How to make a Tourniquet

How to make a Tourniquet

Here is a short list of what we'd love for you to take away from this post:

  • A mindset shift  that Tourniquets are safe & effective
  • An understanding that Tourniquet application is NOT likely to lead to amputation of a limb *1
  • Tourniquets should be considered a First Resort  (not a last resort) for life threatening extremity bleeds



 From hurricanes isolating segments of the population to the dynamic terrorist events in Paris and San Bernardino, the threats to our society are both complex and often overwhelm local resources. Because of their storied success, there is a widely held regard for the availability and professionalism of our emergency medical services, and deservedly so. Accordingly, most of the financial resources dedicated to disaster preparedness and counterterrorism are primarily focused on improving our uniformed response.

Extending the Chain of Trauma Survival


   Let's pretend a major earthquake has just partially destroyed your home. Your 10-year-old daughter was struck by falling debris. She's unconscious, gasping for breath and bleeding profusely from a cut on her leg.  

   With the city in chaos, it could take emergency medical services (EMS) hours to reach you. Fortunately, there are a few simple actions you can take that will drastically increase your daughter's chances of survival.

   This is true even if you lack medical training and advanced equipment.   Envisioning scenarios like this one, communities are embracing the concept of the First Care Provider (FCP). FCPs are medical laypeople who have been trained in basic techniques to manage traumatic injury. They can provide lifesaving interventions in the critical moments following an accident. And in a mass casualty, they can act as "force multipliers," working with professional first responders to save more lives.  

Regular people are the most important people at a disaster scene, everytime.
— The Unthinkable author Amanda Ripley

Before the Ambulance

   As an emergency and disaster medicine physician, it's my privilege to serve on several state and national operational medicine committees. One of our jobs is to formulate mass casualty response guidelines for law enforcement and EMS.
   Traditionally, much of this work has focused on speeding resources and first responders to the scene of the incident. But does this go far enough? Consider that:                                                                                                      

  •  Following the 1999 shooting at Columbine High School, the campus was locked down for several hours, and ambulance crews had no access to the victims inside. During this time, two high school students kept an adult victim (their coach) alive for three hours.                                     
  • The 2013 Boston Marathon Bombing was perhaps a "best case scenario" for terrorism response. The city was already on alert during this high-profile event, with multiple EMS units on standby. However, experts believe that bystander assistance in the minutes following the explosions significantly reduced death and disability among the victims.                                            
  • A man injured in the 2013 Los Angeles International Airport shooting likely saved his own life by applying an improvised tourniquet to his leg. 

These examples highlight an important truth: following a traumatic incident, bystanders can be a crucial link in the "chain of survival." However, our system has done little to empower people immediately responding to a trauma. As a result, witnesses who desire to render aid often stand by helplessly — at great cost to both the injured and the bystander's own emotional health.  

EMS Has Limits

   The United States is fortunate to have one of the world's best EMS services. However, even in a best-case scenario, an ambulance still takes more than four minutes to reach the scene once dispatched. That's long enough for a patient to die of blood loss or experience the beginnings of brain injury due to hypoxia.
   Nor can we always count on this idealized response time. Orange County, Calif., with a population of over 3 million, staffs around 200 paramedics per 48 hour shift. These medics are spread throughout 23 cities. As a resident, it's scary to think how thin those first responders would be spread in the event of a mass casualty.
  And unfortunately, we live in an age where mass public violence is becoming both more frequent and more deadly. Such incidents often result in lockdowns that prevent EMS personnel from reaching the victims quickly. (While this will hopefully change in the future as our tactical responses evolve, it's very much the reality today.)
   In such cases, bystander intervention can mean the difference between life on one hand, and death and disability on the other.
Fortunately, our country has at least two successful blueprints for empowering ordinary citizens to become FCPs.

