Gun violence in Philly means tourniquet use on the rise

By the way blood was pouring from the bullet wound, Lt. Robert Friel knew it wasn’t long.

He fell to the floor of the CVS on South 10th Street, unable to move his legs. Friel had never been shot before, but after 28 years with the Philadelphia police, he realized the bullet had hit a major artery.

The lieutenant froze as a colleague subdued his assailant, then finally called out the words that would save his life:

You must tournicate me or I will die!

Amid an epidemic of gun violence that shows no signs of stopping, Philadelphia is turning more and more to a life-saving tool invented in ancient times: a stiff strap wound so tightly around an arm or leg that it cuts off blood flow.

Tourniquets fell out of favor for much of the 20th century, due to fears that they could damage nerves and even lead to amputation. But in Iraq and Afghanistan, the types of injuries suffered by U.S. soldiers have sparked renewed appreciation for blunt-force devices. The evidence was clear: when used correctly, tourniquets are safe and save lives.

What worked during the war soon found its way into civilian life. Boston issued tourniquets to its police after the 2013 marathon bombing, and Philadelphia followed later that year. Soon, they became standard equipment for construction workers, landscapers and lifeguards. By 2018, area school districts included first aid kits, training teachers and sometimes tourniquets among students.

Community groups are also taking up the cause. In a city where more than 2,000 people die from gunfire each year, knowing how to use tourniquets is a basic life skill, said Christopher Stith, a member of a fraternity that teaches city teenagers to apply. devices at a day camp last summer.

“You never know when that bullet is going to come,” he said. “If something happens in front of them, they’ll be able to jump into action.”

A tourniquet works by sheer force, closing off a blood vessel, like flattening a drinking straw, says Lewis J. Kaplan, M.D., professor of surgery at the University of Pennsylvania’s Perelman School of Medicine.

“There’s no way you can make it too tight,” he said.

The devices are simple, consisting of a strap and a tightening rod called a windlass. It is possible to make one out of cloth and sticks, but in untrained hands, this method can make the bleeding worse. Experts recommend store-bought varieties instead.

If done correctly, it hurts. Kaplan, past president of the Society of Critical Care Medicine, said tourniquets are safe to leave on for more than an hour, even if they deprive the arm or leg of oxygen.

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» Read more: How to Apply a Tourniquet and Stop Someone Bleeding to Death

That makes the concept a perfect fit in hospital-dense Philadelphia, where most locations are a short ambulance ride from life-saving care. City police often take patients to hospital more quickly Taking them in the back of a police cruiser — a long-sanctioned practice called “scoop and run.”

In 2021, 128 patients arrived at a Philadelphia hospital with a tourniquet — an average of once every three days.

Patients survived in 119 cases, according to the Pennsylvania Trauma Systems Foundation, the group that recognizes state hospitals that specialize in treating severe trauma. Doctors say the devices probably aren’t needed in every case, but it’s better to err on the side of caution.

If anything, tourniquets should be used more frequently, says Murray J. Cohen, a trauma surgeon at Thomas Jefferson University Hospital. He said one person was killed in June’s South Street mass shooting because a tourniquet was not used.

Cohen would like to see tourniquets become as common as defibrillators — the electrical devices used to revive someone in cardiac arrest — if not more so, since tourniquets can cost less than $30.

But when he inquired recently at a SEPTA station, Cohen was dismayed to learn that the first aid kit did not include a tourniquet. Philadelphia schools have all the devices, but there is no formal education for students on how to use them.

Organizations like Phi Beta Sigma have stepped in to fill the void. July 22nd is historically black The fraternity joined police to host a one-day “Stop the Bleed” and violence prevention camp at Benjamin Franklin High School in the city’s Spring Garden neighborhood.

More than 40 participants, ages 12 to 18, were given kits with tourniquets, gauze and clotting agents and taught to use them, said Stith, the organization’s regional director of social work.

One fraternity member even made prostheses out of pool floats so students could practice.

On the morning of May 29, 2020, police searched Richard A. throughout the night. Spent searching for a bodybuilder named Krall, who is known to be armed and suicidal.

Driving home after the night shift, shortly before 7 a.m., Lt. Friel finally spotted him near the CVS store on South 10th Street and radioed for help.

