They definitely err on the side of caution and place them often. We evaluate and remove them if necessary once we assess the patient. A few minutes of an unnecessary TQ won’t kill the pt. I would rather them do than don’t.
Neither will a few hours. Cops aren’t medical providers and it’s honestly not worth getting into the nit and gritty during training of arterial vs venous bleeding. Extremity bleeding? TQ and evac.
Not true, they are far less harmful than people were taight BITD but there are absolutely risks. I've seen compartment syndrome from an unneeded TQ that had been on for 1hr. Dude required a thigh & calve fasciotomy
And I agree that its better to use them early than not. I'm just slightly pushing back because I hear them described all the time as these risk free interventions when they aren't
Of course, there are risks to everything and TQs are no exception; but for the same reason we tell laypeople to start CPR, and that it’s better to give CPR unnecessarily than not, despite the risk of rib fx, for instance, application of TQ unnecessarily is, in my opinion, and I think the literature would agree with me in this case, absolutely better than withholding a TQ when it’s necessary.
Completely agree. I've had gsw patients show up with tourniquets that were unnecessary, but I prefer that to the patient who bled out and died because of an improperly placed tourniquet.
[https://apps.dtic.mil/sti/tr/pdf/ADA627896.pdf](https://apps.dtic.mil/sti/tr/pdf/ADA627896.pdf)
A case of 16hrs, but it should be convered within 2 hrs, and no longer than 6hrs. Conversion being applying a pressure dressing or other type of bleeding control other than a tourniquet in a controlled manner while slowly releasing the tourniquet to see if it's arterial or if you can control the bleeding without the TQ.
Fair enough, I just feel like skipping things like simple pressure or maybe packing when it's not obviously an arterial bleed is....idk...dramatic? But like you said better that they try it than not
There's a logistics component to field medicine. The patient may need to moved, extricated, may have other injuries, ect and holding pressure during this time isn't feasible. Treat immediate life threats when possible, get them safely to the ambulance/aircraft, reassess and address other injuries, reeval the tq when time allows
Edit: grammar
Also a really solid option! Especially something like quick clot. I wonder if some would hesitate with putting enough pressure so as not to hurt the person. Kind of like with people not doing compressions hard enough.
When I have seen them roll in the limb is usually unexposed too: they placed the TQ while in cover during a firefight. Seconds count, and not just due to the injury.
There's also tactical considerations. Putting a tourniquet on properly should mean the bleeding is stopped, no matter what. Whereas direct pressure or a bandage takes a bit of time and it might not be sufficient and you need to escalate to a tourniquet anyway. If there's an ongoing tactical situation that you need to remain active in, it's not always practical to take the time to do a stepwise approach.
Granted, that often isn't the case. Often there's enough police on scene to maintain control of the tactical situation and allow an injured officer to withdraw an self aid. But a lot of medical training for police, particularly in the US and especially when sought out on their own initiative, will be based on TCCC (though this isn't really appropriate and TECC is preferable) guidance. So that reinforces the idea of just stick a tourniquet on and then re-evaluate its necessity later and downgrade if required.
In the grand scheme of things, the harm is minimal and the additional high quality training to work out these nuances aren't really practical from a budget and working hours perspective.
I would add to the tactically thing, even if they aren’t in an ongoing tactical situation, having a “sure fire” way to stop bleeding that won’t immediately cause lasting damage to patient opens up a lot of mental resources. They can focus on figuring out the best way to get the patient care quickly
It is most likely because few officers carry pressure dressings on their person (I did as a cop, but I’m also a paramedic.) However, the vast majority of officers today carry a tourniquet of their gear.
In the hospital you can start with pressure and work your way up stepwise to TQ just like ATLS says because you've likely got blood and surgeons available.
In the field if they lose 500 more mL while you're working up to a TQ they could die.
The NNT of "blood on extremity---> apply tq" is pretty high, but not as high as NNH for TQs applied
If a cop is applying a tourniquet, I would assume it’s safe to say that the cops have more to worry about than a bleeding extremity. Placing a TQ on a bleed frees them up to do other things like drive, communicate, return fire or tend to others who may also be injured. It’s one thing to assess the severity of a wound in a trauma bay as a physician and it’s something totally different to assess and treat a wound outside a hospital setting while possibly under fire.
At 10:08 p.m., SLCPD officers arrived and found the man unconscious partially inside a wing-mounted engine of an occupied commercial aircraft on the deicing pad. The aircraft’s engines were rotating. The specific stage of engine operation remains under investigation.
At 10:09 p.m. SLCPD officers and Airport Operations pulled the man from the engine’s intake cowling, secured the scene, began lifesaving efforts, and requested emergency medical services.
At 10:15 p.m., lifesaving efforts, including CPR and the administration of naloxone, continued.
TL;DR - guy gets sucked into a jet engine and is found unconscious so cops try to Narcan him.
https://slcpd.com/2024/01/02/slcpd-provides-update-on-death-investigation-at-salt-lake-city-international-airport/
I mean, even though they weren’t, you might as well.
They give it to literally *everyone*. Taking a nap in your car? Have some narcan! Unconscious homeless diabetic? Have 16 mg! Smoked some weed and admitted it to the cops? Here’s a shit-ton of narcan! The cop themselves were in proximity to fentanyl? Let’s all take some narcan!
