love how you explain everything so well, you are one of my favorite doctors to watch on RUclips. I learn a lot from your videos, keep up the good work. 🎉🎉🎉🎉🎉
You should be applying constant pressure with your knee or other bodypart above where you’re placing tourniquet to reduce the chance of bleeding out. Generally speaking you should have it as high as possible as well since most often whatever is remaining below the tourniquet on the extremity can be saved by an ER. Just my experience from Afghanistan dealing with amputations from IEDs. USMC, 07-12
Also where you’re applying the tourniquet is notoriously hard to control the bleed, especially in a blast where soft tissue tends to roll up into the cavity, which is why you slap the tourniquet closer to the shoulder. Also when in doubt crank the tourniquet down.
I double checked our guidance on location, as you’ve quite literally the life experience, but I wanted to check what we teach - and are told - The 2017 Royal College of Surgeons advises the tourniquet to be placed distally, rather than as far up the limb as possible in order to minimise additional tissue damage fphc.rcsed.ac.uk/media/2398/position-statement-on-the-application-of-tourniquets-july-2017.pdf I double checked another and the ANZCOR 2023 guidelines specify 5cm above the point of bleeding. www.anzcor.org/assets/anzcor-guidelines/guideline-9-1-1-first-aid-for-management-of-bleeding-226.pdf I wonder if there has been a change in guidance since Afghanistan? I’m aware that regrettably our medical techniques do change quite a bit as a result of what we learn during wars. I *believe* because of the care people like yourself provided we’ve greatly improved our limb loss rates out in the community now from things like traffic accidents et.
@DrJamesGill The US military generally goes with TCCC (Tactical Combat Casualty Care; pronunced as "T-triple-C") guidelines on casualty care, which have been constantly evolving over the last 20ish years as battlefield medicine advanced. TCCC guidance calls for two types of tourniquet application, hasty and deliberate. Hasty tourniquets are applied as high up on the extremity as possible, while deliberate tourniquets would be applied two to three inches above the wound site (so roughly five centimeters as previously mentioned). Hasty tourniquets are applied either while still under fire/in imminent danger or when the exact location of the injury on the limb is ambiguous (airing on the side of caution during the confusion of combat). Deliberate tourniquets are meant to be applied when the casualty (and aid provider) are no longer under threat/more thorough evaluation can be done. A hasty tourniquet should be replaced by a deliberate tourniquet at this stage if possible. (Tactical Combat Casualty Care Handbook, 2017 edition)
Great idea to keep in your car! As a retail worker I always have an ankle brace, two knee braces, bandaids, a box cutter, and my work gloves in my backpack in my car when I’m driving, and as a hiker I also keep my hiking pole in there too, and for safety I have an emergency blanket, a hand powered flashlight, and a multi tool but I never thought about a tourniquet.
This is very helpful, thank you Doc! I’m wondering if it is possible to have some videos on dealing with emergency situations like panic attack and hypoglycaemia?
Love the CAT and North American Rescue. We keep several TQs in our car, including a couple of child versions, and I make sure to carry one with me daily both around town and at work with the Forest Service. Just like anything else, make sure you train.
I do know that in some cases, military in Afghanistan, the tourniquet was released before the 2 hour mark, and a study showed it was truly better in these rare war instances to write the limb off, rather than trying to release and save the limb. If help is a long way away, or not immediate, it's better to stay alive. But YES to us all having these and thankfully we're all I hope close enough to a hospital not to have to make such a choice!
I have carried a TQ in my work truck and personal car after a bad workplace accident that thank god didnt need one, but if things had gone slightly differently, the poor guy would have had serious lacerations if not lost one of his legs. I realized afterwards that had that worse case happened, i'd have been totally inept to stop it. I think everyone should have one and know how to use it.
question, there is also a video about how this conversation goes if dementia is suspected and what to test for you as a GP. and one with a video if you, as a doctor, suspect that depression is at play. Still love you video❤
When I did a tactical medicine training, they told us you also have a limited window to remove the tourniquet yourself (I think it was about 20 minutes?) and once that window is closed, the tourniquet should only be removed by a medical professional.
Hey, when John Wayne did this, it always involved giving the patient a bullet to bite on. Did they stop teaching that? Or is that just another difference between the US and UK doctors?
