6 tips for effective tourniquet training
Teach LEOs to use a tourniquet efficiently and effectively with these instructional tips from experienced field operators and Stop the Bleed instructors
This is the second article in a three-part series on tourniquet application to stop severe bleeding written by a SWAT team leader and a paramedic. Part 1 addresses basic tourniquet selection considerations and tips for success. Part 2 covers training with tourniquets. Part 3 addresses advanced tips for the real-world use of tourniquets.
By Jason Williams and Brian G. Anderson
When a department commits to equipping its officers with military-grade tourniquets, training should be a significant part of the initiative. Tourniquets are simple devices, but formal training is necessary if officers are expected to use them to their best advantage during an incident.
Experience in both the training setting and in the field, coupled with lessons learned by warfighters has created a wealth of knowledge about tourniquets and how to use them. The tips presented are intended to supplement, not replace, formal training in the application of this life-saving tool. The tips in this article are based on experience with the military-grade North American Rescue Combat Application Tourniquet (C.A.T.) and the TacMed Solutions SOF Tourniquet but most of the tips will apply to other tourniquets as well.
Before beginning training, consider this important information about Stop the Bleed training, effectively utilizing lecture and group discussion time and basic tourniquet training tips.
Stop the Bleed training
If an organization or individual officer is considering adding tourniquets to their standard equipment issue, formal training should be considered as well. A wide range of training classes are available for law enforcement officers, from the basic Stop the Bleed course to customized training courses delivered by private providers. If in-house tourniquet training is a goal, training officers can attend the Stop the Bleed course and then register as Stop the Bleed instructors. Stop The Bleed instructors have access to all the classroom training materials except for equipment and supplies. Stop the Bleed training is widely available at little or no cost. Class information and schedules are available at the Stop the Bleed website.
Group discussion and lecture tips
A successful tourniquet training experience is a combination of lecture, group discussion, instructor demonstrations and hands-on practice. Here are five tips for making the most of the time scheduled for lecture and group discussion.
1. Tourniquet location. When delivering basic or refresher tourniquet training, the beginning of a training session is a good time to discuss the standard location of tourniquets and trauma kits along with relevant policies, procedures and expectations. Answer these questions for participants:
- Where are tourniquets located? Duty belts, vests, glove boxes, trunks of patrol vehicles or in the back of SUVs?
- How are tourniquets replaced if one is used on a victim?
- What should an officer do if contaminated with blood?
- Who is responsible for processing bloodborne exposure incidents?
- What is classified as a significant bloodborne exposure?
- Who is missing a tourniquet or needs one?
- Does anyone have a non-department-issued tourniquet?
2. Tourniquet indications. Training session content will vary depending on the group, but some material that should be included in the session includes: when and why a tourniquet is used, use of direct pressure, hemostatic agents (QuikClot, ChitoGauze, etc.), artery and vein locations in the extremities.
3. Tourniquet application videos. YouTube is an excellent resource for seeing how officers from other departments have used tourniquets in the real world. Seeing how officers addressed life-threatening bleeding during active incidents can start an important conversation. Even if the video includes imperfect tourniquet application or tactical issues, the dissection of the incident can provide valuable insight and learning.
4. Warfighters in our midst. When delivering tourniquet training to a group of officers, at the beginning of the training session it’s a good idea to ask if any of the participants have applied a tourniquet on the battleground as a member of the military. If an officer raises their hand, they can be asked to describe the setting, decision-making and actions. This interaction can provide valuable real-world information about the use of a tourniquet, provide support for the initiative and perhaps provide some previously unknown information about the officer.
5. Previous LEO tourniquet use. Ask if any officers have applied a tourniquet while on-duty or off-duty. Their experiences and suggestions can be very valuable for the class and drive home the value of the training and having the equipment. LEOs need to know how to apply a tourniquet because fire or EMS may not be available to provide life-saving care for victims. Scenes may not be secure or EMS may be caring for other victims. When it comes to life-threatening bleeding, waiting for fire or EMS is not a viable option.
Hands-on tourniquet training tips (basic)
Minimize time spent on lecture and group discussion to allow as much time as possible for hands-on training, individual practice and competency checks. Here are three top tips for effective hands-on tourniquet training.
1. Pull, don’t push. Ergonomically it’s easier to tighten a tourniquet by pulling the strap than by pushing the strap. There’s a simple way to handle the tourniquet so that it will be set up to be pulled, not pushed tight. Just before slipping the tourniquet onto the limb, be sure to grasp the loop, buckle and tail all in one hand with the tail pointed at the person applying the tourniquet. When using a C.A.T., the red tip at the end of the band should be pointing at the person who is applying the tourniquet. This works when performing self-rescue or when applying it to another person.
2. Tighten up. When practicing tourniquet application on live participants, officers most often will not tighten the tourniquet completely to avoid discomfort to the training partner. This memory of inadequate tightening can cause a problem when the application of a tourniquet is required during an incident. One way to improve performance is to use rescue manikins and to apply the tourniquets tightly. If manikins aren’t available, three or four pool noodles can be inserted into an old pair of uniform pants. A small pillow can be added to simulate the lower abdomen and pelvis.