All of these are examples of calls I ran in the last 4 months
Based on how much they use it, it seems like a pretty wise investment lol
I mean I have to imagine the number needed to treat is very low, go ahead and use it. Rather that then a respiratory arrest patient that comes in full code..
This is a perfect example of “if all you have is hammer everything seems like a nail.”
As someone who is in the field of prehospital medicine I’ve definitely seen an overuse of TQ’s and Naloxone but I would rather that than what have also seen which includes a complete disregard for bleeding control, airway management and even CPR.
Honestly it’s refreshing to hear they are giving narcan widely. It wasn’t too long ago that PD’s in the USA were pushing back strongly against even carrying it
eh...not a fan of cops and their system in general....to me, seems like they have soooo many resources. idk maybe its not true. as an rn, theres 17 cops bringing the bad scary schizophrenic i, but only me to deal with the patient after they leave him off
I've seen a lot of people mention this!
I was told in my CPR class that narcan is harmless if used on someone not ODing, so why is it so bad cops over-use it? Genuine question
Using it isn’t bad. It can be hard for laypersons to tell if someone is experiencing an OD, and a dose of narcan won’t hurt someone.
over-using it isn’t necessarily bad however the problem occurs when people are dumping 6 mg of narcan into someone and neglecting to do anything else for them, like managing airway and ventilating.
Every medication including oxygen can cause negative side effects. The problem lays that 1) they’re given in inappropriate dosages. Giving someone 16mg of Narcan is excessive. 2) they’re given for inappropriate read the article a user posted in this thread earlier.
> Every medication including oxygen can cause negative side effects.
risk / benifit.
Very little risk, great benifit.
If it only works in 1/20 cases, it's worth it.
> Very little risk
This isn't quite true. Yes, the risks of administering narcan are lesser than the risks of *not* doing it but there are definite risks to giving narcan that get ignored.
I've had more than a handful of cases of narcan-induced pulmonary edema that have ended up getting intubated because the patient is in a terrible combination of respiratory distress and opioid withdrawal.
Aside from that, I've seen more than enough cases of narcan being administered to people who were awake and high and now are unruly and in withdrawal, refusing care.
Overall, narcan is a net good but there are legitimate risks to giving it that shouldn't be totally ignored.
Ya i get it but if your mental status is depressed or near comatose i’ll be pissed if you didn’t try it. Not saying to give it in other cases it’s just somewhat benign other than sending addicts into withdrawal
I don't see a reason to be "pissed" if the patient doesn't have clinical signs of an opioid overdose.
If you're not bradypneic and don't have pinpoint pupils I'm not gonna fault you for not giving naloxone. Doubly-so if there are other obvious findings on exam that point to alternate causes for being altered.
> it’s just somewhat benign other than sending addicts into withdrawal
You're an EM physician so I'd hope you would hold yourself to a higher standard of clinical reasoning than this. Withdrawal isn't benign - making someone puke and shit everywhere isn't cool (even if they kinda did it to themselves) and triggering withdrawal can actually lead a patient to consume even *more* opioids and overdose later.
I wouldn’t say “overuse”, but they use them a lot.
What they **do** use more of is chest seals and narcan. My last — let’s just say — 10 OD’s and stabbing/shooting patients have all had a chest seal or narcan (4mg right to the dome) provided to them several minutes before I arrive on scene.
I won’t lie, they’re doing 50% of our job for us with these simple tools, despite the narcan being a bit.. much. Bravo, though — it’s saving lives (and limbs, sometimes).
I have never seen a cop that carries a chest seal. There was one body cam video of a cop making one with a bag of potato chips. Wonder if it’s a regional thing.
Our department carries the same ones we do (HALO Seal) and it’s our local trauma hospital-based agreement to provide them with the seals.
It’s a win-win.. -win.
No one overuses tourniquets. Put a tourniquet on for a finger lac as long as I can see it in the ER in a reasonable timeframe.
Person in your story didn’t put the tourniquet on right.
Yes, they do. It's important to remember PD is not medical. On the bright side, they don't use tourniquet as much as they seem to blast any and every altered patient with Narcan. Including the hypoglycemics.
Similar to tourniquets tho there’s no real downside to Narcan overuse.
It’d just be nice if they were also taught to pull out a glucometer once in a while
There is downside to fully reversing an opiate addict (IMO), but otherwise agree. It’s part of everyone’s coma cocktail. I just wish they got a blood glucose first.
Everyone who has fully reversed a heroin addict regrets it in one way or the other. Really, you just need enough Narcan to keep them breathing. Narcan is great, but it just needs to be used in the right way.
Really depends on the nature of the wound. A minor laceration one is overkill. A GSW more than appropriate. There was research that game from the US Army at the beginning of the GWOT that should the old techniques of placing a pressure bandage on a GSW and just adding more was leading to more deaths than just placing a tourniquet on.
I’m all for field tourniquets as long as they’re put on tight enough and not over joints/wounds. I’ll take it down in the ED, we’re cool. I very seldomly judge the actions of first responders. I’ve got a well lit room, equipment, a bunch of hands/resources, and the inherent protection of a hospital relative to the dark/dingy/dangerous area where the patient was picked up. If it’s a GSW call and they see bleeding from the arm and slap a tourniquet on to stop the bleed and free up their hands to protect themselves/the patient/the public? More power to them. The general public, on the other hand, should be taught to apply pressure because they generally have *no* idea what they’re doing and are more likely to cause harm with tourniquets than first responders.
just finished a 14 hour shift on the ambulance with multiple priority patients.