Hello new patient! How do you spell the name? Amsi? How often is a finding a radial pulse practical when the limb has already been injured enough to require a tourniquet?
I had the same question about finding the pulse. Frankly finding anything but the most basic pulse is probably very unreliable for someone untrained (IMO) even under the best of circumstances. I have to imagine the more realistic approach is maybe give it two turns after tightening it to fingers-can't-get-under level. Some of the military guys here said training is to tighten it as much as you can but I have to imagine that carries risk of doing excessive damage at the application site - perhaps not as necessary outside of battlefield conditions? I'm completely speculating here.
This is for training. So let’s assume that the hand is gone. You can’t check for the pulse, so you tighten as much as needed to stem the blood flow. We highlight the checking the pulse so during training you know how much pressure can stop the bleeding PERSONALLY I disagree with “as tight as possible” because you could do extra damage, but to stop the pulse / bleeding it still has to be flipping right!
This is interesting. I've been doing First Aid courses in New Zealand every three years for 25 years. Every single one says tourniquets are not part of first aid. Too much risk for an inexperienced and under pressure first aider.
Really?? Now that’s interesting. My view is if you don’t have one, and you need one, and you are on your own. The patient will die. We train all of our students and even just tourists doing expeditions with them
I took my first aid for teachers, actually for preschool teachers, and in the end it was "Blood coming out is always bad, these are little children!" In other words act faster. Also, being up NORTH, if a child falls into cold water, they can surprisingly recover if treated properly from freezing cold water. So, don't give up even if it has been say 20 minutes. Even start treatment before 911 if it's an obviously super serious case, if you know what to do and call as soon as you get help or can. With adults it is always 911 first. It was an incredible class (I also took first aid for babies). I will say I had to update for CPR, as what I learned 20 years ago is all changed!
In the military they teach us to apply these tourniquets as high on the limb as possible and as tight as possible (until you can no longer turn the windlass)
That’s interesting. Obviously we’ve not got bleeding vessel here, but in the real world you’d tighten until the bleeding stops. As for as high a possible, I’d actually disagree there, and aim for above the major artery, as if you are using it for > 2 hrs it could mean extra tissue is damaged which doesn’t need to be However in all of those cases ultimately these things are life saving devices so priority one is life, priority two would be limb. So I suppose something that you do and works is better than something perfect that causes confusion and doesn’t work quite as well
Just to clarify location The 2017 Royal College of Surgeons advises the tourniquet to be placed distally, in order to minimise additional tissue damage fphc.rcsed.ac.uk/media/2398/position-statement-on-the-application-of-tourniquets-july-2017.pdf ANZCOR 2023 guidelines specify 5cm above the point of bleeding. www.anzcor.org/assets/anzcor-guidelines/guideline-9-1-1-first-aid-for-management-of-bleeding-226.pdf For ample if you lose the hand, going as high up the arm puts the entire arm at risk of tissue damage. Do you have a military guideline I could take a look at ?
@@DrJamesGill I do not have a medical guideline for the military. This is just how we are trained. The explanation I got on why we are trained to go "as high and as tight as possible" is because we wear baggy uniforms and in combat we carry a lot of gear on our person. In a combat scenario where someone gets shot in a limb, we wouldn't have the time to find out exactly where on the limb the wound is, nor would we have the time to turn the tourniquet windlass and keep checking to see if there is a pulse or not. Basically if a soldier is down and we see blood on their left arm, we automatically assume they've been shot in the left arm and we need to put a tourniquet on as high as possible, as tight as possible, and more importantly as fast as possible so that we can quickly get back to engaging the enemy if we need to, or get the casualty to a safer location. In some cases, the casualties are expected to keep fighting after putting a tourniquet on them.
@tyronesmith3812 ah that makes a lot of sense, and perhaps hopefully, once the casualty is in a safe location and you have time, hopefully a second more distal tourniquet could be applied? But I fully understand what you are saying now. A battlefield must be a terrible place to try to THINK let alone work on a casualty
I was under the impression that having applied a tourniquet that the pressure should be relieved for a few moments every 15 minutes, is this an old technique or in incorrect technique or just bad information?
