Lt. Col. King makes some excellent points. However, despite Dr. King's combat medicine experience, his contribution to this article reveals a gap that still exists between field medicine and hospital medicine.
The case against improvised tourniquets
There is no consensus on the definition of an "improvised" tourniquet. Homemade applications such as neckties and sticks are defined as improvised, but the Boston EMS kits (surgical tubing and Kelly clamps) also could be considered improvised. All of these methods may sound primitive since the advent of Combat-Application Tourniquets; however CATS are relatively new to the scene. Should we consider every tourniquet applied prior to their introduction to have been improvised? For the price of one CAT, we can assemble 10 tourniquet kits. And if Dr. King's initial contention was that tourniquets were in short supply, then it is a better system to deploy as many as possible. This point may be moot, however, because since the Boston bombing incident, federal grant money has allowed the purchase of CAT units in great numbers within the Metro-Boston area.
Tourniquet efficacy
"It is abundantly clear from the literature that improvised tourniquets almost never work." I feel this study had the wrong focus. Rather than ask which tourniquets have a better success rate, the study should have asked whose tourniquets have a better success rate.
Study after study has shown that successful intubation rates have little to do with the level of training of the practitioner, and everything to do with the frequency of intubation. More tubes equal more successful passes. I propose that this applies to tourniquet application as well. Field personnel who do not practice or have the opportunity to apply tourniquets frequently (which is the great majority of us) may not be applying tourniquets properly. This is why we instituted a massive tourniquet training and review program almost immediately following the 2013 bombing at the Boston Marathon.
Another point not addressed in studies is the effectiveness of nonresponder tourniquets. I would contend that an experienced practitioner with a necktie and a stick would be more successful in hemorrhage control that a civilian with a CAT, but those data have not been explored yet either.
The Loading Officer as unsung hero
All our Action Area Officers performed brilliantly (full disclosure, I was the Loading Officer). However the term Loading Officer is a misnomer. Yes, there is a Loading Officer, but there is actually a Loading Team. It consists of staff at the scene who liaise with the treatment areas and the true unsung heroes, the staff in the Operations Division or Dispatch Center. Dispatchers are in constant contact with the hospitals, scene operations, as well as continuing city service. They perform the hospital destination designations because they have a global sense of traffic, while at the scene we have only a worm's-eye view.
The stay-and-play critique
"All critical patients were evacuated within 1 hour, but some argued this could have been accomplished more quickly were it not for a 'stay-and-play' mentality." I take exception to this assertion. First, the point is contradictory. All critical patients were evacuated within 1 hour, but there was a stay-and-play mentality? Every EMT and paramedic knows that transport times translate into positive results with trauma.
Emergency personnel are taught that what matters most in trauma survival is not basic life support, advance life support, or wheelbarrow, but getting them to the ED fast. Yes, there were slowdowns in the medical tents, but most of delays came from non-EMS personnel who were not well versed in field medicine. We questioned, pleaded, and ultimately ordered some practitioners away from patients as they were attempting to perform procedures that we would never attempt on a trauma patient in the field. This is by no means a condemnation on my part. The staff we worked with was exceptional, and I witnessed true skill, heroism, and compassion. But it also demonstrated to me that a disconnect exists between field medicine and hospital medicine.
I see an opportunity here for training to better acclimate responders to working together with our hospital counterparts. We also need hospital personnel to be oriented to realities and limitations of field medicine.
Lt. Brian Pomodoro is a member of the Boston EMS.
