Stop The Bleeding!

Written by Lawrence Heiskell, M.D.

Expedient methods to clot the wound when only seconds count!

Each year, there are more than 70 million emergency department visits for bleeding. Bleeding, or acute hemorrhage in medical terms, is a leading cause of death in trauma cases. Under certain tactical situations, immediate evacuation of gunshot wound victims may be an option. Effective and immediate early hemorrhage control is paramount to saving lives.


The Clotting Mechanism 
The coagulation of human blood is a complex biological process, and a full description is beyond the scope of this article. When a blood vessel is severed or damaged, the body reacts to try and stop the bleeding by spasm of the blood vessel, formation of a platelet plug and subsequent formation of a blood clot.

If the blood flow is under pressure, such as in a femoral artery wound, the normal clotting mechanism fails to stop the bleeding and the victim vcan bleed to death within a few minutes. Bleeding in the chest, pelvis and abdomen is impossible to detect in the field and can result in a large amount of blood loss. Once the blood loss exceeds about 40 percent of the total blood volume, which is about 5 liters, an irreversible shock state begins and the victim dies.

Hemostatic Bandages 
There currently are several blood-clotting hemostatic bandages on the market. Each has a different mechanism to stop the bleeding. Readers are strongly urged to carefully conduct their own investigation to determine what is best for their agency, team and level of training.

The HemCon Bandage is composed of Chitosan, which is a biodegradable, nontoxic, complex carbohydrate of chitin, found in the exoskeletons of shellfish.

QuikClot is composed of granular zeolite and is derived from volcanic rocks. When this material is placed into a bleeding wound, it absorbs the water molecules in the blood and creates a high platelet concentration, to promote clotting.

The RDH or Rapid Deployment Hemostat Bandage is derived from single-cell algae and the mechanism of the material is to act as a catalytic surface that accelerates the normal clotting process. TraumaDEX is a wound-dressing agent material naturally synthesized from potato starch. The particles accelerate natural blood clotting by concentrating blood solids such as platelets and red blood cells.

The Emergency Bandage, Trauma Wound Dressing is an improved version of the time-honored battlefield dressing. This sterile, non-adherent bandage applies pressure to any site, is easily wrapped, secured and can act as a tourniquet in cases of severe bleeding. The beauty of this product is that the bandage can be applied to the head, armpit or groin for control of hemorrhage in these difficult areas.

The M.A.T. (Mechanical Advantage Tourniquet) is well designed and can be rapidly applied to any extremity with one hand. The M.A.T. is the only device that meets all of the DoD’s required and desired features in self-applied tourniquets. With its easy, fast and secure one-handed operation, blood flow can be stopped in less than 10 seconds.


Discussion
All of the hemostatic dressings are supposed to work in seconds, according to claims made by the manufacturers. The questions one must ask are, do they really work and what should be considered for purchase and distribution to tactical medics?

Unfortunately, there are conflicting reports in the medical literature regarding what bandage is the most effective. Unlike drugs that require years of testing and approval by the FDA, the manufacturers of hemostatic dressings are not required by law to conduct extensive research to support their claims. There are very few scientific, objective, controlled studies in the medical literature to support the claims made by some of the companies.

It stands to reason, that if the bleeding is under high pressure or very brisk, none of these products will work. You’ll need to apply direct pressure to the wound or to a pressure point between the heart and the wound. If you then get the bleeding slowed with a pressure point, you might be able to get the wound dry enough to apply the hemostatic dressing into the wound and hopefully it will work. After the dressing is complete, the tourniquet or pressure point may be released.

The one thing we do know is that the time-honored method of direct pressure and a tourniquet application for bleeding really works. It seems prudent that a medic will use the simplest and easiest technique in the field for hemorrhage control. At the International School of Tactical Medicine we recommend that agencies proceed with caution before spending valuable resources on the new blood-clotting agents until further studies are done, and stick with old-fashioned direct pressure and tourniquets.

