I'm enrolled in an EMT-B/WEMT course but haven't started yet, so I've been reading my textbook etc. While reading about external bleeding, I remember having heard something about how the military has moved tourniquet use to the first-line treatment — before direct pressure — for substantial extremity bleeding. I'm curious, then, why EMT-B protocols (I looked at CT, NY, and NH) don't seem to suggest immediate application of the tourniquet, for, say, traumatic amputation due to an MVA or something, whereas the military CLS and 68W guidelines suggest immediate application, as far as I can tell.
Perhaps it's because in a civilian EMS setting you'd expect closer proximity to a hospital with early life/limb-saving surgery that can reattach it?
I haven't started my class yet, so this is really just a question from somebody with a undergraduate-level understanding of biology.
Let me see if I can say this in a simple way.
First and most importantly, most EMS treatments are based on thinking from at least 20 years ago and closer to 40.
Prior to advancements in microvascular treatments and understanding of cellular inflammatory processes, it was thought that a TK would result in loss of the distal tissue or that in order to limit systemic response it would need to be amputated.
This is simply not the case.
Civillian and military medicine have very little overlap. Particularly in trauma and trauma systems.
First, from the system standpoint, there is rapid identification, treatment, and a highly choreographed move through a chain of experts the civillian world cannot devote similar resources to.
There is also the battlefield/remote aspect of treatment. In a situation where superior firepower is the first aid of best result, the faster you definitively manage a wound, the better it is for all.
Wound dynamics.
All wounds are not created equal.
The body has numerous molecular responses to wounds (which I don't feel like typing out now because I am reading about compliment activation by TLRs and NfKb signalling in sepsis)
but suffice to say that military GSW and blast wounds have different characteristics than more "civillian wounds" like truamatic amputations.
Even the types of gunshots makes a difference.
The high velocity rounds and blasts cause more diffuse tissue disruption that marginalizes most endogenous hemostatic mechanisms. ( larger lengthwise disruption, secondary cavitation etc.)
Some civillian rounds are designed to do the same thing by a different mechanism, glazers and hollow points to name a couple.
The combination of the environment, method of tissue destruction, and surgical resources of the military predispose to the use of TKs.
In the civillian world they are losing the stigma of a "last resort" but it is slow, particularly in EMS which moves well behind modern medicine.
The combination of rarely seeing wounds that require a TK over direct pressure along with proximity of definitive trauma resources in urban and suburban environments makes the TK really a device of rural providers and the rarest of grevious civillian injuries.
a TK is simply a tool in the bag. Like any tool, it is better for some jobs and not others. The military environment predisposes to the use of the TK. The civillian to direct pressure. It is not to say that there are not times when these tools are effectively applied in the opposite environment.
"Don't use a cannon to kill a mosquito"
Sorry, couldn't help myself.