3. Stop the bleeding. During drills or exercises, an effective way to reinforce the importance of applying a tourniquet is for the instructors to ask, “How tight are you going to make the tourniquet?” The best answers include “until the bleeding stops,” or “tight!”
4. High and tight. “Go high or die” is the guidance from experienced warfighters when discussing where a tourniquet should be applied on the limb in relation to the wound site. Historically, tourniquet training instructed placement of a tourniquet two inches above the wound, but many of those with battleground experience prefer to apply a tourniquet as high as possible on the limb.
Experience has shown that the wound entry point, whether it is caused by a penetrating weapon/projectile or an explosive/blast, may not conclusively indicate where all the damage has occurred on the limb. There may be multiple penetrating wound sites but during the rush to treat, the officer providing treatment may miss some of them, which could result in a tourniquet being placed below a wound.
5. One tourniquet may not be enough. A lesson learned from our warfighters is that sometimes the application of one tourniquet may be inadequate to control bleeding, making the application of a second tourniquet necessary. Stories from the battlefield have included the need for a third tourniquet to control the bleeding from a large victim.
6. Secure the windlass strap. It’s always the little things that make a big difference. Take a look at the small white or gray windlass retention strap on a C.A.T. tourniquet for a moment to understand its use. When a tourniquet windlass (stick) is tightened enough to stop the bleeding, the windlass is secured in the windlass clip to hold it in place. If the black band is long enough, it is run over the windlass, and it too is secured in place with the windlass retention strap. The small windlass strap may seem insignificant, but it can mean the difference between success and failure. The strap is used to keep the windlass in place as the victim is being dragged, rolled over, loaded onto a stretcher and into a rescue vehicle or helicopter. If the windlass retention strap is not applied, there is a risk of the windlass being bumped out of the windlass clip, causing a release in pressure and loss of bleeding control that may go unnoticed until it’s too late.
How to find bleeding
Not every extremity bleed will be visibly obvious and easily discovered. Make sure to teach students to find the source of bleeding with these tips.
1. Let’s see what you got. Once a tourniquet is in place, it’s time to look for other life-threatening injuries. The most effective way to locate wounds on someone who is lying on the ground is to cut the clothes away with EMS trauma shears, which are an important part of law enforcement trauma kits. Some officers carry them on their uniform gear.
2. This isn’t the movies. There may or may not be an exit wound and what may appear to be an exit wound may be a second entry wound. Entry and exit wounds may be small and be difficult to see without careful observation. One way to locate wounds in an area that is covered with blood is to quickly wipe the skin area with a towel or gauze and watch for blood as it starts to ooze from the wounds in the patient’s skin.
3. Front, back and sides. When looking for injuries it’s important to remember that the victim has a front, back, two sides and inner parts of the legs. A quick survey may reveal multiple points of injury that must be addressed. A pool of blood beneath one leg can be caused by one obvious wound or multiple hidden wounds.
Another source of problems can occur when the victim’s arm or leg is positioned so that a projectile enters the limb and then travels up the limb toward the torso. This can occur when the victim is kneeling, running, has an arm extended (think about holding a pistol or rifle), or instinctively moving the arms or legs into a defensive position.
4. What’s that smell? Dark uniforms and low light can make locating a wound difficult, especially on the legs where thorough, quick visualization of the limb is difficult. When trying to determine if a wound exists, one method that can help locate a wound is running the rescuer’s hand over a section of the victim’s leg or arm and looking for blood on the rescuer’s hand or glove.
If the rescuer is wearing black nitrile gloves or is working in low light conditions, visualization of the blood may be impossible. To locate the bleeding site, rescuers can sweep the limb with their hand and then sniff their hand to detect the odor of blood. Blood has a distinctive metallic odor that can be detected easily.
Locating the blood is a good starting point, but it’s important to recognize that blood in sufficient volume can travel down surfaces of clothing before leaking on the ground or penetrating a uniform. A puddle of blood by a victim’s hip could be from a gunshot wound to the upper arm and a pool of blood near an ankle could be from a wound to the upper thigh.
Tourniquet training FAQs
Finally, here are a few questions we often receive from law enforcement officers. If you have additional tourniquet training questions, complete the form below and we’ll add the answers to the article.
Should we use training tourniquets instead of duty tourniquets during hands-on training sessions?
Tourniquets that are intended to be used to treat a life-threatening bleeding situation should not be used in training because the wear and tear could create problems if the tourniquet is needed to treat a victim. To avoid confusion, some tourniquets are available in blue for training.
Another officer needs a tourniquet. Should I use the tourniquet issued to that officer or my tourniquet?
If an officer is applying a tourniquet to another officer during an active incident, consider using the injured officer’s tourniquet if it’s easily accessible. That leaves the rescuer’s tourniquet available if needed for another victim.
Can tourniquets be applied to children?
This is the question that comes up often, especially when training is done at schools or in preparation for an active shooter exercise. Science-based research and testing are most often conducted with, and for the benefit of military age and size adults, leaving the question of pediatric effectiveness unresolved. Recent research conducted by Kelly, et al. suggested that tourniquets can be effective on children as young as one-year-old.