Precedents for Change

   During the Global War on Terror (GWOT), military experts determined that 24 to 28 percent of military combat deaths were possibly “preventable.” This information led to the creation of a "point of injury" system designed to reduce preventable deaths to nearly zero. This system placed particular emphasis on tourniquet use and control of massive bleeding, and has successfully reduced combat mortality rates from approximately 17 percent during the Vietnam War to about 8 percent today. 
   Using the vast amount of trauma data obtained from the GWOT, the Committee for Tactical Combat Casualty Care (C-TECC) was created to translate applicable practices from the battlefield to the civilian environment. They subsequently adopted guidelines for law enforcement, fire and EMS based on the evolving threat of global terrorism.
   As these events now become commonplace in our communities, our approach must once again evolve. Faced with a growing threat of violence and limitations on professional first responders, our logical next step is to empower ordinary citizens to provide point-of-injury care.
   Our country also has a successful history of empowering civilians as First Care Providers. As early as the 1950s, experts recognized that in the event of sudden cardiac arrest, early cardiopulmonary resuscitation (CPR) by bystanders could increase survival rates several times over. Today, the American Heart Association estimates that 30 percent of Americans (including many children as young as 10) have been trained in CPR.

Shifting Our Focus

   The above examples represent successes we can build on. Unfortunately, we've made little progress in applying these lessons to civilian trauma care.
   This oversight is far from trivial. Trauma is the No. 1 cause of death among people ages 1 to 44. Statistically, children and teens are far more likely to experience an injury at school than sudden cardiac arrest. But while almost every school is equipped with an automated external defibrillator (AED), very few have basic trauma kits available.
   The Obama White House recently set out to change this with its "Stop the Bleed" campaign. One of its goals is to deploy "bleeding control kits" to public places (in the same manner as AEDs). While valuable, these actions probably don't go far enough. Without proper training, it's unlikely that bystanders will attempt to apply a tourniquet.
   We can change that. In my next post, I'll share an evidence-supported model for empowering bystanders to act as First Care Providers in traumatic emergencies.

By: Joshua Bobko, MD, FAAEM

original article as it appeared on CEPAMERICA.COM


By William H. Harris and Joshua P. Bobko, MD

Words are powerful. We all know the pen is mightier than the sword, but what if we told you that one word trumps all other words in a terrorist attack or active shooter situation?  That one word, “landslide,” sends elite military units and experienced SWAT teams scrambling out of a building and headed for cover, even as innocents remain in danger.

“Landslide” in law enforcement speak is a code word for the presence of an improvised explosive device, better known as an IED. Landslide is used to notify all members of a law enforcement team to immediately stop what they are doing and get out.  A Landslide call can be made by anyone on a team and often goes out verbally in lieu of using radios for fear of inadvertently triggering an IED.

In the wake of the recent San Bernardino terrorist attack, which killed 14 people, it has become evident that Syed Rizwan Farook and Tashfeen Malik intended to use IEDs, along with firearms, to inflict a higher casualty rate. Although IEDs are most often associated with the conflicts in Iraq and Afghanistan, the use of IEDs in domestic attacks is by no means a new phenomenon.  IEDs were used in the Columbine High School shooting, the Aurora Colorado theater shooting, Columbia (Maryland) mall shooting, and the Boston Marathon bombing. Fortunately, in many of these horrific attacks, like the one in San Bernardino,  the IEDs did not detonate.  The reason for IEDs not detonating can be attributed to a number of factors, including, but not limited to, things not going as planned, inexperience in bomb making, and luck.

Another plausible explanation for the IEDs failure to detonate in San Bernardino is the IEDs used by the terrorists may not have been intended for the employees. Instead, the IEDs may have been intended to kill the first responders, law enforcement, fire and emergency medical services personnel.  But some how, the attackers weren’t able to detonate the IEDs by the time the responders arrived.

“Baiting” responders is a tactic commonly used by terrorists in Iraq and Afghanistan against our troops. Terrorists plant smaller IEDs with the intent of damaging and disabling vehicles, causing a convoy to stop and provide the terrorists an opportunity to detonate a larger IED in a target rich environment filled with multiple vehicles and a much larger number of troops.  Often times, the troops killed and injured by the larger IED are the protection force and medics treating the initial casualties from the smaller IED.

