Tourniquets: Debunking the Myth

On a recent course we received criticism for teaching tourniquets in First Aid at Work. It seems that many organisations, including some of the Voluntary Aid Societies still won't teach them. This blog will look at the reasons we do teach tourniquets and hopefully debunk a few myths along the way.

In the 2015 European Resuscitation Council (ERC) Resuscitation Guidelines it states:

"Use a tourniquet when direct wound pressure cannot control severe external bleeding in a limb. Training is required to ensure the safe and effective application of a tourniquet".

Subsequently to these guidelines being released  I attended a meeting of the HSE First Aid at Work Quality Partnership that looked at how this statement from the ERC could be implemented. Following pressure from some of the members of the group it was decided that tourniquets should be taught "where risk dictated their use", eg chainsaws, moving machinery, etc, not to every first aider. Many members of the group were not happy with this position, however the guidelines of the group mean I cannot say more about what was actually said at the meeting...

Following this meeting we were left with the situation where many organisations subsequently taught tourniquets and some didn't.

In 2017, the Royal College of Surgeons Faculty of Pre-Hospital Care released a Position statement on the application of Tourniquets. This brought civilian protocols in line with established and proven military protocol and gave a definitive protocol for their use.

Unfortunately their are still considerable myths about the use of tourniquets: 

"They will lose the limb if you apply a tourniquet", 

"I wasn't taught tourniquets on my last course and was told they are dangerous"

"You are being irresponsible teaching them"

We have heard all of these on courses and they are all myths, not backed up by research and medical evidence.

Following extensive use in military situations, and a wealth of good research, there is now considerable evidence that tourniquets are effective, save lives and have a relatively low rate of complications following application. In a 2018 research study, Teixeira & Brown (1) examined the use of tourniquets in a Civilian Prehospital environment. They found an increased survival rate compared to those without tourniquet applied. However, perhaps more importantly there was no increased likelihood of amputation as a result of tourniquet application.

In 2017 Citizen Aid was launched. This award winning initiative was designed to teach the public what to do in case of a terror attack. The founders are legends in UK medicine and include Brigadier Professor Tim Hoggetts (Senior Health Advisor to the British Army and Honorary Professor of Emergency Medicine at the University of Birmingham) and Professor Sir Keith Porter (Clinical Professor of Traumatology at the University of Birmingham and Head of Traumacare).  Professor Sir Keith Porter also heads up "Traumacare" an organisation set up to "Increase Survival from Roadside to Recovery".

CitizenAid tackle the problem of not teaching tourniquets in an article on their website:  CitizenAid: Debunking the tourniquet myth

This article is well worth a read as it shows the clear frustrations of the UK's top trauma surgeons and founders of CitizenAid over torniquets in First Aid.

"The dogma that tourniquets can never be used is one that is still deep-rooted in the first aid community, despite the work of the informed to dig this out. The reality is that tourniquets are used in the operating theatres of our hospitals every day, to control blood loss while undertaking surgical procedures on limbs. In addition, the use of tourniquets during contemporary military operations has saved many lives from otherwise uncontrollable bleeding in amputated or mangled limbs. The evidence is published. And the soldiers who have survived blast injury having suffered single, double and even triple limb amputations are a testament to this.

So why does this mythology persist? The rationale for a tourniquet is life-threatening limb bleeding that cannot be controlled by other means. If this rationale is followed, a tourniquet can only ever do good. The alternative is that the patient will die.

The argument of harm assumes that tourniquets will be applied inappropriately, for injuries that are not life-threatening and that there will be no means of reassessing this within a time period in which avoidable harm occurs.

Unfortunately, the inverted logic of preventing the use of life-saving equipment disenfranchises the very patients that can be saved by the public in the early minutes following severe injury. It is a lazy logic of risk aversion, with the assumed belief that there will be no blame attached to withholding a tourniquet. This is a dangerous assumption. With the wealth of evidence that now surrounds the value of using a tourniquet, it will be difficult to argue that a death attributed to limb bleeding is anything other than avoidable. Where an active decision has been taken to dissuade the use of a tourniquet in these circumstances, how will that decision be justified morally and legally?"

We stand wholeheartedly by this statement from CitizenAid.
CitizenAid was designed to help the public perform lifesaving first aid in terror incidents and there is evidence that it has worked. We are proud to support the principles of CitizenAid in our training. Download the App and tell your friends/colleagues too!

We understand that a tourniquet was applied in the Manchester Arena bombing using the CitizenAid app as advice.

In the London Bridge terror attack again an improvised tourniquet was applied.

In both cases lives were saved due to the quick thinking of bystanders, who didn't listen to the myths about tourniquets.

Let's be frank, if they had not applied improvised tourniquets quickly, then the casualties would most likely have died before medical assistance arrived. Major bleeding can result in death in a matter of minutes and certainly before an ambulance arrives!

So, we are proud to be an organisation that teaches tourniquets routinely to our students:

 They are easy to apply and first aiders shouldn't be frightened of them.

At Marlin we constantly look at what we teach and why we teach it.

In the last few years we have changed our protocols in many areas to offer our customers, and their staff, the most up to date and evidence based training possible. This means that at times what we teach will 'fly in the face' of what some other organisaions are teaching. However, we would rather lead the way with effective evidence based training and let the others follow our lead.

  1. Teixeira PGR, Brown CVR et al.  (2018) "Civilian Prehospital Tourniquet Use Is Associated with Improved Survival in Patients with Peripheral Vascular Injury".  Journal of the American College of Surgeons.  226(5), 769 - 776.e1