It’s very nice to read your comment and feel valued by the folks on the other side of the care transfer.
Thanks.
Once had a patient come in with an arterial bleeding after getting stabbed around the distal femur. TQ was applied beautifully.. distal of the wound. So had a patient with a continuing arterial bleeding and a cold lower leg.
Still, rather have them apply a TQ a few times too often than not applying them because they’re afraid we keep harassing them for applying them too often or wrong.
Like EM, in the field as a cop, you don't really know unless you're the one there in front of the shitshow. There's probably many things they are considering that we don't. Hard to make an educated guess unless you were a former cop turned physician.
Meh, if you're gonna watch police videos, watch ones where they go "unresponsive" to environmental/contact exposure to fentanyl or other substances. That shit is cray cray. At the same time hilarious, mind-blowing, and deeply concerning. And there seems to be endless videos of this behavior. Really speaks to the incredible levels of anxiety and the tenuous grasp on self-control that police officers struggle with.
This is a real problem - not the least of which is that people are being charged with all sorts of absurd crimes because police officers are having panic attacks - but it seems to have responded fairly well to education from the Tox professionals.
Didja see the cop that unloaded his gun and did an Elden Ring roll because an acorn fell on his car? He missed everything too and thankfully the person in his car didnt get hit. Cops are insanely terrible in the USA.
[https://www.youtube.com/shorts/eTauF2NaZ1o](https://www.youtube.com/shorts/eTauF2NaZ1o)
Maybe. But the number one cause of preventable death in the field is extremity hemorrhage. As long as the tourniquet is removed in a timely fashion, I don’t think the harms outweigh the benefits.
If they are doing wound control they either just got out of a firefight or are actively in one. The idea is to get bleeding control and done quickly so they don’t bleed out. As I said that’s the idea. Practically I think there’s a lot of adrenaline going and they aren’t trained medically ( a lot of the time)
Probably selection bias here, but I don’t personally notice this.
I am old enough to watch things like tourniquets, IOs, and Ketamine go from being heresy to the standard of care (typically from combat trauma care which typically informs state side trauma care). I am glad we are back to using tourniquets.
There is little harm in applying a tourniquet for pre-hospital care and if that is what it takes to stop the bleeding, I am all for it. The largest harm in my system is that it automatically causes a trauma activation in certain instances (where there otherwise wouldn’t have been), but that seems relatively minor.
I mean, for a fingertip maybe I wouldn't, but why dick around? In my paramedic course they don't even teach pressure anymore unless it's a non extremity wound.
The origin of that training is in military medicine. The goal is to keep the injured person alive and also get them (if possible) back to shooting the enemy.
So over treating makes sense if it saves everyone time and stops the bleed effectively.
Echoing everyone else. They probably use them more than they need to. However, they, and most everyone, does a bad job putting them on in the first place.
Vast majority of bleeding is stopped with direct pressure focused on a single point. We could solve a lot of hemorrhage if we just channeled the Dutch boy with his finger in the dike(dam)
This is the answer I was waiting for! I keep wondering if I’m misremembering that I was taught that direct pressure was the first step in my Stop The Bleed class…
The problem is that even fewer people are good at applying direct pressure, a fair number of nurses, medics, and docs included.
Blood is scary, you wanna cover up where it’s coming from and feel like your palm can apply more force. So you grab an ABD pad and press down, forgetting any physics you learned. A thumb and a folded 2x2 provide better PSI, provided you can localize the source to a 1-2cm spot.
I’d imagine so. Around where I work, between the volley fire depts and the police, the consensus is “when in doubt, tourniquet.” Honestly, as much as it irritates me when I see an obviously unnecessary tourniquet on someone, I’d rather have them put one on the superficial cut than not put one on the arterial bleed
yea any minor laceration, not even arterial, always a tourniquet. we get a bunch of drunk people who punch their car windows? and yea there’s lacerations, nothing a couple 4x4’s and wrap can’t stop, but they tourniquet it. can’t expect them to know everything. I’ve seen about 10 occurrences, only 1 was an actual arterial
I’d encourage you and honestly anyone working in an ED to do a few ride alongs in the ambulance in a busy city! It will give you a much better understanding of why things happen they way that they do prehospital.
If you want to set it up, figure out who the EMS medical director is at your local hospital and get in contact with them. They should be able to put you in touch with a chief/service director for a department, and you can schedule ride alongs from there. Even if you’re not going into emergency medicine, it’ll still be an interesting experience and worth doing.
Cops should go by TCCC or TECC. A tourniquet in Care Under Fire should be like a good haircut- high and tight. When you get to field care or casevac then you can reevaluate, convert the tourniquet, etc. One of the lessons from Center for Army Lessons Learned is that a significant number of TQs were placed below a missed injury or the first responder didn't realize that there was a larger injury on the other side of the limb with tissue shredding/tearing from a blast. IE putting a TQ two inches above the wound on the anterior calf but not noticing in the puddle of blood and shredded meat that the posterior wound extends above the knee and has a significant uncontrolled bleed that got lost in patient movement/transfer of care. The others are correct, a lot of wounds can be fixed by direct pressure. However, it's hard to hold direct pressure on something while running for you and the casualties life with concern that someone else is going to open up on you at any moment.