Experience in training sessions, however, suggests that tourniquets may not be effective for individuals with very small circumference limbs. Officers would be well served to spend some time working with their tourniquet in training and then consider the size of a pediatric patient’s limb before deciding on how to proceed. The good news is that direct pressure is another option if a tourniquet is ineffective.
When is a good time for me to practice tourniquet application?
Slow periods during the tour can be a good time to practice with a blue trainer tourniquet. A few minutes of practice can make a big difference in performance when the stakes are high. Don’t limit yourself to simply practicing the skill. Also, imagine or visualize a life-threatening bleeding incident to help you prepare for the real thing. The list of situations that could occur is endless, but working through some, such as a partner shot in the leg or a teenager shot in the arm, will better prepare you to act.
Police1 reader questions
Question: Where can I purchase inexpensive practice tourniquets?
Answer: When purchasing tourniquets for use in training, blue tourniquets are the best choice because the color provides a visual clue that they are designated for training, just like blue weapon trainers. They are fully functional and operate the same as the other colors. The blue color helps prevent the trainers from being accidentally issued for use in the field. Click here for the North American Rescue C.A.T. tourniquet where the blue option is available. Click here for the Tacmed Solutions New SOF Tourniquet in blue.
It’s best to use the manufacturers' trainers because they function the same as the tourniquets that will be issued for use in the field, making training realistic. Full functionality of the training tourniquet is important when developing a feel for the devices and when fully tightening the tourniquets on training manikins. Knockoffs and fake tourniquets created for use in games should be avoided.
Question: Do they make tourniquets for children?
Answer: Research is starting to emerge that addresses the use of military-grade tourniquets on children. For example, in a 2019 article in "Pediatrics, Official Journal of the American Academy of Pediatrics," Harcke, et al., examined the effectiveness of the C.A.T. tourniquet when applied to school-age children. Within the online article titled Adult Tourniquet for Use in School-Age Emergencies, Dr. Harcke included a video explaining the results of their research. Here’s a link to the online article and video.
A 2020 article, Efficacy of the Combat Application Tourniquet in Children, provides information about procedures and findings based on research with school-age children.
Kelly, et al., published their findings in "The Journal of Trauma and Acute Care Surgery" in a 2020 article titled Effectiveness of the Combat Application Tourniquet for Arterial Occlusion in Young Children.
All the studies identified above suggest that tactical tourniquets used for adults can be effective when applied to school-age children. The study abstracts provide information about the size of the children that participated in the studies.
If an organization chooses to investigate tourniquets designated for use on children, it would be wise to review the medical research documentation that is cited to support the claim.
The bottom line is that medical and scientific research can serve as a solid foundation for the creation of an organization’s procedure guides and for treating traumatic injuries in the field.
Question: All of the points mentioned in your article were really good and are in line with what we teach and train at our agency. I liked the training aids that you used as well. My question is about the training aids. What do you use for fake blood? Is it something you purchased or is it something you made yourself and if so what is your "recipe"? I've been looking for a better training aid for fake blood & haven't found anything that I've liked so far.
Answer: We use fake blood in our direct pressure and wound packing training but we don’t use for the tourniquet portions. When creating fake blood, we have used a variety of recipes, but we now use tomato juice exclusively. Fake blood can be purchased from simulation supply companies and there are several recipes available online for making it with common ingredients. We encountered a couple of problems with the online recipes including the expense of the components and the preparation time needed to combine them into the final product. Before selecting tomato juice as our preferred product, we used a recipe that included Karo syrup during a high school active shooter exercise. One role player was in an outdoor area and during the exercise, the simulated wound area became covered with ants that were drawn to the sweet syrup. The advantages of using tomato juice are that it is relatively inexpensive, easy to transport, unopened/unused cans can be saved for the next training session and it doesn’t draw ants if outdoors for any length of time. We use the least expensive brand that we can find at the grocery store. It’s not necessarily high-fidelity, but it’s still effective. Just remember to have an old-school can opener to open the cans!
About the authors
Jason Williams is a 20-year veteran of the Aventura Police Department in Miami-Dade County, Florida. Jason has been a member of the multi-agency SWAT team for 16 years, as well as a team leader for the past 12 years. He is currently certified in several instructor areas including Active Shooter Response, less lethal, ballistic shield, mechanical/ballistic breacher and several more. Jason served as a K-9 handler for 12 years working two dual-purpose canines. His experience as a SWAT team leader/member and K-9 handler has pushed him to become a better tactician and to share his expertise.
Brian G. Anderson is a retired battalion chief and paramedic from Miami-Dade (Fla.) Fire Rescue. Prior to retirement, he focused on fire-rescue active shooter procedure development and inter-agency active shooter exercises. He is an instructor at Palm Beach State College and is also a volunteer instructor with Trauma Training Group, Inc., an organization that provides no-cost Stop the Bleed training in South Florida. He has delivered bleeding control training to private, public and charter school personnel and members of city and county law enforcement agencies.