Myth: Tourniquets do not work on Double Bone Compartments

  [caption id="attachment_3670" align="alignnone" width="950"] Anatomy of arteries along forearm, leading some to incorrectly believe they run too deep to be properly occluded. [/caption]

      The placement of the tourniquet in the picture above would have some believe that it is ineffective due to it being over a " double bone compartment."    This post purpose is to address and dispel the common myth to avoid placing a tourniquet(TQ) on the forearm or lower leg because it might be less efficient at total arterial occlusion due to the anatomy of a double bone compartment, or might cause further harm due to a certain wound set.   If you have basic medical training and were taught "high and tight" is the only way to go, this is not saying don't go high and tight during Care under Fire or when hospitals are nearby, this is more a consideration for medical professionals in an austere environment where medical care is hours away and is not as applicable for the layman. Medical professionals have a higher level of care to deliver to their patients than just doing high and tight for every situation. Multiple sources are posted at the end of the article because I believe in evidence based medicine, not "I do it this way because my instructor told me." A study by Dr. John F. Kragh (US Army Institute of Surgical Research) who is a renowned tourniquet expert, found that not only is it not effective, it can be more effective and the benefits of proper tourniquet placement are key (Cited below.) Take into account that often times meaty thighs take two or more tourniquets and it can be easier to understand why a tourniquet would work better when there is a smaller circumference to compress. Why does this even matter?

 Tourniquets don't cause permanent damage until they are on for about 6-8 hours if done correctly, as early as 2 hours if done incorrectly in the case of venous tourniquets causing compartment syndrome. The body will physiologically loosen (even when applied properly) so re-assess your TQ's and expect them to come loose and need to turn the windlass again.. If tissue will be lost because this tourniquet will be on for over 8 hours, the TQ should be 2-4" above the wound to salvage as much tissue and save complications as possible. Optimally, if not an amputation, the tourniquet has not been on too long and the patient is hemodynamically stable, you will want to convert to a pressure dressing directly on the source of bleeding so you can have perfusion back in the limb, but only if you can monitor for re-bleeding. If you already have a "High and tight" placed by a non-medical provider such as a TCCC or First Responder, you can consider  at least approximate the tourniquet by placing a second 2-4" above the wound and loosening the high and tight. Your actions during initial treatment during your TCCC phases can come to bite you later, so consider not going high and tight if the situation is tactically safe. High and tight is for care under fire and non-medical professionals, but when tactically feasible the medical provider should strongly consider deliberately placing the tourniquet 2-4" above the wound,  converting it to a pressure dressing if the criteria is met, and at least approximating the TQ.Even if TQ's needed another revolution or two with the windlass when placed in these areas, the benefits of proximal placing are worth it.  Such is the standard put out by the Committee of Tactical Combat Casualty Care and taught in U.S. Army Combat Medic School and Special Operations Combat Medic School. Sources,  Evidence:

• Practical Use of Emergency Tourniquets to Stop Bleeding in Major Limb Trauma, Dr. John Kragh (U.S. Army Institute of Surgical Research)
• Converting a Tourniquet to a pressure dressing, Journal of Special Operations Medicine Fall 2015
• NAEMT TCCC - Medical Provider slides (Tactical Field Care has TQ Protocols)