Medical

Tourniquet Conversion

Scientific knowledge evolves. As mankind discovers more information, the view of our world and how it works changes as well. The use of tourniquets, which I have discussed at length a couple of times on this very blog, are a great example. We were once taught that, once a tourniquet goes on, it stays on unless the patient is in the room with a trauma surgeon. That turns out to be only partially correct.

At the end of the day, trauma is a surgical emergency. What a trauma patient needs is access to that trauma surgeon. Getting a patient to the hospital within a rapid timeframe, often referred to as “the golden hour” greatly increases the patient’s chances of survival. Remember that serious trauma is first and foremost a surgical emergency. Trauma patients don’t need a tricked out first aid kit- they need a trauma surgeon. All they need you to do in the field is keep them alive and prevent them from furthering their injury until they can get on the operating table.

For that reason, tourniquet training for most Americans has followed simple, strict guidance: apply one high and tight to limbs to stop life-threatening bleeding, and leave removal to advanced medical care personnel. That is no longer the case.

So what changed? The war in Ukraine. In the US, and in US controlled battlefields, people who receive gunshot wounds are one helicopter ride away from a trauma surgeon, and the vast majority of the patients make it to the surgeon’s operating table within that hour and have good results. In Ukraine, the nature of the war there is such that almost no one gets a helicopter ride, and with killer drones circling everywhere, very few of those injured are transported by ground in anything resembling even the “golden day or two” and, if they are wearing a tourniquet, wind up wearing it for days. Casualty evacuation in Ukraine often exceeds 6 hours, and the liberal use of limb tourniquets may have increased morbidity.

That sets up a whole list of new problems.

Leaving a tourniquet on for hours or even days causes other issues. Once a tourniquet is in place, it stops blood from flowing to the affected limb. Once deprived of their blood supply, those cells begin taking measures to protect themselves, and after a period of time, those cells die. As they die, they release their contents into the surrounding tissue. When the tourniquet is removed, those contents make it to the kidneys and clog them up with all of that debris. The condition is called rhabdomyolysis. The longer a limb tourniquet is in place, the higher the risk of compartment syndrome, vascular thrombosis, rhabdomyolysis, and irreversible myonecrosis resulting in major tissue loss and often necessitating limb amputation, kidney failure, and death.

If bleeding is controlled with a tourniquet, attempts to remove the tourniquet as early as possible to avoid the negative consequences are essential. However, if the removal is not done correctly, there is a risk the bleeding that the tourniquet was supposed to stop will also kill the patient. The act of removing a tourniquet (called ‘tourniquet conversion’) is now changing the training being put out to US special forces troops, and is especially important to preppers here in the US.

What this means for you

In the US, we are usually a quick helicopter ride away from a trauma surgeon, but that may not always be the case. In a disaster or TEOTWAWKI situation, those helicopters aren’t coming. At the same time, a tourniquet left on for more than 2 hours can itself be a hazard. Before attempting this, please review my post on treating gunshot wounds that you can find here.

Important: Never attempt tourniquet conversion if the patient is in shock, the wound cannot be continuously monitored for re-bleeding, or if the tourniquet is applied above a traumatic amputation.

Shock being defined here as the loss of consciousness, or a blood pressure less than 90/xx.

The Conversion Steps (The “Plus-1” Method)

  1. Prepare: Place a second, loose tourniquet on the bare limb just above the first one, but do not tighten it yet.
  2. Pack: Firmly pack the wound cavity with hemostatic gauze (if available) or standard rolled gauze, maintaining direct digital pressure for at least 3 minutes.
  3. Dress: Apply a pressure dressing securely over the packed wound.
  4. Release: Slowly loosen the original tourniquet (over at least 1 minute) while meticulously observing the wound for bleeding.
  5. Monitor: If bleeding is controlled, leave the primary tourniquet in place but fully loosened in case bleeding recurs.

Optimal conversion should be attempted within 2 hours of the initial application when conditions are safe and stable. If bleeding restarts upon release, re-tighten the primary tourniquet or utilize the newly placed backup tourniquet.

For more information, see the article Tactical Medicine Tourniquet Conversion or consult the sources below:

Sources:

Misuse of Tourniquets in Ukraine may be Costing More Lives and Limbs Than They Save.

Rethinking limb tourniquet conversion in the prehospital environment (pdf warning)

Tactical Combat Casualty Care skill card: Tourniquet Conversion (pdf warning)

Tourniquet Conversion: A Recommended Approach in the Prolonged Field Care Setting

Tourniquet Conversion: The Critical Skill Nobody Teaches After You Stop the Bleeding (2026)

By Divemedic, ago

Sweat and Drinks

Sweat, or perspiration, is the primary means that humans use to cool themselves through the use of evaporative cooling. Very few mammals actually use perspiration as a cooling mechanism: in fact, other than a few primates, horses are the only mammals that use perspiration to cool down.