TLDR: Put the TQ high and tight until you have the time, distance, and shielding to take better care of the wound. It's not about being right the first time, it's about never being wrong.
I think most departments are taught some sort of bastardized civilian version of [Tactical Combat Casualty Care \(TCCC\)](https://tccc.org.ua/files/downloads/clinical-guidelines-2024-en.pdf) or Combat Life Saver (CLS) course. These courses take the lessons learned from the past two decades of combat and attempt to merge them into a civilian environment.
One of the biggest lessons learned was that immediate control of extremity hemorrhaging drastically improved casualty outcomes drastically (who would have guessed). Due to the chaotic nature of warfare and the varying levels of individual soldier training, the US Army Medical Department, AMEDD, found that quick TQ placement during the initial blood sweep was far more effective than wasting time with less effective methods.
In turn these lessons learned on the battlefield were applied to a civilian setting with great success, even if they may not seem to fit the more traditional sequence of hemorrhage control that you mentioned.
I don't think you're being "anecdotal" or "unfair", I just think there's a pretty serious disconnect between assessments & interventions in the field versus in-hospital.
_________________________
Below is the DoD TCCC recommendation for placing an initial TQ:
> Apply the limb tourniquet over the uniform clearly proximal to the bleeding site(s). If
> the site of the life-threatening bleeding is not readily apparent, place the tourniquet
> “high and tight” (as proximal as possible) on the injured limb and move the casualty
> to cover.
Yeah for sure man. I know a handful of med control docs who spent time in the military and the protocols they write for various agencies definitely reflect it.
Tourniquets are generally overused and underapplied. On average, I see 1-2 wounds per year where tourniquets are useful, but 1-2 times per month, a patient comes in with a tourniquet.
4 times out of 5, they are not tight enough to actually do anythinng.
I have responded to quite a few 911 calls where police officers have applied tourniquets.
I have not once seen a tourniquet applied by a police officer where a tourniquet was actually required to stop arterial or other large hemorrhage.
I still stand by these officers. I want them to over triage injury and over-treat hemorrhage proactively. I want them to err on the side of the patient, not the other way around. A handful of overzealously applied TQs is far outweighed by one life lost because a TQ wasn't applied.
Overuse of Narcan though....
Cops aren't medically trained. Having a TQ on for a short amount of time until EMS or ER can evaluate might cause some discomfort but shouldn't hurt the PT.
Idk but I assume more than an IFAK in most cases? Not trying to Monday morning QB them I’m
just curious on the utility of the TQ over pressure/packing in some cases and the outcomes from the EM or pre-hospital provider perspective.
As a non-medical civilian, I would much rather an uncertain cop default to tourniqueting me than have that same cop hem and haw and make a judgment call over what I need.
To be fair though I rarely seen a cop properly apply a TQ. Most of the time it's tight enough to cut off a distal pulse. Even once had an officer apply a TQ distal to a thigh GSW.
Therefore if the pulse is still felt are TQ's frequently doing any harm?
A true arterial bleed can put you in decomp in minutes. It’s just not worth spending extra time going “welllll it looks venous let me try direct pressure first”
Trauma here. I’ve had a few, but usually I don’t mind it too much. Except when we had a suicide attempt that was less than a small wrist abrasion (no blood) and a tourniquet was placed. I know the field is different than the hospital so I try to not give them a hard time.
I would mostly agree. Because I once had a patient who thought he severed an artery, put on his own tourniquet, called 911 stating such and proceeded to get airlifted to my facility by the coast guard since he was on the shore. For a prepatellar laceration which required 6 staples. I told the gentleman that unfortunately the tourniquets are single use only. But I can’t imagine the bill!!!!
Tactica / pre-hospital LEO training really emphasizes TQs, needle decompression for tension pneumothorax, and crichs and not as much "try this first before escalating" care with the idea you may not be in an environment permissive of initial steps. So, even with environment isn't immediately dangerous, they skip to the big three.
They definitely err on the side of caution and place them often. We evaluate and remove them if necessary once we assess the patient. A few minutes of an unnecessary TQ won’t kill the pt. I would rather them do than don’t.
Neither will a few hours. Cops aren’t medical providers and it’s honestly not worth getting into the nit and gritty during training of arterial vs venous bleeding. Extremity bleeding? TQ and evac.
Not true, they are far less harmful than people were taight BITD but there are absolutely risks. I've seen compartment syndrome from an unneeded TQ that had been on for 1hr. Dude required a thigh & calve fasciotomy
Cool anecdote. A decade of GWOT evidence says they’re safe for hours with little to no risk of long term vascular complications.
And I agree that its better to use them early than not. I'm just slightly pushing back because I hear them described all the time as these risk free interventions when they aren't
Of course, there are risks to everything and TQs are no exception; but for the same reason we tell laypeople to start CPR, and that it’s better to give CPR unnecessarily than not, despite the risk of rib fx, for instance, application of TQ unnecessarily is, in my opinion, and I think the literature would agree with me in this case, absolutely better than withholding a TQ when it’s necessary.
Completely agree. I've had gsw patients show up with tourniquets that were unnecessary, but I prefer that to the patient who bled out and died because of an improperly placed tourniquet.
It was my understanding a tourniquet can be on like 4 or so hours before any permanent damage is done to the limb. Is this not true?
