Yesterday I attended a Stop The Bleed course at one of our local hospitals. It was well presented by an ER nurse who had not only ER skills but who was an excellent presenter. It was about half lecture and half hands-on training on how to use a tourniquet and how to pack wounds.

Since we so often get into discussions about post accident survival, I thought it good to share a few things I learned. The most important one was that uncontrolled bleeding is the primary cause of death from traumatic injuries, and that most of those deaths are preventable if the bleeding can be stopped.

I was taught years ago in Advanced First Aid to avoid using a tourniquet. That's no longer the proper advice. Much has been learned from the traumatic injuries suffered in Iraq and Afghanistan, and as a result, most soldiers now carry small trauma bleeding control packs, which include a tourniquet that can be put on one handed, Quick Clot for less dramatic injuries, and packing material to pack wounds. I have ordered such a pack to add to my otherwise pretty complete First Aid kit, and now I know how to use it!

The emphasis was on doing whatever is necessary to stop the bleeding within the first few minutes of an injury. Tourniquets and packing and pressure range from unpleasant to downright painful for the victim, but the difference in survival rates goes from 10% if the bleeding isn't controlled to 90% if it is controlled.

The apparent goal of the sponsors of the course is for every American adult to take the course. That won't happen, obviously, but if you can free up 1 1/2 hours of your time to take it, please do. The more that take it, the more victims of car accidents, airplane accidents, camping accidents, home accidents, workplace accidents, etc. will be saved. We are all first responders, if we're the first ones at an accident scene.

One of the best parts: it's free!

Incidentally, I have a friend at church who was in a horrible motorcycle accident last summer, up in the Poudre Canyon above Fort Collins. One of her legs was traumatically amputated in the accident. One of those who was first on the scene knew to use a tourniquet. If he hadn't done so, she would have bled to death before the ambulance could have gotten there. She lost her leg, but she survived, and although her road to rehabilitation has been tough, I have no doubt that she's thankful someone was there right away who knew what to do to stop her bleeding. She is now a regular spokeswoman for the Stop The Bleed campaign.

Cary

Thanks for sharing that. I also have a friend who had a bad motorcycle accident one year ago. He lost his right arm and his right leg, but survived because the person following him was a medic in Afghanistan, and knew how to stop him from bleeding out.
We spend so much time discussing survival vests, survival kits, survival knives, PLB's etc., which is all important, however a basic First Aid course should be included in our "must have" bag, if we are pilots taking on the responsibility of flying passengers.
Good post, thanks again.

One of the first rules of emergency medicine: All bleeding eventually stops. Everything Cary wrote is true, and much has been learned through the unfortunate aspects of warfare and austere conditions. I'm an EMT/Wilderness EMT, but basic blood control is well within the grasp of anyone. My kit includes a tourniquet, quick clot, and IBD (Israeli Battle Dressing) for plugging large holes, and then other stuff for when I have to deal with it for a prolonged period of time.

Tourniquets fell out of favor for a while because the blood essentially becomes toxic behind the bandage, and if released improperly can actually cause far more severe concerns. That's why when it's on, it's on - only an ER doctor gets to remove it because they have the resources to combat what's next. The good news is it generally takes hours for limb loss to be a given, so stop that bleed and then activate your GPS PLB/beacon/smoke signal to get help ASAP. Modern research (generally at the behest of military) has shown that a TQ is far preferable to dying right then and there, and when undone the right way the chances of limb recovery are actually pretty good.

I'd also recommend learning some basic shock management. The stuff likely to kill us in the field first is bleeding and shock (the latter often, but not always, coming from the former). Other problems (infection, dehydration, etc) won't kill you in the next 15 minutes like those two things will. Shock mgmt is critical because not all bleeding is external or within the ability to even mitigate in the field, so you're left with trying to help the body compensate until help arrives.

Refresher training is never a bad thing either. It's amazing how much emergency field medicine is actually based on some doc's gut feeling somewhere down the line, and actual research and data is making significant headway in improving outcomes through processes generated by science and not a guess. Even CPR was changed up some years back once they realized the training had been wrong to that point.

colopilot wrote: Even CPR was changed up some years back once they realized the training had been wrong to that point.

CPR has changed at three times since I first took CPR in high school.

Stopping the bleeding has indeed become the first priority of pre-hospital care, where it used to be ABC =Airway (A) Breathing (B) and Circulation (C) it now it CAB. Because if there is no blood to carry the oxygen everything else don't count.

When I saw the subject line I thought it was going to be about talking sense into people who are mortgaging their future to restore an airplane...

