21
Combat Gauze is $41.31. Thus, having two of each rhage. Finally, being a retrospective review, follow-up
22
per transport vehicle is adequate without adding exces- with patients in regard to outcomes and morbidity was
sive expense or taking up disproportionate space in oth- limited due to the distribution of patients throughout
erwise fully loaded vehicles. the state: only 40% of the patients were initially trans-
ported to our trauma center.
Training
To achieve and maximize effectiveness, training is vital. Our report provides a foundation for further investiga-
Training played a crucial role in our study for both the tion in civilian tourniquet and hemostatic gauze use.
tourniquet and hemostatic gauze. In our system, tourni- Inpatient follow-up from our statewide trauma data sys-
quet training includes computer-based didactic training tem is ongoing. Other needs include prospective studies
with hands-on practice, which was initiated 1 month with larger population sizes to determine effectiveness,
prior to implementation in June 2009. Subsequent skills and morbidity and mortality rates in varied civilian
testing within 6 months of implementation showed pro- populations.
ficiency of 98.5% (326 of 331 providers). For those
providers who failed this skill testing, immediate reme- Conclusion
dial training was completed. The follow-up skills testing
within 2 years showed a maintenance of proficiency at The use of tourniquets and hemostatic gauze in pre-
98% (350 of 357 providers). hospital civilian care is safe and highly effective, with
success rates of 98.7% and 95%, respectively. Further-
The training for the hemostatic gauze was similar to more, training and subsequent proficiency of skills are
tourniquet training. The computer-based and hands- maintained despite infrequent use of only about two
on training 1 month prior to implementation was de- times per month. Our single-system experience can be
ployed, but subsequent skills testing within 12 months applied to other prehospital care programs, including
only showed proficiency of 90% (338 of 375 providers). other first responders. Our experience has shown that
Nonetheless, with revisions of the guidelines and train- hemodialysis units may wish to stock tourniquets and
ing manual, the proficiency improved to >95% and has hemostatic gauze for emergency use in this heretofore
been maintained. unrecognized vulnerable patient population.

A major outcome of this retrospective study is the train- Disclosures
ing for and implementation of tourniquets and hemo-
static dressings with law enforcement and firefighter The authors have nothing to disclose.
units. As seen in our results, 22% of tourniquets were
placed prior to the arrival of EMS personnel. Of those, References
98.7% of the commercial tourniquets were successful, 1. Bellamy RF. The causes of death in conventional land war-
while the three improvised tourniquets (belts) were un- fare- implications for combat casualty care research. Mil Med.
successful. Additionally, with 7% of the tourniquets be- 1984;149:55–62.
ing used for hemodialysis-shunt hemorrhages, it may be 2. Champion HR, Bellamy RF, Roberts CP, et al. A profile of
beneficial for hemodialysis units and/or hemodialysis combat injury. J Trauma. 2003;54:S13–19.
patients to carry tourniquets, with the proper training to 3. Sauaia A, Moore FA, Moore EE, et al. Epidemiology of trauma
deaths—a reassessment. J Trauma. 1995;38:185–193.
help prevent exsanguination in the case of major shunt 4. Mabry RL, Holcomb JB, Baker AM, et al. United States Army
hemorrhage. rangers in Somalia: an analysis of combat casualties on an ur-
ban battlefield. J Trauma. 2000;49:515–528.
Limitations to this study include its retrospective nature 5. American College of Surgeons Committee on Trauma. Ad-
and small sample size. While the numbers are small, vanced trauma life support program for doctors. 7th ed. Chi-
cago, IL: American College of Surgeons; 2004.
ours is the first and largest civilian report of tourniquet 6. Lee C, Porter KM, Hodgetts TJ. Tourniquet use in the civilian
and hemostatic agent use. The realities of prehospital prehospital setting. Emerg Med J. 2007;24:584–587.

52 Journal of Special Operations Medicine Volume 15, Edition 2/Summer 2015