Thankfully not. You wouldn’t be able to stop your own blood supply. That numb arm is likely nerve compression There is something called Saturday night palsy, where someone falls asleep and damages their nerve on the back of a chair due to positioning there arm hanging over the back
I could only imagine Dr gill on an MVA in his calm voice “I’m Dr gill and you have an arterial bleed, this tq is going to hurt but it will save your life” 😂
You should take a real trauma course and really learn how to apply that tourniquet. It goes as high as you can get it. Your teaching way outdated techniques
The 2017 Royal College of Surgeons advises the tourniquet to be placed distally, NOT as far up the limb as possible in order to minimise additional tissue damage fphc.rcsed.ac.uk/media/2398/position-statement-on-the-application-of-tourniquets-july-2017.pdf ANZCOR 2023 guidelines specify 5cm above the point of bleeding. www.anzcor.org/assets/anzcor-guidelines/guideline-9-1-1-first-aid-for-management-of-bleeding-226.pdf For ample if you lose the hand, going as high up the arm puts the entire arm at risk of tissue damage. Do you have an alternative guideline?
Placements wrong 🙄 and it's life over limb you don't just twist until no pulse you twist to no pulse plus bleeding slows or stops. Before applying you are to hold pressure
As a non medical person, I'd love to see more first aid videos to help educate myself a little bit until I can go on a course.
We’re certainly planning on doing more
Only Dr. Gill could make a lesson on a life or death emergency medical treatment so calming.
Crucial skills. I have to update my first aid certs. Got the basics in national non military service and more bare boned emergency aid at work.
love how you explain everything so well,
you are one of my favorite doctors to watch on RUclips.
I learn a lot from your videos,
keep up the good work.
🎉🎉🎉🎉🎉
Wow, thank you!
You should be applying constant pressure with your knee or other bodypart above where you’re placing tourniquet to reduce the chance of bleeding out. Generally speaking you should have it as high as possible as well since most often whatever is remaining below the tourniquet on the extremity can be saved by an ER.
Just my experience from Afghanistan dealing with amputations from IEDs. USMC, 07-12
Also where you’re applying the tourniquet is notoriously hard to control the bleed, especially in a blast where soft tissue tends to roll up into the cavity, which is why you slap the tourniquet closer to the shoulder.
Also when in doubt crank the tourniquet down.
True. I have thought that doing the video on the leg would have been better to simulate the applying constant pressure part.
I double checked our guidance on location, as you’ve quite literally the life experience, but I wanted to check what we teach - and are told - The 2017 Royal College of Surgeons advises the tourniquet to be placed distally, rather than as far up the limb as possible in order to minimise additional tissue damage
fphc.rcsed.ac.uk/media/2398/position-statement-on-the-application-of-tourniquets-july-2017.pdf
I double checked another and the ANZCOR 2023 guidelines specify 5cm above the point of bleeding.
www.anzcor.org/assets/anzcor-guidelines/guideline-9-1-1-first-aid-for-management-of-bleeding-226.pdf
I wonder if there has been a change in guidance since Afghanistan? I’m aware that regrettably our medical techniques do change quite a bit as a result of what we learn during wars.
I *believe* because of the care people like yourself provided we’ve greatly improved our limb loss rates out in the community now from things like traffic accidents et.
@DrJamesGill The US military generally goes with TCCC (Tactical Combat Casualty Care; pronunced as "T-triple-C") guidelines on casualty care, which have been constantly evolving over the last 20ish years as battlefield medicine advanced.
TCCC guidance calls for two types of tourniquet application, hasty and deliberate. Hasty tourniquets are applied as high up on the extremity as possible, while deliberate tourniquets would be applied two to three inches above the wound site (so roughly five centimeters as previously mentioned). Hasty tourniquets are applied either while still under fire/in imminent danger or when the exact location of the injury on the limb is ambiguous (airing on the side of caution during the confusion of combat). Deliberate tourniquets are meant to be applied when the casualty (and aid provider) are no longer under threat/more thorough evaluation can be done. A hasty tourniquet should be replaced by a deliberate tourniquet at this stage if possible. (Tactical Combat Casualty Care Handbook, 2017 edition)
this is advice that is important and applicable to the masses, excellent sharing of medical knowledge in your unique style Dr Gill, thank you.
I've been watching a lot of military videos in which they showed this tourniquet so it's super interesting to watch this detailed video also
Glad it was helpful
Great idea to keep in your car! As a retail worker I always have an ankle brace, two knee braces, bandaids, a box cutter, and my work gloves in my backpack in my car when I’m driving, and as a hiker I also keep my hiking pole in there too, and for safety I have an emergency blanket, a hand powered flashlight, and a multi tool but I never thought about a tourniquet.