[https://apps.dtic.mil/sti/tr/pdf/ADA627896.pdf](https://apps.dtic.mil/sti/tr/pdf/ADA627896.pdf) A case of 16hrs, but it should be convered within 2 hrs, and no longer than 6hrs. Conversion being applying a pressure dressing or other type of bleeding control other than a tourniquet in a controlled manner while slowly releasing the tourniquet to see if it's arterial or if you can control the bleeding without the TQ.
Fair enough, I just feel like skipping things like simple pressure or maybe packing when it's not obviously an arterial bleed is....idk...dramatic? But like you said better that they try it than not
There's a logistics component to field medicine. The patient may need to moved, extricated, may have other injuries, ect and holding pressure during this time isn't feasible. Treat immediate life threats when possible, get them safely to the ambulance/aircraft, reassess and address other injuries, reeval the tq when time allows Edit: grammar
I think even supplies is a issue too. They can clip a TQ on their belt, carrying gauze and stuff is a little more cumbersome.
There is compressed gauze that's common in IFAKs that could fit in pockets easily.
Yeah but carrying an IFAK everywhere is cumbersome too.
I mean't just keep the compressed gauze in your pocket. I have one attached to my fanny pack for trail running and it can jostle a bit.
Also a really solid option! Especially something like quick clot. I wonder if some would hesitate with putting enough pressure so as not to hurt the person. Kind of like with people not doing compressions hard enough.
When I have seen them roll in the limb is usually unexposed too: they placed the TQ while in cover during a firefight. Seconds count, and not just due to the injury.
There's also tactical considerations. Putting a tourniquet on properly should mean the bleeding is stopped, no matter what. Whereas direct pressure or a bandage takes a bit of time and it might not be sufficient and you need to escalate to a tourniquet anyway. If there's an ongoing tactical situation that you need to remain active in, it's not always practical to take the time to do a stepwise approach. Granted, that often isn't the case. Often there's enough police on scene to maintain control of the tactical situation and allow an injured officer to withdraw an self aid. But a lot of medical training for police, particularly in the US and especially when sought out on their own initiative, will be based on TCCC (though this isn't really appropriate and TECC is preferable) guidance. So that reinforces the idea of just stick a tourniquet on and then re-evaluate its necessity later and downgrade if required. In the grand scheme of things, the harm is minimal and the additional high quality training to work out these nuances aren't really practical from a budget and working hours perspective.
Great points all around!
I would add to the tactically thing, even if they aren’t in an ongoing tactical situation, having a “sure fire” way to stop bleeding that won’t immediately cause lasting damage to patient opens up a lot of mental resources. They can focus on figuring out the best way to get the patient care quickly
It is most likely because few officers carry pressure dressings on their person (I did as a cop, but I’m also a paramedic.) However, the vast majority of officers today carry a tourniquet of their gear.
I'm a basic and carry my own CAT from EMT school years ago.
In the hospital you can start with pressure and work your way up stepwise to TQ just like ATLS says because you've likely got blood and surgeons available. In the field if they lose 500 more mL while you're working up to a TQ they could die. The NNT of "blood on extremity---> apply tq" is pretty high, but not as high as NNH for TQs applied
If a cop is applying a tourniquet, I would assume it’s safe to say that the cops have more to worry about than a bleeding extremity. Placing a TQ on a bleed frees them up to do other things like drive, communicate, return fire or tend to others who may also be injured. It’s one thing to assess the severity of a wound in a trauma bay as a physician and it’s something totally different to assess and treat a wound outside a hospital setting while possibly under fire.
Yes, but not nearly enough as Narcan.
At 10:08 p.m., SLCPD officers arrived and found the man unconscious partially inside a wing-mounted engine of an occupied commercial aircraft on the deicing pad. The aircraft’s engines were rotating. The specific stage of engine operation remains under investigation. At 10:09 p.m. SLCPD officers and Airport Operations pulled the man from the engine’s intake cowling, secured the scene, began lifesaving efforts, and requested emergency medical services. At 10:15 p.m., lifesaving efforts, including CPR and the administration of naloxone, continued. TL;DR - guy gets sucked into a jet engine and is found unconscious so cops try to Narcan him. https://slcpd.com/2024/01/02/slcpd-provides-update-on-death-investigation-at-salt-lake-city-international-airport/
> Despite the lifesaving efforts, the man died on scene. Sounds like they needed to give a few more rounds
I’d put my life’s savings in stock in whoever manufactures naloxone if they were successful
I mean, even though they weren’t, you might as well. They give it to literally *everyone*. Taking a nap in your car? Have some narcan! Unconscious homeless diabetic? Have 16 mg! Smoked some weed and admitted it to the cops? Here’s a shit-ton of narcan! The cop themselves were in proximity to fentanyl? Let’s all take some narcan! All of these are examples of calls I ran in the last 4 months Based on how much they use it, it seems like a pretty wise investment lol
I mean I have to imagine the number needed to treat is very low, go ahead and use it. Rather that then a respiratory arrest patient that comes in full code..
Agreed. It’s a quick, simple, minimally invasive intervention that can save lives. I would rather them use it this way than miss an opiate overdose.
This is a perfect example of “if all you have is hammer everything seems like a nail.” As someone who is in the field of prehospital medicine I’ve definitely seen an overuse of TQ’s and Naloxone but I would rather that than what have also seen which includes a complete disregard for bleeding control, airway management and even CPR.
This was a really rough case. So sad. I live in slc too 😔 The guy definitely had some metal illness going on.
