Tourniquets -

When too Tight just ain't right... (from issue 10)

Around 80% of injuries IV drug users face can be traced back to poor injecting techniques. Injecting is a delicate procedure & a lot can & does go wrong. Tourniquets are a subject rarely discussed but are essential to better injecting
practices.

If there's one comment about safer using we hear at BP more than most, it's about tourniquets. On the whole, most people didn't realise that sharing tournis can be a source of transmitting Hepatitis C and still others didn't know that keeping your tourni pulled too tight actually makes it harder to get a hit. There were other queries too. This got us thinking that an article on tourniquets and their safer use is well overdue and what with all our combined mileage on using tournis, belts, ties and tights - we thought we'd better research it - for all our sakes!

When you first start injecting, you may not have used a tourniquet, indeed sometimes just a twist of the old shirt sleeve was enough to get a vein up. But as time goes on, and veins get harder to find, tourniquets become a necessity for most of us. However a brief glance around at your injecting mates will tell you that we ain't all using them right. Not only that but incorrect tourniquet use will make finding veins even harder, leaving you poking, prodding and bleeding more than you need to be and this can have numerous health implications. (see safety tips below).

The reason why tourniquets are recommended is because they make it easier to inject and easier injecting usually means safer injecting.

There are two ways tourniquets help. Firstly, tournis are used to dilate veins, making them bigger so they are easier to find and inject into. Secondly, dilating the veins helps to 'anchor' them so they don't roll around as much when you're trying to insert the needle.

Even if you are able to ditch using tourniquets because your veins stand out enough on their own, it is still worth developing a good tourni technique as using one will still help stop the vein rolling. Of course the fiddleyness sometimes involved in releasing a tourniquet, can still put people off using them. However there are ways to use tourniquets so they can be easily removed without having to take your hands off your injecting, important as quite a bit of tearing to the wall inside the vein can get done when you have to leave your needle sometimes dangling in your arm while you fiddle with releasing your belt. Of course, if you can manage by twisting your shirt sleeve above the elbow and holding the twist between your arm and your ribcage, it must be said that this works well and allows you, with slight movement of the arm, to release the twist without ever having to take your hands off what your doing. Holding the end of an easily released belt with your teeth or your foot if you’re sitting down, can also let you loosen the tourni without removing your fingers from the task at hand. All good in keeping a steady hand and eye on what you’re doing.

Loose tourniquets are not much help at all but by far the overriding issue for injectors is tourniquets that are just too tight.

While one may think that the tighter you pull your tourni the bigger your veins will bulge - it is actually not true at all. In fact, having your tourni too tight actually stops the blood supply to the veins, cutting off circulation and making finding a vein even harder. You only need apply enough pressure to block the veins but not the arteries so blood can still flow to the limb but is stopped returning back up the limb towards the heart by the tourniquet. Tourniquets should be equal to 'a light squeeze'. Not a choke, not a strangle, just a light squeeze!

The aim of applying a tourniquet is to block the flow of blood in the veins going back to the heart. Say you put your tourniquet around your bicep area. (Note: 3 fingers width from the crook of your elbow is supposed to be the right place to tie your tourniquet or a small 1/3 up the limb). You tighten it gently so the arterial blood can still flow to the tips of your fingers. Then, as the blood returns up the arm on its way back to the heart (now via the venous system), it gets held up by the tourniquet. Thus, you will see your veins dilate and become more visible. The tourniquet should not be tighter than 'a light squeeze' because greater pressure will just block the arterial blood flow entering into the limb. Then there won't be enough blood continuing to flow into the arm to be able to build up in the veins behind the tourniquet, which is necessary to dilate them. This makes it impossible for your veins to dilate, and in fact they may even seem to sink or disappear. Hardly surprising considering there is no blood build up in them. This of course defeats the entire purpose of the exercise.

A Tourniquet is too Tight When:

* You notice your veins aren't dilating like they should.

* You feel tingling or pins and needles in your hand because the blood supply to your nerves and tissues has been cut off. Your hand may ache or feel heavy, become painful and then numb. It will also look pale or bluish. Take it off!

* When you release a tourniquet that is too tight you will feel a surge of warmth as the blood rushes back into the arm through the arteries. Not good signs.

Safer Tourniquet Techniques

Place the tourniquet above where you're trying to inject and tighten it gently. TIGHTER IS NOT BETTER. Make sure you can still feel your pulse at all times.

Squeeze your hand a few times. Sometimes gently tapping or rubbing the skin over the vein a few times also helps but apparently there is not much value is spinning your arm around like a windmill - if you must, not with the tourni.

Be patient. Yes, we know it's hard but give your veins a minute to fill up with blood and dilate. It will save you grief later on.

If you're having trouble finding a vein in one arm, try the other and stay calm. It's hard when your hanging out but it'll only be worse if you're still trying 20 minutes later.

Take breaks between unsuccessful attempts. Stopping the bleeding from each puncture wound before moving on to the next injecting site is important. Use tissue to stem the flow not alcohol swabs as swabs just slow the clotting process and you'll bleed more/heal slower. Sitting there with blood all over your arms is also upsetting and can cause distress which prevents you from concentrating. From a blood borne virus perspective it is also important to ensure you don't end up covered in blood - this reiterates just why it is so important never to share or borrow a tourniquet as they do get blood on them. Try to give yours a clean as often as you can too.

Make sure the vein 'bounces' when you press it. If it's more like a solid cord then its probably collapsed or clotted, which is no good for injection.
Once you've found a suitable vein and inserted your needle (bevel upwards), draw back the plunger slightly. If blood enters the chamber you know you are in a vein and in that case - release the tourniquet. DO NOT leave the tourni pulled tight while you depress the plunger. You could split the walls of the vein, leaking gear into the skin tissue. If you are worried you may lose your vein if you let go of the tourniquet, make sure you have such a technique that you don't have to remove your hands from your needle to release the belt. Release the tourni slowly - not quick, and you should stay in the vein. Make sure it is fully loosened before depressing the plunger.

Lastly, choose the material you use for your tourniquet very carefully. It needs to be easily releasable, made out of something softish and preferably cleanable. Sometimes, the fabric chosen dictates how you’ll use it as a tourni. For instance, stockings or tights may seem a good idea, but getting them to release without fiddling can be problematic. Silky ties can be good, forming a gentle squeeze around the arm while gripping the other end with your teeth can mean an easy release when the time’s right. Just say aaarhh! Hospital ones are good but they often tend to release via a button mechanism, rather quickly too. Check the newer ones.

You don’t have to use the typical tourniquet tie-up either. Depending on the release-ability of the fabric, sometimes just a gentle wind round the arm a few times, held against your side, without any tie-up will do. An easy movement of the arm releases the pressure without you having to take your hands of what you’re doing. Some people wind belts round the arm and hold the end in their teeth so they can just let go when they need too. Not a bad idea just don’t pull to tight! The yanks use rubber tubes a lot, tied in a traditional tourni way (slip knot) and everyone has used a belt at some stage. However, while there are numerous variations in how people tie their tournis, the most important thing is that it releases easily when you need it to and it doesn't get stuck. Preferably, also without you having to remove your fingers from the task at hand. Experiment. It is worth getting it right. Your veins will depend on it.