Sweat is 99% water. Dissolved in each liter of this water are the following minerals:

  • Sodium 900mg
  • Potassium 200 mg
  • Calcium 15 mg
  • Magnesium 1.3 mg

This means that perspiration has a much lower concentration of electrolytes than does blood. Still, as we sweat, we are not only losing water, but a lot of key electrolytes. If you are sweating heavily, you are losing more than just water, and that needs to be replaced. If you aren’t sweating heavily, then you shouldn’t have a lot of these because too many electrolytes is just as bad as not enough of them, especially if you have high blood pressure or heart failure.

There are a ton of electrolyte drinks out there: Gatorade is perhaps the most well known, but there is also Pedialyte, as well as a plethora of others. My biggest issue with many of these drinks is that they also contain an incredible amount of sugar. That’s why I only drink the zero sugar versions of these.

Gatorade has the electrolytes, but also comes with a lot of sugar. It carries 2 grams of sugar, 13.3mg of Sodium and 4.2mg of Potassium per ounce. I only drink these when I am exerting myself, and even then, I only drink the zero sugar versions. Cost is about 65 cents for a 16 ounce serving.

Liquid IV is a powder that is mixed with 16 ounces of water. When mixed, it carries 0.7 grams of sugar, 31mg of Sodium, and 23 mg of Potassium per ounce as mixed. I haven’t tried this one, but I know a lot of people who swear by it. Cost is $1.38 per 16 ounce serving.

LMNT (pronounced “element”) is another powder. It has 0.8g of sugar,16.5 mg of Sodium, and 12.5mg of Potassium per ounce as mixed. Cost is $1.30 per 16 ounce serving. I have never tried it, but I have seen advertising for it.

Pedialyte is a powder that is designed to replace electrolytes in children. It has about 0.675g of sugar, 16.25mg of Sodium, and 11.25mg of Potassium per mixed ounce. Cost is about $2 for a 16 ounce serving. I know that there are some athletes that like this stuff, but I hear that it tastes like armpit sweat.

I drink Gatoraid zero or another drink called Propel. I think they did well for me because my electrolytes were just a tiny bit low when I was in the hospital. Had I been drinking water, they would have been much lower, due to perspiration losses.

The disclaimer: I don’t advertise, and receive nothing for my reviews or articles. I don’t think that I ever will. I have no relationship with any products, companies, or vendors that I review here, other than being a customer. If I ever *DO* have a financial interest, I will disclose it. Otherwise, I pay what you would pay. No discounts or other incentives here. I only post these things because I think that my readers would be interested.

By Divemedic, ago

More on Medicine Preps

There are those who will tell you that learning CPR is a waste of time because when society collapses there won’t be any hospitals to complete the chain of survival. That’s shortsighted. Each day in the United States, one thousand people go into cardiac arrest. Preparing for disaster doesn’t just mean preparing for a society ending event. Most disasters are personal.

When each of my parents passed away, I was struck by the fact that the rest of the world continued as it did the day before, even though my own world had experienced such a shock. That’s the nature of disaster- they can affect a single person, a household, family, region, or an entire nation- even the world. It is prudent to prepare for long term, widespread disaster, but the one you are most likely to face will be limited and personal.

I spent my career responding to disasters, and most of them involve just a single person. Start small: Learn first aid, learn CPR, all because knowledge is power, and once attained, knowledge is never wasted.

By Divemedic, ago

It’s Hot, Dammit

A local man was part of a landscaping crew, and wasn’t feeling well because he had used a little meth that morning. His coworkers told him to go take a break in the truck with the air conditioner running. He crawled in and passed out without starting the truck. That day, the heat index was 105 degF. Inside of that uncooled truck, it was much higher. An hour later, they went to check on him and found him unresponsive and covered in vomit, so they called 911. The ambulance crew rushed him to the ED, and he went into cardiac arrest during the trip to the hospital.

When he arrived at the hospital, his rectal temperature was 110 degrees F (43.3 C). We worked him for an hour and a half. I was in charge of getting fluids into him. I pressure infused 6 liters of refrigerated Normal Saline into him. He was covered in cold blankets and had a fan blowing on him. We finally got his rectal temp down to 100degF, and got pulses back. He wasn’t even 30 years old, and wound up dying later that day of the heat stroke that literally cooked his brain.