Nice video Dr. Gill. I actually didn't know what a tourniquet was until now, so that new information for me. Also I hope baby Gill is doing well.
He’s doing well thank you
This is very helpful, thank you Doc! I’m wondering if it is possible to have some videos on dealing with emergency situations like panic attack and hypoglycaemia?
Love the CAT and North American Rescue. We keep several TQs in our car, including a couple of child versions, and I make sure to carry one with me daily both around town and at work with the Forest Service. Just like anything else, make sure you train.
I do know that in some cases, military in Afghanistan, the tourniquet was released before the 2 hour mark, and a study showed it was truly better in these rare war instances to write the limb off, rather than trying to release and save the limb. If help is a long way away, or not immediate, it's better to stay alive. But YES to us all having these and thankfully we're all I hope close enough to a hospital not to have to make such a choice!
We can provide prothetic limbs, we can’t do prothetic bodies yet
Amazingly valuable information. Thank you Dr.
Glad it was helpful!
Nice video, very instructive as always
Glad it was useful
The world is a violent, messed up place. Knowing how to do this is critical, regardless of where you are and why you're applying it.
👍
I have carried a TQ in my work truck and personal car after a bad workplace accident that thank god didnt need one, but if things had gone slightly differently, the poor guy would have had serious lacerations if not lost one of his legs. I realized afterwards that had that worse case happened, i'd have been totally inept to stop it.
I think everyone should have one and know how to use it.
I always believe knowledge is a life saver 😊
question, there is also a video about how this conversation goes if dementia is suspected and what to test for you as a GP. and one with a video if you, as a doctor, suspect that depression is at play.
Still love you video❤
Not yet. But they might be good ones to start
When I did a tactical medicine training, they told us you also have a limited window to remove the tourniquet yourself (I think it was about 20 minutes?) and once that window is closed, the tourniquet should only be removed by a medical professional.
Hey, when John Wayne did this, it always involved giving the patient a bullet to bite on.
Did they stop teaching that?
Or is that just another difference between the US and UK doctors?
We’re just trying to reduce lead exposure these days
This was Great 👍
Hello new patient! How do you spell the name? Amsi?
How often is a finding a radial pulse practical when the limb has already been injured enough to require a tourniquet?
I had the same question about finding the pulse. Frankly finding anything but the most basic pulse is probably very unreliable for someone untrained (IMO) even under the best of circumstances. I have to imagine the more realistic approach is maybe give it two turns after tightening it to fingers-can't-get-under level. Some of the military guys here said training is to tighten it as much as you can but I have to imagine that carries risk of doing excessive damage at the application site - perhaps not as necessary outside of battlefield conditions? I'm completely speculating here.
This is for training. So let’s assume that the hand is gone. You can’t check for the pulse, so you tighten as much as needed to stem the blood flow.
We highlight the checking the pulse so during training you know how much pressure can stop the bleeding
PERSONALLY I disagree with “as tight as possible” because you could do extra damage, but to stop the pulse / bleeding it still has to be flipping right!
Come for the ASMR, stay for the life saving advice
Would love to see this for the leg as well.
Same process basically. Just a thicker stump to put the strap around.
This is interesting. I've been doing First Aid courses in New Zealand every three years for 25 years. Every single one says tourniquets are not part of first aid. Too much risk for an inexperienced and under pressure first aider.
Really?? Now that’s interesting.
My view is if you don’t have one, and you need one, and you are on your own. The patient will die.
We train all of our students and even just tourists doing expeditions with them
I took my first aid for teachers, actually for preschool teachers, and in the end it was "Blood coming out is always bad, these are little children!" In other words act faster. Also, being up NORTH, if a child falls into cold water, they can surprisingly recover if treated properly from freezing cold water. So, don't give up even if it has been say 20 minutes. Even start treatment before 911 if it's an obviously super serious case, if you know what to do and call as soon as you get help or can. With adults it is always 911 first. It was an incredible class (I also took first aid for babies). I will say I had to update for CPR, as what I learned 20 years ago is all changed!
In the military they teach us to apply these tourniquets as high on the limb as possible and as tight as possible (until you can no longer turn the windlass)
That’s interesting. Obviously we’ve not got bleeding vessel here, but in the real world you’d tighten until the bleeding stops.