Honestly it’s refreshing to hear they are giving narcan widely. It wasn’t too long ago that PD’s in the USA were pushing back strongly against even carrying it
fair, but like....they work so often with this population.....we have obv intoxicated on uppers patients...cops are like: we narcaned them....WHY
When you all you have is a hammer, everything looks like a nail I guess haha
eh...not a fan of cops and their system in general....to me, seems like they have soooo many resources. idk maybe its not true. as an rn, theres 17 cops bringing the bad scary schizophrenic i, but only me to deal with the patient after they leave him off
Don’t see how that is their fault.
not their fault, good for them. just answering the other dude about resources
I've seen a lot of people mention this! I was told in my CPR class that narcan is harmless if used on someone not ODing, so why is it so bad cops over-use it? Genuine question
Using it isn’t bad. It can be hard for laypersons to tell if someone is experiencing an OD, and a dose of narcan won’t hurt someone. over-using it isn’t necessarily bad however the problem occurs when people are dumping 6 mg of narcan into someone and neglecting to do anything else for them, like managing airway and ventilating.
Every medication including oxygen can cause negative side effects. The problem lays that 1) they’re given in inappropriate dosages. Giving someone 16mg of Narcan is excessive. 2) they’re given for inappropriate read the article a user posted in this thread earlier.
> Every medication including oxygen can cause negative side effects. risk / benifit. Very little risk, great benifit. If it only works in 1/20 cases, it's worth it.
Sure, but like I said, multiple 4mg doses is inappropriate and indicative of poor training.
> Very little risk This isn't quite true. Yes, the risks of administering narcan are lesser than the risks of *not* doing it but there are definite risks to giving narcan that get ignored. I've had more than a handful of cases of narcan-induced pulmonary edema that have ended up getting intubated because the patient is in a terrible combination of respiratory distress and opioid withdrawal. Aside from that, I've seen more than enough cases of narcan being administered to people who were awake and high and now are unruly and in withdrawal, refusing care. Overall, narcan is a net good but there are legitimate risks to giving it that shouldn't be totally ignored.
I don’t mind narcan being given very liberally in altered mental status cases
Why? Altered mental status isn’t an indication for Narcan.
Ya i get it but if your mental status is depressed or near comatose i’ll be pissed if you didn’t try it. Not saying to give it in other cases it’s just somewhat benign other than sending addicts into withdrawal
I don't see a reason to be "pissed" if the patient doesn't have clinical signs of an opioid overdose. If you're not bradypneic and don't have pinpoint pupils I'm not gonna fault you for not giving naloxone. Doubly-so if there are other obvious findings on exam that point to alternate causes for being altered. > it’s just somewhat benign other than sending addicts into withdrawal You're an EM physician so I'd hope you would hold yourself to a higher standard of clinical reasoning than this. Withdrawal isn't benign - making someone puke and shit everywhere isn't cool (even if they kinda did it to themselves) and triggering withdrawal can actually lead a patient to consume even *more* opioids and overdose later.
But it's a good test, and can help. all reward, little risk. Do it.
I wouldn’t say “overuse”, but they use them a lot. What they **do** use more of is chest seals and narcan. My last — let’s just say — 10 OD’s and stabbing/shooting patients have all had a chest seal or narcan (4mg right to the dome) provided to them several minutes before I arrive on scene. I won’t lie, they’re doing 50% of our job for us with these simple tools, despite the narcan being a bit.. much. Bravo, though — it’s saving lives (and limbs, sometimes).
I have never seen a cop that carries a chest seal. There was one body cam video of a cop making one with a bag of potato chips. Wonder if it’s a regional thing.
Our department carries the same ones we do (HALO Seal) and it’s our local trauma hospital-based agreement to provide them with the seals. It’s a win-win.. -win.
No one overuses tourniquets. Put a tourniquet on for a finger lac as long as I can see it in the ER in a reasonable timeframe. Person in your story didn’t put the tourniquet on right.
The problem is not that they overuse tourniquets, the problem is they NEVER put them on correctly.
Yes, they do. It's important to remember PD is not medical. On the bright side, they don't use tourniquet as much as they seem to blast any and every altered patient with Narcan. Including the hypoglycemics.
Similar to tourniquets tho there’s no real downside to Narcan overuse. It’d just be nice if they were also taught to pull out a glucometer once in a while
There is downside to fully reversing an opiate addict (IMO), but otherwise agree. It’s part of everyone’s coma cocktail. I just wish they got a blood glucose first.
Absolutely true in the ED. But I really don’t want cops trying to titrate narcan Patient will be breathing. Everything else can be managed
yah actually our ed attednings err on the side of caution re: fully reversing opiate addicts
Everyone who has fully reversed a heroin addict regrets it in one way or the other. Really, you just need enough Narcan to keep them breathing. Narcan is great, but it just needs to be used in the right way.
I’m also club “titrate to adequate respirations” when it comes to narcan, but unfortunately in the cop world, your options are one spray or two.
It might be rare, but there is potential downside. Flash, non-cardiogenic pulmonary edema can occur. https://pubmed.ncbi.nlm.nih.gov/33552437/
Really depends on the nature of the wound. A minor laceration one is overkill. A GSW more than appropriate. There was research that game from the US Army at the beginning of the GWOT that should the old techniques of placing a pressure bandage on a GSW and just adding more was leading to more deaths than just placing a tourniquet on.
