Stop The Bleed

Tommy was bleeding out fast! It was a gunshot wound spilling blood. I didn’t even think of looking for an exit wound. No one knew how he got hit. I kept packing a long line of gauze into the wound, stuffing in as much as I could. Thumb over thumb. When the bleeding stops, I knew applying pressure would save his life. But the blood kept coming. I started to panic as Tommy was non-responsive.

But Tommy was always like that – non-responsive. The poor bastard was a latex dummy on the Pracmed ‘Stop the Bleed’ basic lifesaving course and pretty much bled for a living.

I was still panicking because Pracmed owner, Simon Ritson, was both grinning at my panic and pumping on a plastic bottle containing fake warm blood at the same time. Tommy was a squirter. I managed to stop the bleed from the fake artery so I leaned on it with both hands, applying as much pressure as my scrawny 65 kilograms allowed. Tommy was good to go!

“Pressure wins wars! In a real life scenario three to ten minutes of pressure will be enough to make blood clot begin,” Simon says. 

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According to research by the New Zealand Mountain Safety Council (NZMSC) and published in A hunter’s tale in 2017, there were over 12,000 recorded hunting accidents between 2004 and 2016 of which 41 were fatalities. Of the 41 fatalities, over half involved a firearm, with nine incidents involving misidentification of target, eight where hunters accidentally shot themselves, and five where a hunter accidentally shot another hunter. The remainder of the fatalities (11) involved falls. 

Accidents involving a firearm are not the only life threatening events happening on hunts. The report also lists wounds by knife, game animal attacks, wounds from pig tusks and firearm malfunctions. In this period, 421 serious pig tusk wounds were reported. Of the total injuries, 628 involved the discharging of a firearm.

“No Kiwi should die of these wounds,” Nate Norton, who instructs for Pracmed, says.

“Mediocre first aid is costing people their lives. No one should die from injuries that can be treated. Major bleeding kills you before an ambulance arrives,” Nate says.

According to Nate, it’s not only those pursuing outdoor activities that need basic lifesaving skills. In 2019, over 350 people died in motor vehicle accidents in New Zealand and the normal citizen was faced with an increase in violent crimes. On average 2.1 people were stabbed daily in Auckland alone.

Nate served in the New Zealand Defence Force (NZDF) for 23 years, of which ten years was spent as an operator in the Elite Special Operations Group. On the course he recounts incidents, eyes wide, where he and others had to stop life threatening bleeding. The skills taught at Pracmed NZ’s trademarked ‘Stop the Bleed’ have been tested in real life and are backed by evidence collected fresh from the battlefields of Iraq, Afghanistan and other areas of conflict.

Simon joined the NZDF in 2003 and spent most of his time as part of the Royal New Zealand Infantry Regiment. He left the army in 2013 and fulfilled various roles as a private security contractor, including as a team medic, until late 2017. 

He says after years of practising emergency lifesaving in conflict areas and subsequently returning home, he had a realisation that in New Zealand there wasn’t anyone teaching basic first aid properly to the general public.

“The most impactful for me was a mission to Indonesia following a tsunami. 180,000 people were killed. I observed emergency procedures and realised it wasn’t such a ‘black art’. I also spent time as a reconnaissance operator as a detachment medic. I combined 10 years of service with four-and-a-half years of private work into what we have here, this isn’t a pop up company with no background in legitimate first aid.”

“I came home from overseas and began working with a training company. Their syllabus was very poor and focussed on a wide spectrum of information that is difficult to retain rather than simple life saving decision making processes and techniques. I offered to rewrite it and I was basically shut down via bureaucracy and a limited ability to implement what was needed.

These companies are more concerned with New Zealand Qualifications Authority clients than with what works in the real world. I refused to accept that, so I quit and started Pracmed NZ. We translate everything I know to civilian terms to make sure people have evidence based medicine in dealing with major bleeds and lifesaving before an ambulance arrives.”

“So far we know of 33 separate incidents where our training has made the difference between life and death prior to a casualty making it to a hospital.”

How To Deal With a Wound

“When one looks at the DRSABCD’s, (Danger, Response, Send for help, Airway, Breathing, CPR and Defibrillate) there is no mention of bleeding or major haemorrhaging in their priority of treatment. Major bleeding is something that kills you before an ambulance arrives.”

“An adult has on average 5–7 litres of blood in their body, pumping between 55ml–80ml per heartbeat. If you get a big enough hole in a body you can lose about half a litre in a minute,” Nate says.