As for as high a possible, I’d actually disagree there, and aim for above the major artery, as if you are using it for > 2 hrs it could mean extra tissue is damaged which doesn’t need to be
However in all of those cases ultimately these things are life saving devices so priority one is life, priority two would be limb. So I suppose something that you do and works is better than something perfect that causes confusion and doesn’t work quite as well
Just to clarify location
The 2017 Royal College of Surgeons advises the tourniquet to be placed distally, in order to minimise additional tissue damage
fphc.rcsed.ac.uk/media/2398/position-statement-on-the-application-of-tourniquets-july-2017.pdf
ANZCOR 2023 guidelines specify 5cm above the point of bleeding.
www.anzcor.org/assets/anzcor-guidelines/guideline-9-1-1-first-aid-for-management-of-bleeding-226.pdf
For ample if you lose the hand, going as high up the arm puts the entire arm at risk of tissue damage.
Do you have a military guideline I could take a look at ?
@@DrJamesGill I do not have a medical guideline for the military. This is just how we are trained.
The explanation I got on why we are trained to go "as high and as tight as possible" is because we wear baggy uniforms and in combat we carry a lot of gear on our person. In a combat scenario where someone gets shot in a limb, we wouldn't have the time to find out exactly where on the limb the wound is, nor would we have the time to turn the tourniquet windlass and keep checking to see if there is a pulse or not.
Basically if a soldier is down and we see blood on their left arm, we automatically assume they've been shot in the left arm and we need to put a tourniquet on as high as possible, as tight as possible, and more importantly as fast as possible so that we can quickly get back to engaging the enemy if we need to, or get the casualty to a safer location. In some cases, the casualties are expected to keep fighting after putting a tourniquet on them.
@tyronesmith3812 ah that makes a lot of sense, and perhaps hopefully, once the casualty is in a safe location and you have time, hopefully a second more distal tourniquet could be applied?
But I fully understand what you are saying now. A battlefield must be a terrible place to try to THINK let alone work on a casualty
Is there surgery for people with glaucoma?
I was under the impression that having applied a tourniquet that the pressure should be relieved for a few moments every 15 minutes, is this an old technique or in incorrect technique or just bad information?
I can’t say if it’s old. But certainly isn’t the current protocol.
I’d highlight these things change every few years as we learn more
@@DrJamesGill Thanks, I work in construction and carry a tourniquet so I’m glad to have the latest information.
@hypo345 and I sincerely hope you never need it
You said we have 2 hours before tissue starts to die. Does that also apply to a numb arm we sometimes experience when we wake up?
More often than not, that's a nerve, not a blood vessel.
Thankfully not. You wouldn’t be able to stop your own blood supply. That numb arm is likely nerve compression
There is something called Saturday night palsy, where someone falls asleep and damages their nerve on the back of a chair due to positioning there arm hanging over the back
Thank you doktor
You are welcome
It hurts like hell to put on a tq 😂 but better than the alternative
100%. I had it applied to me first as the demo
I could only imagine Dr gill on an MVA in his calm voice “I’m Dr gill and you have an arterial bleed, this tq is going to hurt but it will save your life” 😂
❤
I prefer the Nelson Muntz method: “If you tie a string around your finger real tight, it’ll turn purple.”
I swear my just waking up ears heard" the cat fornicates"
FIRST!!!!!
He just puts me to sleep
You should take a real trauma course and really learn how to apply that tourniquet. It goes as high as you can get it. Your teaching way outdated techniques
The 2017 Royal College of Surgeons advises the tourniquet to be placed distally, NOT as far up the limb as possible in order to minimise additional tissue damage
fphc.rcsed.ac.uk/media/2398/position-statement-on-the-application-of-tourniquets-july-2017.pdf
ANZCOR 2023 guidelines specify 5cm above the point of bleeding.
www.anzcor.org/assets/anzcor-guidelines/guideline-9-1-1-first-aid-for-management-of-bleeding-226.pdf
For ample if you lose the hand, going as high up the arm puts the entire arm at risk of tissue damage.
Do you have an alternative guideline?
Placements wrong 🙄 and it's life over limb you don't just twist until no pulse you twist to no pulse plus bleeding slows or stops. Before applying you are to hold pressure