Trauma Surgery

Building Dams like Beavers

History is a bath of blood.

William James

Hello there…

Today we are going to talk about the Stop the Bleed course by the American College of Surgeons Committee on Trauma (ACS COT). Truth be told, we have already mentioned it in one of our previous posts (The Five Letters on Which Trauma Stands – Part 2 & Part 4). However, in today’s post, we will discuss more accurately the different aspects of this program…

But first things first… Let’s start with our usual case scenario…

It’s incredible, but you are on vacation… After several years of continuous overtime working, you have finally obtained a week off, and you took advantage of that going on a cruise to an exotic island… You know, the one with coconuts, white beaches, crystal clear water, and tasty cocktails…

So… You are sunbathing on the deck when you hear somebody screaming… One of the guys traveling with you on the boat was swimming when a 3.5 mt long tiger shark bit his left leg…

The skipper hoists him aboard, revealing a completely torn-off leg bleeding profusely. The man is clearly agitated and pale. The skipper calls immediately for help and says the helicopter will need 15 minutes to arrive. You know the man will not survive that much if left as he is…

So then, what to do???

Recent terrorist events or mass shootings in the States and Europe have changed the pattern of trauma injuries in the civil setting, increasing patients dying from external hemorrhage. Previously, these injuries were usually seen in soldiers on the battlefield.

An analysis conducted on these dead patients showed how most of these deaths were preventable if only the source of bleeding was addressed promptly. The problem in these terrorist events is the high number of victims involved which prevents the paramedics from treating everybody. To reduce these preventable deaths, the ACS COT decided to create a simple and immediate course to teach non-medical people how to stop a hemorrhage.

The Basic Protocol

Before throwing yourself at the bleeding patients, you must check that your position is safe enough… Remember that this protocol has been mainly created to respond to disaster events, meaning terrorist attacks or mass shootings… If the killer is still out there, it is not wise to expose yourself just to take a bullet in your brain… It is not useful for the other victims, and it is not good for you as well…

Once you are sure your safety is not at stake, you can check the status of the victims, looking for life-threatening bleeding. During this phase, you need to remember that bleeding control outside the hospital walls cannot always be obtained. One of the main purposes of the Stop the Bleed program is to determine in which patients the hemorrhage can be stopped at the scene. In this, we need to speak clearly: if you have many bleeding patients, you must decide who to treat first… And this decision must be guided by the survival chances every single patient has. In the triage world, in case of disaster events, one more code is introduced: the blue one. It means the patient is alive, but his/her conditions are so critical that it is not worth spending resources to try to save him/her… so, he/she is left to die… It is not fair, we know, but trying to save these patients means losing far more human lives…

The same principle (more or less) is used in the Stop the Bleed algorithm… The decision of what to do is based on the site of hemorrhage: torso, limbs, and junctional points…

  • Torso (i.e. chest and abdomen): the bleeding cannot be stopped outside the hospital (it means to move forward);
  • Limbs (i.e. arms and legs): apply direct pressure or use a tourniquet;
  • Junctional points (i.e. neck, armpits, and groins): apply direct pressure and wound packing.

Another thing you need to consider is the availability of a first-aid kit… After all, if you don’t have a tourniquet, why even consider it?!…

1. Direct Pressure

The direct pressure on the bleeding site is a simple yet effective way to stop the hemorrhage. This maneuver requires just your bare hands (use both hands to apply enough pressure). However, if you can use any clean tissue (e.g. sterile gauzes, a shirt, etc…), it would be better.

If the wound is large and deep, it is useful to “stuff” the tissue down into the wound. This will help obtain complete hemostasis. 

In case of direct pressure, one applied, it shouldn’t be released until medical personnel arrives. We know, this means you cannot help any other victim, but if you release your pressure the bleeding will start again, and all your efforts will be good as nothing…

2. Hemostatic Dressing

The principle is basically the same as for direct pressure, but the main difference is that in this case you have medicated gauzes that help the blood to clot. So, insert one or more of these medical supplies deep into the wound and apply pressure on it (the “time of pressure” will be 5 minutes, depending on the type of bandage you are using).

3. Tourniquet

The tourniquet is a medical device useful in case of life-threatening hemorrhage from a limb. It should be placed about 5-8 cm proximal to the bleeding site. It is preferable to place the tourniquet on arms and thighs (one bone, one big vessel). Nevertheless, provided it works effectively, it may be placed on forearms and legs as well. Moreover, if needed, it could be placed on top of clothing. However, avoid placing it directly over pockets and joints (i.e. elbow or knee).

Once you have found the correct position, tighten the tourniquet until the bleeding stops. Remember that tourniquets hurt (a lot), so do not stop tightening them if the patient starts screaming in pain… If one tourniquet is not completely effective in stopping the bleeding, it is possible to apply a second one above the first one.

When the tourniquet is effectively applied, report the time of positioning. Tourniquets left in place for more than 2 hours may cause irreversible ischemic damages to the limbs. However, do not remove it before the arrival of medical personnel. It is better to have a patient alive without a limb than dead with the four of them…

That’s it… Easy peasy… After all, it has been created for normal (non-medical) people… It should be as simple as possible…

Let’s go back to our clinical case…

Lucky you there is just one victim… and the bleeding injury is involving the leg…

You ask the skipper for the first-aid kit. He fetches it, but no tourniquet is inside.

And now? What to do? Direct pressure and hemostatic dressing are not effective in a mangled limb (that’s quite obvious)… And it is better if you don’t try to catch the bleeding vessel to ligate it… In all that blood you cannot see a thing, and the vessel is retracted inside the muscle tissues…

The only option is to build a homemade tourniquet…

Let’s MacGyver it…

Ingredients: two bandages (or long tissue straps, large about 5 cm), one stick (or something straight and resistant).

Procedure:

  1. Tie one bandage about 5-8 cm above the wound;
  2. Insert the stick (or similar) above and knot it to the bandage;
  3. Twist the stick until the bleeding stops and/or the distal pulse cannot be felt;
  4. Secure the stick in place with the second bandage.

That’s all folks…

Until next time: be good, be brave, be an acute care surgeon…

References
  1. American College of Surgeons – Committee on Trauma. Stop the Bleed. Accessed on August 4, 2021. Available at [https://www.stopthebleed.org/].
  2. Ballas R, et al. Clinical features of 27 shark attack cases on La Réunion Island. J Trauma Acute Care Surg 2017;82:952-5.
How to Cite This Post

Bellio G, Marrano E. Building dams like beavers. Surgical Pizza. Published on December 13, 2021. Accessed on July 24, 2022. Available at [https://surgicalpizza.org/trauma/building-dams-like-beavers/].

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