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Inside the store, as he helped Officer Marco Fernandez subdue the suspect, Friel felt a bullet hit the outside of his left leg, just above his knee. He fell to the floor in agony, blood quickly coagulating beneath his feet.

Fernandes soon arrested Krall. Officer Caitlin Harper then wrapped Friel’s leg with a tourniquet, twisting it so tightly that it almost hurt like a bullet wound.

Minutes later, when Friel arrived at Jefferson’s emergency entrance in the back of a police cruiser, his legs went numb.

Getting out of bed and looking at the doctors and nurses as they prepared him for surgery, he remembers saying one last thing:

save my leg

Hindu physicians began using tourniquets more than 2,500 years ago, wrapping the limbs of snakebite victims to reduce the spread of venom. Yet the field of medicine has been slow to realize that the devices can save lives by stopping blood loss, according to a review in the American Journal of Surgery.

Even at the start of the American Civil War, many soldiers failed to carry or use tourniquets despite evidence in their favor, much to the dismay of the influential Philadelphia surgeon Samuel D. Gross.

“They allow their life-stream to run out, as water is poured from a hydrant,” wrote the Jeffersonian physician in 1861.

The devices became more popular during the bloody conflict of World War I — the Mutter Museum has some shiny metal varieties from that era — but amid concerns that tourniquets increased the risk of amputation, their use declined again for the rest of the 20th century.

As far as Iraq and Afghanistan. Elinor Kaufman, a trauma surgeon at Penn Presbyterian Medical Center and an assistant professor at Penn’s Perelman School of Medicine, said soldiers suffered fatal leg injuries from the widespread use of improvised explosive devices (IEDs). Yet because many were protected by body armor, their torsos were relatively unscathed.

“They lived in a way where the extreme problem was the most serious problem,” he said.

Doctors have again determined that tourniquets make sense, provided that two conditions are met.

One, the devices were not left on for more than an hour or two.

Two, soldiers receive proper care after their tourniquets are removed, to prevent collateral damage if blood flow to an arm or leg is suddenly restored, Penn’s Kaplan said. Battlefield surgeons made prophylactic cuts through the fascia — the thin layer of connective tissue that surrounds the muscle — to accommodate the swelling.

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The results were clear. Soldiers with tourniquets were more likely to survive.

The lessons were soon applied back home. Inspired by 2012 After the Sandy Hook school shooting, the American College of Surgeons met with the US government to develop a domestic training campaign, now called Stop the Bleed, aimed at making tourniquet skills as common as knowing how to administer CPR.

Friel’s leg was a mess.

The bullet shattered his femur and severed his femoral artery, the leg’s primary source of blood.

Cohen, who oversaw the lieutenant’s May 2020 surgery in Jefferson, knew a successful repair would require careful choreography. Restoring blood flow to the limb was essential, but the surgeon and his colleagues had to begin a temporary repair.

“You can’t fix the vessel until the bone is back to the proper length, or you’ll tear the vessel,” he said.

First, vascular surgeon Don Salvatore attached a piece of flexible tubing to each severed end of the artery, draining blood to the muscle and bone beneath the injury.

Orthopedic surgeon James Krieg then screwed in a cage-like frame for stabilization Broken bones at the right length. Just like military surgeons in Iraq, the team also performed a fasciotomy, cutting the tissue around Friel’s calf muscles so that there was room for them to swell.

Then, it’s Salvatore’s turn again. He replaced the temporary tube with a permanent graft, which continues to supply blood to Friel’s leg today. The next day, Krieg replaced the broken bone with a metal rod and finally removed the external frame.

“It’s a team sport,” Cohen said.

Two and a half years after the shooting, fragments remain in Friel’s leg, which is numb below the knee. His feet are constantly asleep. He cannot sit or stand for any length of time and has not yet been cleared to return to work.

Cohen, her surgeon, said the lingering symptoms weren’t surprising, since the tourniquet compressed the nerves in her leg.

But there’s no question that applying the strap was the right call, Cohen said. And with physical therapy, the numbness can still get better.

At the trial of her alleged assailant later this month, she expressed gratitude for the quick work of her colleagues and doctors.

“They saved my life,” he said. “Another thing, I can deal with.”

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