Philadelphia police lieutenant Robert Friel shows where a colleague placed a tourniquet on his left leg, allowing him to survive a bullet that shattered his thighbone and severed his femoral artery.

Why the tourniquet, a relic from the early days of medicine, is back amid the gun violence epidemic

By the way blood was gushing from the bullet wound, Lieutenant Robert Friel knew he wasn’t for long.

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

The lieutenant held on as a colleague overpowered his assailant, then finally spoke the words that would save his life:

You have to bind me or I’ll die!

Amid an epidemic of gun violence that shows no signs of abating, Philadelphia is increasingly turning to a lifesaving tool invented in ancient times: a sturdy strap wrapped so tightly around an arm or leg that it cuts off the blood flow.

Tourniquets fell out of favor for much of the 20th century, due to fears that they could cause nerve damage and even lead to amputations. But in Iraq and Afghanistan, the patterns of injuries sustained by US soldiers have sparked renewed interest in blunt devices. The evidence was clear: when used correctly, tourniquets are safe and lifesaving.

What worked in the war quickly 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 rescuers. In 2018, school districts across the region were including tourniquets in first aid kits, training teachers and sometimes students.

Community groups are also mobilizing. In a city where more than 2,000 people are hit by gunfire each year, knowing how to use tourniquets is a basic skill, said Christopher Stith, a fraternity member who taught the town’s teenagers how to apply. the devices during a one-day camp last summer.

“You don’t know when that ball is going to come,” he said. “If something happens in front of them, they will be able to take action.”

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

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

The devices are simple, consisting of a strap and a clamping rod called a windlass. It is possible to make one from a rag and a stick, but in untrained hands this approach can make the bleeding worse. Experts recommend store-bought varieties instead.

If it’s done right, it hurts. Although a tourniquet deprives the arm or leg of oxygen, it is safe to leave it in place for more than an hour, said Kaplan, past president of the Society of Critical Care Medicine.

» READ MORE: How to put on a tourniquet and stop someone from bleeding to death

This makes the concept perfectly suited to Philadelphia, where most sites are a short ambulance ride from life-saving care. The municipal police often bring patients to the hospital even faster by taking them into 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 in place – an average of once every three days.

In 119 of those cases, the patient survived, according to the Pennsylvania Trauma Systems Foundation, the group that accredits public hospitals that specialize in treating serious injuries. Doctors say the devices probably weren’t needed in all cases, but it’s best to err on the side of caution.

Rather, tourniquets should be used more often, said Murray J. Cohen, a trauma surgeon at Thomas Jefferson University Hospital. One of the South Street shooting victims in June died because a tourniquet was not used, he said.

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

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

Organizations such as Phi Beta Sigma have stepped in to fill the void. July 22, the historically black fraternity joined police in hosting 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, received kits containing tourniquets, gauze and clotting agents, and learned how to use them, said Stith, regional director of social work for the organization.

One fraternity member even made artificial limbs out of pool floats for the students to practice on.

On the morning of May 29, 2020, police had spent all night searching for a man named Richard A. Kralle, a bodybuilder who was allegedly armed and suicidal.

Returning home from his night shift, shortly before 7 a.m., Lt. Friel finally saw him near the CVS store on South 10th Street and radioed for help.

Inside the store, while helping Officer Marco Fernandes subdue the suspect, Friel felt the bullet hit the outside of his left leg, just above his knee. He fell to the floor in agony, blood pooling rapidly under his leg.

Fernandes quickly placed Kralle under arrest. Officer Katelynn Harper then wrapped Friel’s leg with the tourniquet, twisting it so hard it hurt almost as much as the bullet wound.

Yet minutes later, when Friel arrived at the Jefferson ER entrance in the back of a police cruiser, his leg was numb.

Looking up from his bed 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 slow the spread of venom. Yet the field of medicine was slow to realize that the devices could save lives by stopping blood loss, according to a review in the American Journal of Surgery.

Even early in the American Civil War, many soldiers did not wear or use tourniquets, despite mounting evidence in their favor, much to the dismay of influential Philadelphia surgeon Samuel D. Gross.

“They let their vital current run out, like water running from a fire hydrant,” the Jeffersonian physician wrote in 1861.

The devices became more popular during the bloody conflict of the First World War – the Mütter Museum has varieties of shiny metals from this era – but amid fears that tourniquets increased the risk of amputation, their use declined again for much of the remainder of the 20th century.

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

“They were surviving in a way where the extremities problem was the biggest problem,” she said.

Doctors determined once again that tourniquets made sense, provided two conditions were met.

First, that the devices have not been left in place for more than an hour or two.

Second, soldiers received proper care after their tourniquets were removed, to prevent collateral damage that can occur when blood flow is suddenly restored to an arm or leg, Penn’s Kaplan said. Battlefield surgeons made preventative incisions in fascia – the thin layers of connective tissue that surround muscles – to make room for swelling.

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

The lesson was soon applied at home. Prompted by the 2012 Shooting from the Sandy Hook School, the American College of Surgeons met with the US government to develop a national training campaign, now called Stop the Bleed, which aimed to make tourniquet expertise as common as knowledge of CPR .

Friel’s leg was a mess.

The bullet had shattered his femur and severed his femoral artery, the leg’s main blood supply.

Cohen, who oversaw the lieutenant’s surgery in May 2020 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 start with a temporary repair.

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

First, vascular surgeon Dawn Salvatore attached a piece of flexible tubing to each of the severed ends of the artery, directing blood to the muscle and bone below the injury.

Orthopedic surgeon James Krieg then screwed in a cage-like frame to stabilize the broken bone to the correct length. Much like military surgeons in Iraq, the team also performed a fasciotomy, cutting through the tissue surrounding Friel’s calf muscles so they had room to bulge.

Then it was Salvatore’s turn again. She replaced the temporary tube with a permanent graft, which continues to deliver blood to Friel’s leg to this day. The next day, Krieg replaced the broken bone with a metal rod and finally removed the outer frame.

“It’s a team sport,” Cohen said.

Two and a half years after the shooting, fragments of the bullet remain in Friel’s leg, which is numb below the knee. His foot constantly feels sleepy. He cannot sit or stand for some time and has still not been allowed to return to work.

Cohen, her surgeon, says the lingering symptoms are not surprising, as the tourniquet compressed the nerves in her leg.

But there’s no question applying the strap was the right move, Cohen said. And with physical therapy, the numbness may still improve.

As the trial of his alleged attacker nears later this month, he is grateful for the quick work of his colleagues and doctors.

“They saved my life,” he said. “Other things I can take care of.”

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