I saw Graybeard’s post about the hot days of summer, and I will second that. The people who live here know that anything needing to be done outside is best done before 11 am, when the thermometer typically breaks 90 deg. It isn’t the temperature, it’s the dew point. As of right now, the dew point here in Sector Ocho is 73 degF. Yeah, we do this every year. Here we are complaining about humidity from back in 2016.

The dew point temperature is the temperature at which the air can no longer hold all of its water vapor, and some of the water vapor must condense into liquid water. At 100% relative humidity, the dew point temperature and the air temperature are the same, and clouds or fog can begin to form. Dew point is the best indicator of comfort in a hot climate. Once the dew point of the air exceeds 66 degrees Fahrenheit or so, the air begins to feel hot and uncomfortably stuffy. The reason for this, is that your perspiration can not evaporate to cool you off.

The thermometer temperature and the dew point are used to calculate the heat index (feels like) temperature. Any heat index above 125 degrees is likely to produce heat stroke, which is deadly.

Here in Florida, there are 4 seasons:

Hot: March through May
F’ing Hot: June through mid September
Still Hot: Mid September through Mid November
Snow Bird: Mid November through February

When it’s hot, you get your outside work done in the morning, then stay in the air conditioning until at least 4:30 in the afternoon, when the afternoon thunderstorms come calling. That is what we do from mid June until about the middle of September.

By Divemedic, ago

Be Positive

Miguel points out that many people don’t know their blood type. He says you should find out. It will help you avoid what happened to my friend when he got shot. He needed blood, but we didn’t know his blood type. He kept telling us to be positive, but it’s really hard to do while your friend is dying.

Get yourself a blood tag like one of these, and affix it to your kit, or to your usual range attire. It will save some time when time is critical. (And no, my blood type isn’t B+)

By Divemedic, ago

Posturing

The nice folks over at GunFreeZone posted a link to a video and expressed an opinion on posturing. I invite you to go and check it out. Unfortunately, that opinion is incorrect. JKB makes the claim that the loser of the fight is displaying decorticate posturing. He is wrong.

What you see in the video is decerebrate posturing. In the difference lies a huge change in prognosis. All posturing is a common outcome of severe brain injury. It refers to involuntary and abnormal positioning, and the presence of posturing after TBI suggests a poor prognosis.

Both types of posturing often indicate some extent of damage to the brainstem, which is the part of the brain that controls important functions like breathing. Decerebrate posturing, which is what we see in the video JKB linked to, is caused by damage to deeper brain structures and is much more common than the other type, decorticate posturing. Decorticate posturing is caused by damage to both hemispheres of the cerebral cortex and is rarer than decerebrate posturing, but is generally associated with better survival rates.

Generally, the recovery outlook for individuals with abnormal posturing after brain injury is poor. Even though there are instances where individuals regain consciousness and recover, only 37% of those who display decorticate posturing after a head injury survive. Only about 10% of individuals with decerebrate posturing survive.

In the video JKB links to, the individual displaying this posturing has one thing going for him: Youth. If he is admitted into the hospital within 6 hours of his injury, he is likely to double his chances of survival, even though it is still likely that he will have some permanent disability. So an 80% chance of death, and a 20% chance of permanent disability. All of that from a punch to the head.

Think about that the next time someone says that a concealed carrier should just take “his beating like a man.”

By Divemedic, ago

Airplane Medical Kit

Because of the comments to the post about the doctor on the airplane, I wanted to do a follow up. So let’s first talk about what is in the medical kit on a commercial aircraft. The FAA requires an AED, and a medical kit that contains the following items:

The most common inflight medical events are:

  • Gastrointestinal/Nausea (31%)
  • Neurological, such as fainting or seizures (26%)
  • Respiratory (7%)
  • Cardiovascular (5%)
  • Dermatological (5%)

My wife was on an aircraft flying from JFK to Heathrow where there was a death in flight. The flight attendants cleared out the back row of the plane and put the body on the seats, covering him with a blanket. That is where he stayed for the remainder of the flight.

I myself have been on two flights were there were medical issues. In both cases, the flight crew called for medical personnel. I wasn’t going to volunteer, but no one else did, so I raised my hand. The FA brought me a radio headset that was connected to the airline’s on call doctor, who consulted with me and we agreed upon a course of action.

The first was a moderate allergic reaction (urticaria, wheezes, pruritus) on a flight from Orlando to Boston. The passenger got himself 50mg of IV diphenhydramine and some inhaled albuterol. He was fine and slept the rest of the flight.

The second was on a flight from Las Vegas to Orlando. It was a guy who was having himself an anxiety attack. He was hyperventilating and complaining of shortness of breath, chest pain, along with numbness and tingling to his fingers and lips.