Trenchfoot - A Common Ailment of Hikers

An acquaintance of mine once lost all the feeling in his toes for three months from “trenchfoot.” He was lucky, in the end, that he suffered no permanent damage.

How did this happen? Well, you might guess that he froze his toes off in pursuit of an extreme adventure — high-altitude mountaineering or dogsledding across the North Pole — but no. He was backpacking, in June, near his home in Wyoming.

He started his five-day hike at a popular entry into the Wind River Range in sunny, warm, even hot conditions. In a matter of hours he gained enough elevation that he encountered winter snow that hadn't yet melted off, so he ended up hiking through freezing puddles of water on the trail. His boots became saturated with cold, icy water, and still hiked on. On the second day it started to snow and it grew much harder to take the time and effort to stay warm and dry.

His feet got cold when the icy water poured in over his boot tops; at some point they stayed cold and he didn’t do anything about it. And so his feet stayed cold for hours and hours, setting the stage for trenchfoot, more accurately known as “immersion foot” or a “nonfreezing cold injury.”

The physiology is simple. In response to the moisture and temperature, his body acted to narrow the tiny blood vessels that fed his toes. This is a standard reaction to cold exposure called “vasoconstriction.” Smaller tubes meant less blood got through, so the other tissues in his feet, the skin, bones, nerves, muscles, did not get the oxygen that they needed to stay healthy. Nor did they get cleaned of the normal cellular waste they generated, which is supposed to be flushed away by the blood, filtered by the kidneys and eliminated through urine. This waste built up.

The first tissue to be affected drastically was nerve tissue, which seemed to stop functioning. He perceived this as numbness that went away that evening when he warmed his feet, then came back the next day and persisted after the second cold day no matter how much he warmed his feet. In fact, the sensation of numbness in his toes persisted for about three months after he finished the trip!

His skin became red, itchy and painful when warmed, but that was about it. His feet did return back to 'normal' after three months; and he didn’t experience immersion foot at its worst: ulcers, infection of those ulcers, permanent nerve dysfunction, tissue death, amputation. All of these are possible.

You’d be better off not repeating his mistakes. The main rule is to never tolerate cold, wet feet. This starts with planning your activity and choosing appropriate footwear. Boots and shoes should fit well (and not squeeze the feet), insulate for the cold, and keep socks dry. Because any boot can become saturated if conditions are wet enough, consider using vapor barrier socks for your dampest slogs. Or, you can improvise these by using plastic bags to line your boots.

If your feet do get wet, take the time to dry them off, massage them warm again and change or at least wring out your wet socks. If you’re camping, sleep in a pair of dry socks that you keep at the bottom of your sleeping bag to guarantee that your feet get to stay warm and dry overnight at least.

Simple precautions and a little discipline will help you enjoy the wet conditions and not suffer from the cold.

A First Responder’s Top 4 Items Of Medical Equipment: Lessons From Haiti

By Dr. Paul S. Auerbach

Prior to departing for my assignment in Haiti for International Medical Corps, I didn’t have much time to pack, so wasn’t able to bring everything I might need. However, I was able to carry a few items that proved quite useful. First and foremost was a new EMS-type trauma shears. Scott Forman, MD of Adroit Innovation, LLC has created a very functional titanium shears in which one finger loop has been replaced by a carabiner, so the shears can easily hang from a belt or other loop. I used them all the time to cut tape, change dressings, slice through wire, and other assorted tasks. I just purchased one for each member of the Stanford team.

California Hotels Continue to Analyze Defibrillators for Facilities

The February 24th edition of the Wall Street Journal ran a story by Scott McCartney entitled "Why Hotels Resist Having Defibrillators." In a nutshell, the position reportedly taken by the hotel industry is that the risk of being sued as a result of having an automated external defibrillator (AED / defibrillator) on the premises outweighs the lifesaving benefits to the public of putting them there.

Without question the number of civil lawsuits over the past years has and continues to grow at an unprecedented, even explosive, rate. Businesses in general are reluctant to voluntarily take positive action, even for the public good, which could subject them to the substantial cost of defending their good deeds in court, and sometimes paying out money damages.