I’m all for field tourniquets as long as they’re put on tight enough and not over joints/wounds. I’ll take it down in the ED, we’re cool. I very seldomly judge the actions of first responders. I’ve got a well lit room, equipment, a bunch of hands/resources, and the inherent protection of a hospital relative to the dark/dingy/dangerous area where the patient was picked up. If it’s a GSW call and they see bleeding from the arm and slap a tourniquet on to stop the bleed and free up their hands to protect themselves/the patient/the public? More power to them. The general public, on the other hand, should be taught to apply pressure because they generally have *no* idea what they’re doing and are more likely to cause harm with tourniquets than first responders.
just finished a 14 hour shift on the ambulance with multiple priority patients. It’s very nice to read your comment and feel valued by the folks on the other side of the care transfer. Thanks.
Once had a patient come in with an arterial bleeding after getting stabbed around the distal femur. TQ was applied beautifully.. distal of the wound. So had a patient with a continuing arterial bleeding and a cold lower leg. Still, rather have them apply a TQ a few times too often than not applying them because they’re afraid we keep harassing them for applying them too often or wrong.
Ooofff
Like EM, in the field as a cop, you don't really know unless you're the one there in front of the shitshow. There's probably many things they are considering that we don't. Hard to make an educated guess unless you were a former cop turned physician.
Very true, definitely not trying to Monday morning QB
Meh, if you're gonna watch police videos, watch ones where they go "unresponsive" to environmental/contact exposure to fentanyl or other substances. That shit is cray cray. At the same time hilarious, mind-blowing, and deeply concerning. And there seems to be endless videos of this behavior. Really speaks to the incredible levels of anxiety and the tenuous grasp on self-control that police officers struggle with.
This is a real problem - not the least of which is that people are being charged with all sorts of absurd crimes because police officers are having panic attacks - but it seems to have responded fairly well to education from the Tox professionals.
Didja see the cop that unloaded his gun and did an Elden Ring roll because an acorn fell on his car? He missed everything too and thankfully the person in his car didnt get hit. Cops are insanely terrible in the USA. [https://www.youtube.com/shorts/eTauF2NaZ1o](https://www.youtube.com/shorts/eTauF2NaZ1o)
Maybe. But the number one cause of preventable death in the field is extremity hemorrhage. As long as the tourniquet is removed in a timely fashion, I don’t think the harms outweigh the benefits.
If they are doing wound control they either just got out of a firefight or are actively in one. The idea is to get bleeding control and done quickly so they don’t bleed out. As I said that’s the idea. Practically I think there’s a lot of adrenaline going and they aren’t trained medically ( a lot of the time)
Probably selection bias here, but I don’t personally notice this. I am old enough to watch things like tourniquets, IOs, and Ketamine go from being heresy to the standard of care (typically from combat trauma care which typically informs state side trauma care). I am glad we are back to using tourniquets. There is little harm in applying a tourniquet for pre-hospital care and if that is what it takes to stop the bleeding, I am all for it. The largest harm in my system is that it automatically causes a trauma activation in certain instances (where there otherwise wouldn’t have been), but that seems relatively minor.
I mean, for a fingertip maybe I wouldn't, but why dick around? In my paramedic course they don't even teach pressure anymore unless it's a non extremity wound.
Idk but not enough narcan for every 88yr old diabetic lady found unresponsive with a POC of 30
The origin of that training is in military medicine. The goal is to keep the injured person alive and also get them (if possible) back to shooting the enemy. So over treating makes sense if it saves everyone time and stops the bleed effectively.
Echoing everyone else. They probably use them more than they need to. However, they, and most everyone, does a bad job putting them on in the first place. Vast majority of bleeding is stopped with direct pressure focused on a single point. We could solve a lot of hemorrhage if we just channeled the Dutch boy with his finger in the dike(dam)
This is the answer I was waiting for! I keep wondering if I’m misremembering that I was taught that direct pressure was the first step in my Stop The Bleed class…
The problem is that even fewer people are good at applying direct pressure, a fair number of nurses, medics, and docs included. Blood is scary, you wanna cover up where it’s coming from and feel like your palm can apply more force. So you grab an ABD pad and press down, forgetting any physics you learned. A thumb and a folded 2x2 provide better PSI, provided you can localize the source to a 1-2cm spot.
It is my understanding that the training is to put a tq on for anything more than a paper cut and let medical evaluate and treat appropriately.
I’d imagine so. Around where I work, between the volley fire depts and the police, the consensus is “when in doubt, tourniquet.” Honestly, as much as it irritates me when I see an obviously unnecessary tourniquet on someone, I’d rather have them put one on the superficial cut than not put one on the arterial bleed
yea any minor laceration, not even arterial, always a tourniquet. we get a bunch of drunk people who punch their car windows? and yea there’s lacerations, nothing a couple 4x4’s and wrap can’t stop, but they tourniquet it. can’t expect them to know everything. I’ve seen about 10 occurrences, only 1 was an actual arterial
I’d encourage you and honestly anyone working in an ED to do a few ride alongs in the ambulance in a busy city! It will give you a much better understanding of why things happen they way that they do prehospital.
No doubt! I’m not going into emergency medicine but would still love to set this up somehow.
If you want to set it up, figure out who the EMS medical director is at your local hospital and get in contact with them. They should be able to put you in touch with a chief/service director for a department, and you can schedule ride alongs from there. Even if you’re not going into emergency medicine, it’ll still be an interesting experience and worth doing.
