Tips On Controlling External Bleeding

"Jay's Gentle (if long) Rant on Controlling External Bleeding." It has been very slightly rewritten for this page.

When I teach my FA/CPR classes, I like to teach that a great deal of prehospital emergency care is an exercise in passing the buck (um, er, I mean patient).

Let's assume that we're dealing with a typical urban/suburban situation in which a First Responder unit can get to the patient in about five to fifteen minutes. (Situations dealing with the wilderness, with disasters, and with other "extended response time" situations need special training.)

Anyway, in such a situation, the essence of the job of the First Aiders -- to use the excellent British term for a trained civilian -- is to keep the patient alive until the First Responders (no capacity to transport) get there. The job of the First Responders is to keep the patient alive until the ambulance crew gets there, and the job of the ambulance crew is to keep the patient alive until they arrive at the hospital.

Given this scenario, it's logical to ask which conditions have significant capacity to kill a patient in the five to fifteen minutes it would take a First Responder unit to arrive, and to concentrate on teaching the First Aiders how to deal with those situations.

At this point, I typically tell the students that there are five such situations that usually fall into this category, and ask them to name the conditions. The students usually guess most of them.

(Additional conditions of concern include internal bleeding, spinal cord precautions, and respiratory distress. While I certainly also cover those, and others, the above listed are "The Big Five" -- in my opinion, anyway.)

Regarding dealing with external bleeding, and assuming that the body substance isolation (BSI) issues have already been covered, here is my point of view.

In the eight years I spent doing street duty, I arrived at many, many emergency scenes to find one or more people with various amounts of blood on them and/or their surroundings. This sort of situation is very common.

In the overwhelming majority of cases, external bleeding will _stop_by_itself_ long before it becomes life-threatening even if _nothing_ is done by the patient or First Aider regarding it. Our bodies are actually built to deal with this situation and in most cases our bodies do just fine on their own. Blood vessels constrict, clots form, and the bleeding stops -- just as planned.

This means that when I arrive in my ambulance I usually encounter a patient whose blood has "dried." I was sometimes amazed at how the bleeding from even a very large wound would nonetheless stop by itself long before the patient became shocky from blood loss.

The good news/bad news aspect of the above is that if I arrived and saw "wet" blood on the patient, I immediately had two big points of concern:

1. The presence of "wet" blood means that, for whatever reason, whatever has been done so far hasn't been enough to control the bleeding. (This can rather strongly imply negligence, perhaps even gross negligence, on the part of those emergency care providers who arrived before I did, but let's not get into _that_ mess just now.)

(2) If the patient is still bleeding by the time I arrive, there is entirely too good a chance that they've already lost a truly alarming amount of blood and therefore I'm about to get really busy.

When a First Aider does attempt to control bleeding, good old direct pressure works just fine in the vast majority of cases -- and I do mean the vast majority. About 98% of the time, simple direct pressure is all that will be needed, however there are a few tips and fine points to keep in mind.

A. Normal clotting time runs from about five to fifteen minutes, so I tell the students to resist the temptation to "peek" at the wound to see how it's doing. For small, superficial wounds, hold the pressure for a least five uninterrupted minutes. For larger and/or deeper wounds, hold the pressure longer and without interruption.

B. You can control the bleeding or you can wash out the wound, but you have to make up your mind which of the two you are going to do. A wound will essentially never clot shut if you press a _wet_ dressing onto it. (I have seen some poorly trained emergency workers who were distinctly unclear on this concept.) If your goal is stopping bleeding, use dry dressings only please. You can wash out the wound later, if you think this necessary, under more controlled conditions.

C. An old cop's trick is that if you go into a residence and discover that somebody inside is bleeding badly, you can usually find towels in the bathroom that are readily available and will work just fine for direct pressure.

D. The main thing I want from a first aid kit, in terms of helping me to provide emergency care, is help in controlling bleeding. This means 4x4 gauze pads and triangular bandages. I want at least ten 4x4 gauze pads and at least two triangular bandages. (You can almost judge the effectiveness of a first aid kit by noting how many triangulars it contains. If it doesn't contain at least two -- one to use as a dressing and one to use to hold the dressing in place -- there is a good chance that the kit will fail you in a "really bad" situation.)

Tip: The 4x4s do not need to be sterile. I take them out of their sterile wrappings and put them, five at a time, into a baggie along with a roll of non-sterile 3-inch gauze. Please remember that there is no part of the human body that cannot be adequately bandaged given enough time and enough 3-inch gauze.

E. If the dressing becomes blood-soaked while you are applying direct pressure, the adage about applying additional dressings over the original dressing and continuing to apply direct pressure instead of removing the soaked dressing to apply a fresh one is a good one to keep in mind. Remember that your main objective here is to stop further blood loss, not to soak up what's already leaked out. Removing the original dressing will disturb any clots that are trying to form.