ADF Health 2009 - Volume 10 Number 1Letter to the EditorTO THE EDITOR: In 2007, McLean et al discussed the use of tourniquets to control major peripheral haemorrhage 1 .This is a particular problem in blast wounds sustained from Improvised Explosive Devices (IED). CDRE Walker responded to that article, noting that the Combat Application Tourniquet (CAT) was introduced into operational environments in 2006 2. Guidance on their use was contained in Defence Health Bulletin 4/2006 3. Whilst this guideline does supply information on the indications for the use of CAT’s Maclean et al claimed that it lacks information on the technique of field application. Policies vary on the correct application of military tourniquets - ranging from certain distances ‘above the lesion,’ (as with the ADF) through to ‘high and tight.’ Some guidelines condone the use of tourniquets below the elbow or knee, despite the common practice in orthopaedic surgery to only use tourniquets on single long bones. No direction exists in the current ADF policy. The time when tourniquets should be applied also varies - from early application through to “a last resort to save life” as with the ADF. Further research is indicated to identify the ideal positioning and timing for tourniquet application. There are two main scenarios for use of the Combat Application Tourniquet. Both involve harsh environments with medics or first aiders in attendance. In the ADF’s current operations the injuries are usually the result of detonation of an improvised explosive device with no other hostile threats in the vicinity or during engagement with enemy forces –so called ‘Care- Under-Fire” (CUF). The ADF policy does mention that CAT’s can be used occur when ‘operational circumstances preclude conventional management’ and for CUF this technique excels. Combat caregivers have limited ability to assess and treat their patients and salvage needs to occur whilst a mission proceeds. When this is the case tourniquets should be applied ‘high and tight’ as soon as possible, with review once the scenario allows. Coalition forces in the Middle East are already employing this strategy and ADF policy should be amended to reflect this. Nicholas L. Gray References
Editorial CommentBRIG A Gill has indicated that these concerns have been addressed in Health Directive 704 Combat Application Tourniquet™ _ Instructions for use in the Australian Defence Force dated 17 Sep 09. Letters to the Editor are strongly encouraged.
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