The military tactics perfected by terrorists in the battlefields of Iraq and Afghanistan are now coming home to be used against civilian and domestic law enforcement agencies. These aggressive and deadly tactics are causing domestic law enforcement agencies to adapt at a rapid rate.

For instance, mobile threats preclude domestic law enforcement agencies from being able to cordon off and setup a perimeter around a situation. Instead, law enforcement personnel run toward the sound of gunfire in hopes of minimizing civilian casualties.  Negotiations have taken a backseat to stopping active shooters as quickly as possible.  Terrorists use our innate goodness and desire to help one another against us.

This changing threat places first responders on the frontline of a new conflict, one we know all too well from facing it on the other side of the world. This conflict may lead to increasing numbers of causalities in our communities and first responders.

The Dec. 2, 2015 attacks are a reminder that we need to be prepared that the wartime tactics are coming home and of the importance of the term “Landslide.”

Bill” Harris is a nationally certified paramedic and decorated special operations combat medic with multiple overseas deployments.  He now works for the U.S. State Department preparing government personnel for overseas assignments.  Joshua P. Bobko is an Assistant Professor of Emergency Medicine at Loma Linda Medical Center, and a tactical physician with various law enforcement teams. He is a national authority on high-threat civilian medicine and has authored the landmark papers on pediatric casualty care and the civilian First Care Provider.

in Tickle the Wire

Link to the        Original Article

Valiant act in an active shooting incident

Valiant act in an active shooting incident

Ke'Arre Stewart knew how to act, and made a difference.  He was a First Care Provider trying to help others.  Using the experiences learned from his time in the military, Mr. Stewart shows that everyone can make a difference.  Actions and Communication are key to survival.  Treatment is often necessary.  Ke'Arre Stewart is a hero that his children can be proud of. 

The "How" of being a First Care Provider

FirstCareProvider.Org is proud to partner with The Koshka Foundation for Safe Schools and the Committee for Tactical Emergency Casualty Care in presenting Building Community Resilience to Dynamic Mass Casualty Incidents: A Multi-Agency White Paper in Support of The First Care Provider.  Using civilian-focused approach to improving resilience in our communities is the critical link to improving outcomes.  Thank you to all who contributed to this effort.  Please share this paper with anyone you think would benefit from it.  Please join us as we move to address this critical gap in our emergency response system.

Is your childs Hockey Helmet unsafe?

    Virginia Tech University has recently released their STAR (Summation of Tests for the Analysis of Risk) Ratings for Hockey Helmets.  This unbiased 3 year independent study uses a  rating sytem based on collection of millions of data points. The engineers at Virginia Tech have revolutionized the Football Helmet industry since publishing their results in 2011.  

  Helmets were originally designed to prevent catastrophic skull and spinal injuries and not to prevent Traumatic Brain Injuries (TBI) commonly reffered to as a concussion.  All sports participants can potentially suffer a Concussion, even with the best of protection. Better helmets lower head acceleration therby loweing the risk of injury but No Helmet is Concussion Proof.


Based on the results that can be seen here hockey helmet technology is lacking when compared to Football helmets. None of the helmets tested were awarded a coveted  5 star (Best) rating, in fact none of them recieved a 4 STAR (Very Good), and only one helmet was rated a 3 STAR (Good) rating. A 2 STAR rating was given to 6 helmets, 1 STAR was given to 16, and sadly 9 of them were awarded a ZERO STAR - Not Recommended rating.

    Similiar results were noted in the initial football helmet testing done in 2011, prompting the helmet manufactures to go back to the drawing boards and redesign the helmets. This years crop of football helmets have 8 helmets with the 5 STAR rating.    

    It is important to note that the cost of the helmet has no corrolation to it's STAR rating. The highest rated Hockey helmet is the Warrior Krown 360 with a 3 Star rating, it retails for $79.99. While some of the helmets that were rated 0 or 1 STAR cost over $250. 