I was in the medical field for 40 years. I have seen several things go from state of the art care one year to never should be done and back to state of the art care years later (precordial thump just one example). The CPR done 40 years ago will still work fine today. Tourniquets have always been recommend for life vs limb that has not changed they just encouraged more direct pressure use if possible in the past. I predict once more people start showing up at the ER's with Tourniquets for bleeding that could be stoped with direct pressure the training will change once again. Also airway will return to the top of the priority list. I think basic first aid should be taught to everyone including how and when to use a tourniquet. Due to time limitations most programs have simple rules to follow. Take everything you learn from the course and apply it as best as possible, no real right or wrong just do what works best at the time. Do expect the training and recommendations to change over time.


Medical practice is a Art not a Science and everyone hold the brush differently as they paint the same picture!!

DENNY

Headoutdaplane wrote:CPR has changed at three times since I first took CPR in high school.

You must be young!

DENNY wrote:I was in the medical field for 40 years. I have seen several things go from state of the art care one year to never should be done and back to state of the art care years later (precordial thump just one example). The CPR done 40 years ago will still work fine today. Tourniquets have always been recommend for life vs limb that has not changed they just encouraged more direct pressure use if possible in the past. I predict once more people start showing up at the ER's with Tourniquets for bleeding that could be stoped with direct pressure the training will change once again. Also airway will return to the top of the priority list. I think basic first aid should be taught to everyone including how and when to use a tourniquet. Due to time limitations most programs have simple rules to follow. Take everything you learn from the course and apply it as best as possible, no real right or wrong just do what works best at the time. Do expect the training and recommendations to change over time.


Medical practice is a Art not a Science and everyone hold the brush differently as they paint the same picture!!

DENNY

I'm with you Denny. Most of this stuff is like wiping your butt on a hoop...it's sure to come back around to greet you again! I will say, however, that the most recent changes in CPR appears to be a big improvement with some good end results. Early, hard, fast (100-110bpm) and consistent hands only CPR with minimal or no breaks seems to be working better! And technology is helping to show that even the shortest of breaks can cause a lot of lost ground hence no more pauses for breaths.

As far as tourniquets go the biggest change I see is that we are no longer scaring people out of using them. Direct pressure, elevation, hemostatic dressing and/or tourniquet...stop the bleeding.

I do think it's great that relevent classes like this are being offered and that folks like ourselves can take them and be more prepared and hopefully more level headed when the time comes to use the skills!

CW

Hammer wrote:When I saw the subject line I thought it was going to be about talking sense into people who are mortgaging their future to restore an airplane...

The minimal breaks thing was around over 20 years ago. Just took some time to get traction. The big issue is moving blood without O2 is not helping. Proper chest compressions will move air in and out, much like hyperventilation. But air won't move without an airway, hence my prediction of airway coming back into vogue (it is still there but on back shelf).

The hard part about trauma for most is to ignore the blood, screams, pain, and gore. If they are screaming they have a airway, and the heart is working so jump right to saving the red cells. Pain and suffering does not kill trauma victims it is from still being in harms way or loss blood and old school ABC's. Whatever training you have just follow the steps they will lead you down the road, adjust as needed. It is very similar to flying always think ahead and use whatever control you have to get the job done.

DENNY

I hate to be the bummer here, but the fact is that tourniquets will save more lives than CPR. CPR in a hospital setting only has a 10% success rate, and I suspect that is due more to defibrillation than good CPR. Out of hospital CPR, without AED within minutes, is basically not successful (I believe only .6 percent of patients live, I would have to find a source).... after all, you are starting with 'dead'.

An appropriately used tourniquet will stop a patient from losing blood, which actually could keep you from having to do CPR.

Like Denny said, anything you can do, with what you have.

(10 years EMT, 0 CPR saves that they actually eventually walked out of the hospital....erf).

Self qualification.....paramedic 4 years before medical school with 1 year certified as a wilderness medic. 4 years medical school. 10 years emergency physician. Now let the lies begin.

I have seen tourniquets come back and for good reason, we have found that limbs can last a lot longer before the need for reperfusion, up to 6 hours as a matter of fact. I believe this to be a good thing and agree that they should be a part of anyone's medical kit and could definitely be life saving.

I think that the life saving ABC's are being taken out of context. The ABC's are really meant to be done in rapid succession with patients who are unconscious and unresponsive. If anyone does another important class that is required for ER physicians is called ATLS and is about trauma life support and it preaches surveys, there is a primary survey and a secondary survey. These are each to take a matter of seconds to minutes to assess what is wrong and what is going to kill a person the fastest or to stop the thing that is going to kill the patient the fastest. Thus I really do not suggest throwing the baby out with the bath water. The ABC's pneumonic is so easy to remember and easy to follow and best at identifying life threatening issues to be addressed in some sort of logical manner.