How do you deal with a wound? First you need to figure out the mechanism of injury so you can deal with it appropriately. Knowing where the wound is will allow you to decide if it needs indirect pressure, packing or a tourniquet.

Cutting off clothing and exposing the wound is one of the first steps. “Trauma naked 30 seconds does the job,” Nate says.

Blood Sweep

A blood sweep is a systematic process to see where someone is bleeding from. It is a tool used to identify a major haemorrhage when we suspect it but cannot see anything obvious immediately.

“It’s a hard and fast drill from head to toe. If someone is losing blood you only have minutes to deal with it. No time to muck around,” Nate says.

To do a blood sweep use your open palms to check the back of the neck, chest, armpits, abdomen, lumbar region and limbs.

“After each ‘sweep’ check your palms to see if there is significant blood.”

Break each limb into two sections by, for example, sweeping from the shoulder to the elbow with your open palms, then check your palms to see if there is blood, if not, do the same from the elbow to wrist. 

“There are a few ways to manage and stop bleeds. The first is indirect pressure, which is pressure away from the point of the injury. Then you have packing, which is filling a void created by injury with material like gauze. You can also use a tourniquet.”

Junctional areas, like armpits, the torso or pelvis are more technical to deal with as you cannot tourniquet them and will have to apply pressure to stem bleeding. 

Indirect Pressure

When you can’t stop blood flow directly at the wound site or can’t get to it, then indirect pressure is a useful temporary control. Indirect pressure is gained by delivery of pressure on an artery above the wound as severed arteries retract into the body. 

Get something solid behind the body part you are applying pressure to. But anything to do with indirect pressure is an interim measure and isn’t something you can manage for a long time. You use indirect pressure until someone can get a pressure bandage,” Nate says.

“There are four control points on the body we use for indirect pressure. They are all easy to find when you are in a stressful situation.”

The first is the radial control point, which is basically the pulse point on your wrist. Putting pressure there will cut blood flow to the hands in case of a major bleed. 

Next is the brachial point, this is delivered by applying pressure onto the brachial artery that runs on the inside of the humerus. 

The subclavian control point sits in the hollow just under, or behind, the collarbone. Applying pressure to this point will manage arterial bleeding to the respective side arm and this is particularly useful if an injury involves arterial bleeding around the armpit region as this generally rules out the application of a tourniquet. 

The iliac control point is used to control bleeding from the femoral artery in the thigh or the deep femoral in the back of the leg. This point is controlled by applying pressure between the midline and the iliac crest (hip bone) and will stop blood flow to the limbs below it.

Pressure to the iliac point is uncomfortable and someone who is injured won’t lie still when you are leaning with all your weight on it. Putting pressure on the iliac control point will stem blood flow via the iliac arteries that transcend into the legs.

“Applying pressure is an aggressive tactic. When applying pressure count to 10 out loud. After 10 seconds one can see if the bleed is stopping. Counting also shows bystanders you are doing something and helps you keep your head in the game. If the bleeding doesn’t slow, assess again and figure out where pressure is needed.”

After blood flow has stopped, a pressure bandage can be applied to some parts of the body to stop it from starting again. ‘Normal’ crepe bandages do not really make the cut when aiming to apply pressure, and a pressure bandage or ‘Israeli bandage’ performs much better. A properly applied four inch pressure bandage can create enough pressure to stem flow and provide the basis for the clotting cascade to begin.

Always leave foreign bodies in a wound as they may be acting as a plug. Wrap pressure bandages around it.

Pack, Wrap and Gap!

Packing is taking material and filling a void created by an injury so you can stop blood flow and retain fluid in circulation within the body. 

“Packing is used where pressure or a tourniquet is not possible and is mainly used for junctional areas where limbs join the body. Pack against the flow of blood. Keep constant pressure by packing material thumb over thumb, and moving down from the wound.”

Once a void is filled, three minutes of constant pressure is needed for the blood to clot.

“You don’t want to sit around after packing. Put compression on and get the person out of there! Pack ‘em, wrap ‘em, and gap it!”

Tourniquet

When dealing with a tourniquet (TQ) one must deal with the myths first. Research shows applying a tourniquet is not likely to lead to the loss of a limb.

“There’s a fear about TQ’s, but we are here to change the conversation. I’ve seen TQ’s save many lives. Everything we do has not only been used by us in some of the most unfriendly tourist destinations in the world, but we do research to back it up,” Nate says.

In a US study of 2,838 casualties with major limb trauma, the use of a tourniquet meant a 90% survival rate. In the cases where it was not used, but was needed, there was a 0% survival rate. Only 1.7% had transient nerve palsy: a tingling in the nerve where a tourniquet was used, for a period afterwards. In these studies, the median time a tourniquet was on was 75 minutes.