  1. Rowson B et al. Hockey STAR: A Methodology for Assessing the Biomechanical Performance of Hockey HelmetsAnnals of Biomedical Engineering, 2015 DOI: 
  2. Concussion Considerations
  3. Ice Hockey Causes 44.3% Of All Traumatic Brain Injuries Among Canadian Kids

  4. USA Hockey Concussion information

Why do we continue to expect simulation to be better than reality?

In a new article from Prehospital & Disaster Medicine, renown authors from Los Angeles report that unsurprisingly, it appears that ACTUAL people are a more effective learning stimulus than simulators.  Due to the increasingly difficult time acquiring role-players and the perceived variation between actors, electronic simulation is now thought by many in Emergency Medicine to be a panacea of medical education.  Tens of thousands of dollars are spent on Sim-Man models at universities and medical centers across the country, with faculty members now specializing in operating these mannequins.  Ironically, learning to operate these machines to talk and respond to interactions from the learners is becoming a full time job.  Now, please do not take this as a condemnation of simulation, but there are limits on their efficacy.  Anyone that believes that their simulation can effectively reflect the anxiety of a trauma injured casualty pulling on your pant leg and shouting at you to help them, while you attend to three other casualties, is kidding themselves.  Of course actors cannot act the signs and symptoms of a pneumothorax, but the Sim-Man's canned verbal interactions are unrealistic as well.  Accordingly, there needs to be a balance between real-life and simulation in educational situations.  As educators, we must recognize the value of each and plan our curricula accordingly.  

We can help. Join us.  Learn to save a life.

#FirstCareProvider #FCP #Couldyousavealife? #TECC

People really are shooting each other more often

In what will come as a surprise to absolutely no one, a "new" article confirms what we already know.  People are shooting each other more than ever.  What's interesting is not that we now have dramatic statistical evidence demonstrating the increased frequency of these events, but that they are in fact so frequent that there is debate over what is considered a "mass shooting."  This begs the question, are we really OK with shootings as long as it doesn't involve 3 or more people?  Take a moment and read the article. It is enlightening and discusses the variables associated with these events including: actual numbers of gun deaths from smaller events, and the misperception that the 24-hour news cycle is what gives the impression of increased frequency (it isn't).  Regardless, the threats to our society continue to evolve, yet our ability to care for ourselves and our loved ones has waned.  Join us.  Become a First Care Provider, and learn to save a life.  @1stCareProvider @CommitteeTECC @Couldyousavealife?


2015 National School Safety Conference!!!

Busy month for First Care Providers everywhere.  Last week we reached universities and hospital systems at the Campus Safety Conference at LAX.  This week we're in Las Vegas at the National School Safety Conference.  Driving the First Care Provider concept into our schools and pushing C-TECC guidelines into the national spotlight.  Join us tomorrow when we present:  Evolution of the School-Based First Responder: The First Care Provider

@1stCareProvider @CommitteeTECC @TacticalMedical @TQSresponse


Just saying...

So today 2 Americans were gored while at the drunken fest that is San Fermin in July.  Sure, it sounded like a good idea at the time, but how the heck are you going to get care if something goes sideways?  Of course we don't do this here do we?  Sure we do.  In Riverside, CA a company from Boston used to stage a "running of the bulls" at Temecula Downs as recently as a few years ago.  So if you happen find yourself on the business end of a charging two thousand pound bull, make sure you have an idea of how you're going to treat yourself if it doesn't shake out the way you planned.  Become a First Care Provider, save a life.  #FirstCareProvider #FCP #TECC #couldyousavealife    Read more by clicking the title.

What if EMS can't get to you?

What if EMS can't get to you?

We have the best medical providers in the world.  But what if they can't get to you when you need them?  First Care Providers may provide that necessary link between disaster and medical care.  San Francisco had a problem, and their fire department has been working diligently to improve their response times for EMS.