The Situation Dictates The Medicine

Let’s say you witness someone cut themselves. How do you help them treat the injury? Well, that depends on a couple of things.

1) How severe is the bleeding?

2) What equipment do you have on hand?

In the “Tac Med” world, we’ve been preaching TQ use for the last several years as the “go-to” item when someone is bleeding out because it works. It keeps blood in the body where it belongs. But, if my daughter cuts her finger open on a piece of broken glass in the sink, I’m not going to be going full-on “Tac Med Ninja” on her and slapping a CAT on her arm. She’s probably going to need enough therapy as it is since she’s grown up with me as her dad. (that’s a joke, by the way) No, I’ll probably just grab a paper towel, hold direct pressure on it until the bleeding stops, check it out, clean it up, throw on a “Hello Kitty” band-aid, give her a little piece of chocolate and tell her to ruck up, drink water, take Motrin and carry on.

So, about this severe bleeding stuff. What’s that all about and how can we take care of it? Typically, we look at doing the following things to control bleeds: Direct Pressure, Pressure Bandages, Hemostatic Agents and Tourniquets….but, not necessarily in that order as it depends on the type and nature of the bleed, the environment you’re in AND do you have that material on hand? If you don’t, you, unfortunately, have to start looking around at items in your environment which replicate the necessary action as would their commercial counterpart.

But, what is a “Life-Threatening” bleed? Good question. Most of the bleeding we encounter can be taken care of with some form of direct pressure, but we need to be able to evaluate whether we need to step up our game a bit and get a little more aggressive. If we recognize the bleed as arterial (bright red, spurting/spraying) and it’s a high-volume/high-velocity bleed from a large diameter vessel (ie. Femoral, Brachial, Popliteal) we’d recognize that as life-threatening and we need to stop the bleeding as quickly as possible and the tool of choice for me would be the tourniquet. Now, that’s not to say that venous bleeding isn’t serious because all bleeding is bad, mmmkay? It’s not a “high-pressure” bleed but if a large enough vessel is dissected, life-threatening bleeding can occur and it’s up to you to stop it. Think of water pouring out of a pitcher. That’s life-threatening. How you do that is up to you, but the gist is to understand how to stop the bleeding and that is situationally dependent.

If someone cuts their finger off, chances are, in a healthy individual, they won’t bleed to death and some form of direct pressure will stop the bleed, even though small arteries have been severed. So, that shows that not all arterial bleeds need a tourniquet. It depends on the amount of blood being lost and how quickly it’s being lost. If, however, you put a pressure bandage on and the individual bleeds through, you can move up to another level and apply a hemostatic agent OR if the situation doesn’t allow you the luxury of time, you can throw a TQ on it, then you can come back to it and address it with the hemostatic agent/pressure bandage combo because if you keep putting fresh pressure bandages on without addressing the cause, what may not have been life-threatening initially can become that way due to blood loss over time. (documented case during OIF) However, we state “healthy” individual. There are many folks out there on blood thinners (Aspirin, Plavix, Coumadin (Warfarin) and even steady use of other NSAIDs like Aleve and Motrin as well as Omega 3’s) and these folks will bleed…a lot…so, you may want to think about that as well when you’re dealing with bleeding.

Protocols are changing in the civilian sector, finally, as they see the success we’ve had with military hemorrhage control protocols since 2001. Even NREMT’s latest text reflects those changes by stating if a life-threatening bleed is recognized, a tourniquet can be placed and if a bleed, which may not appear as a life-threatening bleed initially, can’t be controlled with direct pressure/pressure bandage, then a TQ can be applied. We’ve got to get away from the archaic thinking that a “TQ is just for last resort” as it works effectively at keeping the blood in the body where it belongs. TQ’s have been used since the late 1800’s in operating rooms and there are studies from OIF which show their efficacy WITHOUT loss of limb.

This is just a snippet of information and is by no means a replacement for a class as there is a ton of information presented and questions asked and answered during a class and that can’t be accomplished here. However, it does show the individual that in order for us to be successful in these types of situations, we must remain as fluid as the situation and adapt and change with it and not be rigid, stolid and checklist oriented. Carry the proper equipment and, more importantly, know HOW to use it, WHY you’re using it and WHEN to use it.
Think outside the med kit because scenarios change minute-by-minute and the situation dictates the medicine.
Blood belongs in the body. It’s science.
And, that’s a fact.

Stay safe,

Pocket Doc