I tell this story often because it made such a lasting impact on me and my carrier. I was in residency and a VERY bad trauma patient came into the department. My attending (BOSS) was a little frustrated because there where a LOT of people and a LOT of noise and commotion going on, he screamed stop and had everyone take there pulse, and said if its over 100 beats per minute get out Everyone left the room but him and he proceeded to take care of the patient from complex procedures to simple tasks all by himself in a controlled manner and very expeditiously.

The lesson I learned was that if your not in control yourself and calm then no amount of training or pneumonic like the ABC's are going to help in that true moment of chaos. The second lesson I learned was that I could do any amount of care for a single patient myself. The third lesson is someone has to be in charge and it was now my responsibility to be that person, calmly.

SO my suggestion would really be to take a course, any course that will give you some type of coping skills to manage a disaster situation. The best one that I could suggest is a wilderness first responder course. These are fun and very thoughtful and have a ton of information to deal with a lot of medical emergency's that one would expect with a plane crash and other back country problems you might encounter such as hypothermia or asthma attacks.

OK I'm done ranting.

Uhh, its mnemonic.

I Love the medical topics. We are finishing day 5 of a Wilderness First Responder class in Telluride. This is our last one of the year, but we will be doing multiple classes throughout the Southwest next year: Sedona, Moab, Telluride, and Durango.

My schedule will be up soon at wildernessmedic.com (site is down currently do to hack!)

Our classes are great for pilots- I am a pilot/paramedic. The classes are accelerated and fun, you just need to read the book before hand and have 5 days to give.

Brad

If you are going to apply a tourniquet don't do it half way you have to be all in on this. If it is not tight enough to stop artery inflow it actually promotes bleeding by preventing venous outflow and hence more bleeding from an open wound. Expect this also to be a very painful experience for the recipient. A properly applied tourniquet is very tight and the pressure hurts. After about 30 to 60 minutes the pain caused by lack of oxygen is incredible. At about 2-3 hours they will be screaming from the pain if they are alert enough to care. Limb survival decreases dramatically after 4 hours.

Come on don't you know dokters cant spelllll?

Coyote wrote:If you are going to apply a tourniquet don't do it half way you have to be all in on this. If it is not tight enough to stop artery inflow it actually promotes bleeding by preventing venous outflow and hence more bleeding from an open wound. Expect this also to be a very painful experience for the recipient. A properly applied tourniquet is very tight and the pressure hurts. After about 30 to 60 minutes the pain caused by lack of oxygen is incredible. At about 2-3 hours they will be screaming from the pain if they are alert enough to care. Limb survival decreases dramatically after 4 hours.

Hey, it's called "stop the bleed", not "slow down the bleed"!

The instructor emphasized that the whole process of stopping bleeding is painful to the victim. But the whole idea is to keep the victim alive, so if there's pain, additional damage, etc., that's a whole lot better than dead. She said that many serious trauma victims will be dead within 5 minutes if the bleeding isn't stopped, but that if the bleeding can be stopped, their chances for survival increase dramatically. I seem to recall that a slashed femoral artery unchecked results in death much sooner than 5 minutes.

The afternoon I came home from the course, I ordered a complete kit plus QuikClot from Amazon and it arrived Thursday, so they're in my first aid bag now. The kit was $65 and the QuikClot was $20, or about 1 1/2 hours of LL for my airplane. Well worth it, I think.

Cary

I can attest to the severe pain caused by a tourniquet when I sliced through both arteries in my left thumb. Perhaps that’s why I’m more attuned to making direct pressure work.

One thing I can contribute to this thread is for pain management and lacerations. The contents of my airplane first aid kit contains toradol 30mg/ml, 2% lidocaine and suture kit in addition to the standard stuff. If I’m hurt toradol keeps my head clear and takes the edge off....and I can’t do myself in by mistake which could happen with morphine.
On the CPR topic...I’ve never been successful. Intubation, O2 and compressions is the only way to make pink skin. With the 15-2 compression to ventilation ratio using O2 and a bag valve mask you can watch the patient turn from almost pink to blue when you pause compressions. And I like the precardial thump......when a patient is on a 12 lead ECG......and...each and every time it feels like I’m performing CPR for family members or bystanders. Only one time have I/we come close to success...that patient electrocuted himself and that was....in 1978.