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innovation, emergency medicine, tourniquet: innovation, emergency medicine, tourniquetFigureFigureFigureThe tourniquet has certainly had its share of critics. We'll never know how much of the negative press was from improper education, poor logistics, or prolonged application times, but the criticism has persisted since the Civil War even though no evidence substantiates any particular opinion. The criticism was mostly anecdotal, and negative results were likely due to flawed medical infrastructure, not the device. Emergency tourniquets have now achieved a certain degree of respectability. Bolstered by the United States' military medical experience in Iraq and Afghanistan, emergency tourniquets have been found to be truly life-saving without being limb-compromising, as long as they are in place for no more than two hours. Success overseas prompted medical experts to advocate for using emergency tourniquets in civilian emergency medical services. A growing contingent within the medical infrastructure is calling for commercial tourniquets and appropriate training even for the general public, especially in light of our recent tragic mass-shooting events. Commercial tourniquets have already been introduced at public venues adjacent to or within automated external defibrillator stations. This makes perfect sense because the first responders in any mass-casualty incident are usually civilians. What if commercial tourniquets are not available? We can use an improvisational one. This is a last-resort device because complications could develop depending on its design, construction, or material, but it can save lives if the extremity is actively hemorrhaging and no one else is around, as was reported in several disaster situations. We came up with a laundry list of items that could be found anywhere to serve as improvisational tourniquets, and developed a simulation model to test our theory. A 1-2 kg pork loin stood in for an adult's upper extremity or a child's lower extremity. It was encased in netting and polyethylene food wrap, and placed in a serving tray. Surgical tubing (1-2 mm diameter) attached to an IV bag of normal saline was inserted into a tunnel in the pork loin, and a 3-4 cm incision (the wound) was made in the pork down to the tubing. Adding the Windlass Then we began collecting and using various common items as a tourniquet (e.g., scarves, ties, belts, scrubs, etc.). We tested each item's efficacy by measuring how much fluid was in the tray once we opened the IV and applied the tourniquet (time limit: 1.5 minutes). Each of us is of a different weight, size, and strength, which gave us confidence in our initial results. We measured the fluid accumulation for each of our attempts, and used that as our individual control and documented the results. We then repeated the tests but added an improvisational windlass (e.g., dry-erase markers, trauma shears, pens, mosquito hemostats, Schnidt forceps, etc.). We discovered that the windlass was a critical part of the tourniquet. The amount of IV fluid each of us lost was much less than the amount lost during our control experiments using the windlass. Using a dress-tie tourniquet only, the fluid loss by each researcher was 144 cc, 102 cc, and 102 cc for the three researchers. We added a routine hemostat as the windlass, and the fluid loss dropped to 36 cc, 60 cc, and 29 cc. It took effort, however, to twist these objects to achieve cessation of the hemorrhage. Next we tried using a telephone receiver. It was the best improvised windlass we tested, a benefit because telephones are found virtually everywhere. Repeating the same experiment but adding the phone receiver windlass, the fluid loss was 26 cc, 22 cc, and 12 cc. Not only was the phone receiver easy to apply, it was the easiest to twist and stopped the flow of fluid virtually immediately.FigureWe learned from our experiments that a pork loin can serve as a relatively inexpensive model for improvisational tourniquet training. We also found that a windlass is an important aspect in stopping a severe extremity hemorrhage. Applying pressure while twisting the windlass is critical because it's virtually impossible to tuck it into the tourniquet proper like you can with the commercial variety. Many items can serve as a windlass, but the phone receiver appears to be the most efficacious one to stop a major bleed quickly and is more ubiquitous than other items. We have tweaked our “Impede-the-Bleed” educational program for our students based on this preliminary study, teaching them how to make an improvisational tourniquet using a phone receiver when nothing else is readily available. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].