The reason for it was hilarious. He had gotten married to his fiancé (a white woman) while in Vegas. He was Puerto Rican, and was dreading his mother’s reaction when he told her that he had married a woman (who wasn’t Puerto Rican) that his mother hadn’t even met yet. If you know anything about Puerto Rican mothers, you would know that they are much like Italian mothers. He had every right to be afraid.

Anyway, I told the doctor that his vitals looked good and I felt like it was an anxiety attack. The doctor agreed. I traded seats with his wife for about half an hour and talked him down. Once he felt better, I went back to my seat. An hour later, his wife came and got me a second time. During that second visit, his wife told mine that I was a very patient and nice man.

That’s it for my aircraft stories.

By Divemedic, ago

Childhood Development

When a child is very young, from birth to about 18 months, their first attraction is to their primary caregiver. The secondary caregivers are added to that, and the child remains firmly bonded to those caregivers until about 9 years of age. This early childhood bonding is important, because that is how children learn about trust: a parent being loving while caring and nurturing the child teaches them to trust. That the parent doesn’t “spoil” the child by over coddling also teaches the child a healthy mistrust that is important to a child’s development. If a person learns to trust others too much, then wind up in unhealthy, dependent relationships and never learn self reliance.

Anyway, the child at age 9 has learned a healthy balance between trust and mistrust, and soon this develops into a sense of independence that allows them the confidence to begin exploring relationships outside of the family.

At that point, children become attracted to (not in a sexual way) same sex peers (usually same sex peers, but there are some exceptions- think the traditional tomboy who played baseball with the boys) who are outside of the household. They begin to emulate those peers, children their own age, plus or minus a year or two. This learning behavior is a normal part of childhood development, and is driven by the fact that humans are social animals.

We emulate the behavior of other humans so that we can enter societal groups and not be outcasts. This normal attraction to same sex friends has been called the “normal homosexual phase.” Homosexual in this case not referring to an erotic, sex driven attraction, but to an emulation of those who would become a child’s social peers. Those of you reading this who are boys might remember this as your “girls are icky” phase. These are the days of summer camps, fishing with your best friend, or girls playing house and dolly. Skipping rocks, making mudpies, and playing pickup games of baseball. This is when children learn traditional societal roles and responsibilities.

There are adults who use this phase as an opportunity to confuse children. It is during this phase that children begin to form friendships and a sense of their role as it relates to the society in which they live. Those adults who want to take advantage of this have a narrow window of opportunity, because beginning about two years later, children begin to show the first signs of sexual attraction to the opposite sex. It is during this “normal homosexual phase” that children are most easily groomed into being confused about their role and can be swayed into accepting a nontraditional role such as transgenderism or homosexuality. The formative years from about 9 to 12 or so is when children form their sense of who they will become. It would be easy for a manipulative adult to convince a child that his deep friendship for his same sex best friend is really some sort of homosexual attraction of a more erotic nature, rather than of a developmental nature.

Children who are emotionally, sexually, and mentally abused or those who receive emotional trauma during these formative years are those who go on to experience mental health issues as adults. This is why allowing teachers to push these alternative roles upon children in the age groups from Kindergarten through seventh grade is so damaging to children.

This is also why there are teachers who are fighting so hard for access to children in this age group. It is access to young children that allows them to build the next generation of adults with misaligned emotional and psychological compasses.

By Divemedic, ago

Medicines to keep on hand

One thing that people who prepare for emergencies frequently overlook is medicine for “routine” medical problems. There are a couple of over the counter medications that I consider to be essential. When you are in a situation where medical care is not readily available, these medications can literally be lifesavers.

Acetaminophen: This one is good for pain and for control of fever.

Benadryl: This drug is good for allergic reactions, and also works well as a sedative and sleeping aid.

Ibuprofen: This is a non steroidal anti inflammatory. Anyone who has ever been in the military will tell you that this drug is used by them for everything from headaches to broken bones.

Immodium: Diarrhea is a killer because losing fluids and electrolytes can be dangerous. In a survival situation, take some as soon as the second incident of liquid bowel movement occurs.

Meclizine: This one is sold under many brand names. It’s good for mild nausea and can prevent vomiting. Like diarrhea, vomiting causes a loss of fluids and electrolytes that can be life threatening. It’s best to take this as soon as you feel queazy. If you wait until you are vomiting, it may be too late. Just remember that it can make you drowsy.

I’m sure that there are others I have forgotten. I am open to suggestions on what you may feel is essential.

By Divemedic, ago