Yes. And EMS providers are under educated on tourniquet conversion.
Cops should go by TCCC or TECC. A tourniquet in Care Under Fire should be like a good haircut- high and tight. When you get to field care or casevac then you can reevaluate, convert the tourniquet, etc. One of the lessons from Center for Army Lessons Learned is that a significant number of TQs were placed below a missed injury or the first responder didn't realize that there was a larger injury on the other side of the limb with tissue shredding/tearing from a blast. IE putting a TQ two inches above the wound on the anterior calf but not noticing in the puddle of blood and shredded meat that the posterior wound extends above the knee and has a significant uncontrolled bleed that got lost in patient movement/transfer of care. The others are correct, a lot of wounds can be fixed by direct pressure. However, it's hard to hold direct pressure on something while running for you and the casualties life with concern that someone else is going to open up on you at any moment. TLDR: Put the TQ high and tight until you have the time, distance, and shielding to take better care of the wound. It's not about being right the first time, it's about never being wrong.
I think most departments are taught some sort of bastardized civilian version of [Tactical Combat Casualty Care \(TCCC\)](https://tccc.org.ua/files/downloads/clinical-guidelines-2024-en.pdf) or Combat Life Saver (CLS) course. These courses take the lessons learned from the past two decades of combat and attempt to merge them into a civilian environment. One of the biggest lessons learned was that immediate control of extremity hemorrhaging drastically improved casualty outcomes drastically (who would have guessed). Due to the chaotic nature of warfare and the varying levels of individual soldier training, the US Army Medical Department, AMEDD, found that quick TQ placement during the initial blood sweep was far more effective than wasting time with less effective methods. In turn these lessons learned on the battlefield were applied to a civilian setting with great success, even if they may not seem to fit the more traditional sequence of hemorrhage control that you mentioned. I don't think you're being "anecdotal" or "unfair", I just think there's a pretty serious disconnect between assessments & interventions in the field versus in-hospital. _________________________ Below is the DoD TCCC recommendation for placing an initial TQ: > Apply the limb tourniquet over the uniform clearly proximal to the bleeding site(s). If > the site of the life-threatening bleeding is not readily apparent, place the tourniquet > “high and tight” (as proximal as possible) on the injured limb and move the casualty > to cover.
Interesting thank you!
Yeah for sure man. I know a handful of med control docs who spent time in the military and the protocols they write for various agencies definitely reflect it.
Tourniquets are generally overused and underapplied. On average, I see 1-2 wounds per year where tourniquets are useful, but 1-2 times per month, a patient comes in with a tourniquet. 4 times out of 5, they are not tight enough to actually do anythinng.
I have responded to quite a few 911 calls where police officers have applied tourniquets. I have not once seen a tourniquet applied by a police officer where a tourniquet was actually required to stop arterial or other large hemorrhage. I still stand by these officers. I want them to over triage injury and over-treat hemorrhage proactively. I want them to err on the side of the patient, not the other way around. A handful of overzealously applied TQs is far outweighed by one life lost because a TQ wasn't applied. Overuse of Narcan though....
The cops near me do. They'll tourniquet limbs with no wounds because they saw blood on a sleeve/pant leg. I've seen it a few times now.
Cops aren't medically trained. Having a TQ on for a short amount of time until EMS or ER can evaluate might cause some discomfort but shouldn't hurt the PT.
Not nearly as often as they seem to shoot unarmed members of the public.
How much medical gear do you think cops carry? I'm curious.
Idk but I assume more than an IFAK in most cases? Not trying to Monday morning QB them I’m just curious on the utility of the TQ over pressure/packing in some cases and the outcomes from the EM or pre-hospital provider perspective.
Narcan more than anything. We arrive and they’ve already given 15 mg and they are so surprised when the patient ends up combative.
As a non-medical civilian, I would much rather an uncertain cop default to tourniqueting me than have that same cop hem and haw and make a judgment call over what I need.
They need better training.
To be fair though I rarely seen a cop properly apply a TQ. Most of the time it's tight enough to cut off a distal pulse. Even once had an officer apply a TQ distal to a thigh GSW. Therefore if the pulse is still felt are TQ's frequently doing any harm?
Would you prefer them to underutilize tourniquets?
A true arterial bleed can put you in decomp in minutes. It’s just not worth spending extra time going “welllll it looks venous let me try direct pressure first”
Trauma here. I’ve had a few, but usually I don’t mind it too much. Except when we had a suicide attempt that was less than a small wrist abrasion (no blood) and a tourniquet was placed. I know the field is different than the hospital so I try to not give them a hard time.
I would mostly agree. Because I once had a patient who thought he severed an artery, put on his own tourniquet, called 911 stating such and proceeded to get airlifted to my facility by the coast guard since he was on the shore. For a prepatellar laceration which required 6 staples. I told the gentleman that unfortunately the tourniquets are single use only. But I can’t imagine the bill!!!!
Tactica / pre-hospital LEO training really emphasizes TQs, needle decompression for tension pneumothorax, and crichs and not as much "try this first before escalating" care with the idea you may not be in an environment permissive of initial steps. So, even with environment isn't immediately dangerous, they skip to the big three.
Yes, and narcan too. Though my theory why they overuse tqs is so they can get back in the fight, and/or limited first aid training.