A TQ must not be used on a joint as it is unlikely to cut blood flow due to the lack of muscular tissue that can be compressed providing the pressure to occlude arterial flow. It can also potentially cause injury to the joint once the TQ windlass is turned to apply pressure.

As a general rule, a tourniquet is fitted three inches above a wound, as a severed artery may retract into a limb. 

“Count to ten and see if the blood stops. Don’t take it off once applied. If it does the job don’t fiddle with it. Get the person to a hospital where there are safe ways to take it off. Mark the time the TQ is applied so a doctor knows how to handle it.”

Suckin’ Chest Wounds!

“Suckin’ chest wounds,” Nate’s voice booms across the room.

A wound from the collar bone to the low rib is considered penetrating chest trauma.

Penetrating chest wounds can create an opening in the chest wall through which air can enter the chest cavity during breathing while not allowing it to escape. This can lead to a life-threatening condition known as a tension pneumothorax.

A hemothorax can occur if there is a build-up of blood in the thoracic cavity or pleural space reducing the ability of the lung to function freely as it should.

“Generally, you won’t die immediately if you are shot in the gut, but a chest wound is dangerous ground. In civilian life, stabbings or construction accidents can often result in such wounds.”

For the first person on scene there is very little one can do with a chest wound. Wipe down the blood so you can see exactly where the wound is, look for tell-tale bubbling and stick a vented chest seal (a large plaster designed solely for chest wound) over the wound. A vented chest seal evacuates blood and air that has built up in the chest cavity by acting as a one-way valve.

“If you’ve applied a vented chest seal, move the person onto their wounded side so as not to get fluid onto the unaffected lung. The exit wound needs to be covered completely,” Nate says. 

Then get them to a hospital fast!

Shock

Add hypovolemic shock to any of the above wounds and you have a disaster on your hands.

Hypovolemic shock, or shock due to low blood volume, in a basic life support context has three stages. Stage one can occur when there is blood loss of up to 15%. If one encounters someone at that stage they will feel faint. If you control bleeding in stage one and get a patient to a hospital they will most likely recover fully.

If you can’t stop the bleed at this stage someone with a major bleed goes into stage two hypovolemic shock. 

 “In stage two someone has lost 15–30% of their blood (their total body volume will determine the amount they can lose before transcending into stage two). In this stage, their heart rate increases, they become disorientated, weak and will begin to lower in their level of consciousness rapidly. Unfortunately, with an increased heart rate blood is pumped from the wound faster.”

Stage three hypovolemic shock, also known as irreversible shock, is generally regarded as the patient losing 30–40% of their total body volume of blood. If not dealt with prior to this stage, chances are the patient simply will not survive.

A simple survival blanket can delay the onset of serious shock.

This helps mitigate the one aspect of the lethal triad you can have a cause and effect on at basic life support level: hypothermia.

Without diving too far into the technicality of this, the patient’s ability to clot blood is reduced by the patient’s core temperature which in turn causes a lack of oxygenated blood to circulate due to decreased cardiac (heart) output. This is a result of the body switching to glucose as its primary fuel system and in turn reduces circulation, transcending the patient further into hypovolemic shock and an inability to begin clotting.

No trauma patient with associated hypothermia and a core temperature of 32 degrees Celsius or less on arrival to hospital has survived.

Four days after I attend the course I travel to a farm for work in my business vehicle. A road worker runs across the road and is hit by the driver in front of me. The worker does a quadruple somersault over an entire lane and falls on his head. I pull over. Fuck! My new kit I bought from Pracmed NZ is in my private car. It has a vented chest seal, tourniquet and pressure bandage in it – everything I need to save a life. My work car does not have a medikit, but I put gloves on and rush over. There’s blood freakin everywhere. 

Someone yanks a medikit from their car and puts it next to me. Because I have gloves on they assume I know what I’m doing. There’s almost nothing I can use in the medikit. But I tape the dude’s head so the bleeding can stop. I know it won’t kill him. There were no sharp objects but I do a blood sweep. His leg is … well … something is wrong. It’s twisted real bad. I expose the leg and see bone sticking out of his skin. Fuck again, I have no splint. But I know there is no major bleed. I tear through the medikit and find a space blanket. Another bystander helps me wrap him up. No need for him to go into shock. The cavalry arrive and we lift him into the ambulance. When I get home I stash my medikit into my work bag, and I order another one for my wife.

We cannot have ‘what ifs’ plaguing us. That’s how people die.