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 I have heard of and used 2 tourniquets before in patients with difficult access. But I have never heard of, used or seen 3 or 4 tourniquets used at the same time on any patient. The rationale for multiple tourniquets is to put the first one on high on the extremity to trap as much blood as possible within that extremity. If this does not distend the veins sufficiently to be palpated then put a second tourniquet on a few inches below the first to again trap more blood volume and distend the vein. Trauma patients will present with many different factors that a patient that has difficult veins for other reasons (e.g., frequent venipunctures, age-related changes, disease-related changes). In trauma, there could be severe blood loss and peripheral veins will not distend due to a simple lack of blood volume. The same thing occurs in dehydrated patients. Or there could be venous constriction due to other reasons both physical and emotional. If you are having difficulty in trauma patients, practice is changing to stop trying unsuccessfully for venipuncture and go immediately to intraosseus for fluid and medication infusion to save a life. If time allows, you could have greater success with using infrared light devices to locate superficial peirpheral veins or ultrasound to locate deeper peripheral veins. Lynn