Training Day: 3 steps for bleeding control (not necessarily in order)
Tim Nowak // June 2, 2020
We’ve all been taught a step-by-step bleeding control method through some textbook or instructor in our primary EMS education. Apply pressure, use cold packs, elevate the extremity, constrict pressure points and, finally, apply a tourniquet.
But it doesn’t always have to happen in this order – and there are some new tools on the market that weren’t around in the early 2000s when half of our workforce was initially trained. Bleeding control has changed a quite a bit over the past decade, but not all agency protocols have followed suit.
Have you ever taken a trauma certification course where a few blood-soaked items are sitting in the front of the classroom and your task is to determine which one has the most blood volume contained? (It’s a trick situation – they’ve all got the same amount!)
The point of that exercise is twofold: 1. to show you that working based on estimations from prior bleeding is difficult and 2. that we shouldn’t get caught up in the past but focus on the future.
More time bleeding equals more blood loss. Aggressively controlling it, then, is the answer, and here’s what we should be teaching our students and providers – and not necessarily in a sequential order.
There’s still a place for direct pressure
Step 1: Apply direct pressure. Prior methods for bleeding control were limited to hand-applied direct pressure applications only. When one bandage doesn’t do the trick, add another and push harder!
The caveat here is that this only applies for two situations: 1. initially with any bleeding, and 2. long-term for minor, or some locations of moderate bleeding. From this point, the method by which you escalate is not so cut-and-dried. In fact, it’s now that way for a reason.
Now, the concept of applying direct pressure isn’t only or necessarily applied by the means of a person pushing harder – it can also be performed by using an appropriate pressure dressing, which involves more than simply wrapping a traditional dressing even tighter.
Packing the wound
Step 2: Pack the wound. Using hemostatic agents is different from what traditional direct-pressure, dry dressings offer. While different options have come and gone, the methods that seem to stick around today are the ones that involve either packing a wound with clot-accelerating, impregnated gauze, or directly covering wounds with a similar bandage or roll.
This, combined with pressure dressings and direct pressure applied for a few minutes, can be an effective tool to help control your patient’s moderate to severe bleeding. After all, applying a tourniquet is only permitted for extremity injuries, not those affecting the head, neck or core of the body. (And contrary to what many of us have been taught, it is sometimes OK to poke your finger into a wound.)
Step 3: Stop the bleeding. That’s right – stopping circulation is the goal! It seems counter-productive, right? In instances of severe bleeding, this may be the only option (and even the first). Police officers, backpackers, divers and all kinds of civilians are now carrying tourniquets in order to stop severe forms of bleeding.
The use of these devices, however, isn’t always taught appropriately. To some extent, the naive use of these devices actually proves to be beneficial. What started as moderate venous bleeding can certainly transition into an extensive volume of blood loss. The early application of a tourniquet can be beneficial in these cases. 
Your patient’s injury doesn’t necessarily need to require bright red blood squirting or pulsating from the wound in order for a tourniquet to be indicated. It can be applied much earlier than many of us have been originally taught – but following manufacturer recommendations and local protocols are still considered best practices.
What’s interesting about all these options is that they’re all considered basic – even for civilians. Sporting goods stores now carry hemostatic agents, grocery stores have dressings and wraps, and the internet can direct you toward dozens of sources to obtain your own tourniquets. Having said this, would it make any sense for your ambulance to not have these "household" items?
Provide training on the latest tools
New products change the way we control moderate and severe bleeding, but the education practices on how to use those products don’t always keep pace. In fact, I can remember back to when I was first given a single package of hemostatic gauze to put on my ambulance. There was no initial training on this product – we had to rely on our own research, and many of my crew members were under the impression that we should just place this sticky gauze over the top of any bleeding hole and treat it like the dry, bulky dressing that we always knew (boy, were we wrong!).
Without the proper training on how to use anything beyond direct pressure, educators, administrators, and medical directors are only setting their crew members up for failure. When it comes to basic bleeding control, a simple 1-2-3, one-two or “straight to 3” approach is pretty easy to handle – with the proper education and tools, of course.