My name is Dr. Jeffrey Nahmias and I'm one of the trauma surgeons and the director of the
surgical intensive care unit at University of California, Irvine Medical Center, UCI Health.
Today we're going to be going over stop the bleed. This is a course that was developed
by The American College of Surgeons in conjunction with The Committee of Trauma, The American College
of Emergency Physicians, The National Association of Emergency Medical Technicians and The Committee
on Tactical Combat and Casualty Care. This is a multi-disciplinary team effort to develop
a course where we can teach you how to save people's lives. What we are going to be showing
you is something that can be disturbing for some people so feel free to turn away for a moment if
you need to take a break, put pause, whatever you need to. But these are important things,
because the number one reason that people die related to trauma is from bleeding. And
actually trauma is the number one cause of death for people under the age of 45 years old. So it's
really important that all of us know how we can potentially prevent deaths related to injury.
So where can you use this training? Many people think of the most common thing that comes to mind,
sadly, which is mass casualty events. And while that's an important thing to be ready because
this is something that we experience as a culture and in our society, but it's also more important
probably for you to understand the other places that you will use this training which are much,
much more likely. That includes at home, from home accidents, such as falls within a shower.
Other things can be when you're driving to work or seeing a car accident, as well as inclement
weather that causes things. Then unfortunately there's firearm violence throughout our society.
And so you may see somebody injured through firearms. These are some of the more common
ways that you will use the training that we will do in this course. And our goal for this course
is for all of you to feel comfortable after this to be able to stop bleeding. So the goals of this
program will be one: you need to be able to identify what is life-threatening bleeding.
All of us have experienced some form of bleeding whether it's as simple as a paper cut
or as substantial as something that maybe required you to go to the emergency room and get stitches.
In terms of life-threatening bleeding, that is the type of bleeding and hemorrhage that
you'll be able to save someone's life if you can identify it. The second thing is,
once you identify it, we're going to teach you how you can stop bleeding and so that could be
as simple as holding direct pressure, packing a wound or the use of what's called a tourniquet,
which we'll go over in more detail as the course goes on.
First and foremost, whenever you're helping someone, whether it's us in the hospital or
if you're out in the field, you must think of your own safety, because that's a priority. You can't
help others if you're not safe yourself. And so some of the most important things
is to first stop, then move to safety and then, if you can, take any victim with you to a safe area.
And this is important whether you're on a highway in the middle of the road or if there's a mass
casualty event to do these steps, okay? Another thing that's important is, if possible, it should
be your priority to protect yourself in the form of personal protective equipment, such as wearing
gloves if you have that, and then if you get any blood onto your skin or your body surface, then
you should immediately tell someone if there's a first responder or a healthcare provider,
and then allow them to help direct you for the next steps to provide you safe way to dispose of
the blood or clean it off. We're going to go over some ABCs and this is a way for you to know how
you should proceed. And so the first part, A, is to alert 9-1-1. No matter how experienced you are,
you're going to need help when someone's bleeding and it's a potentially life-threatening bleeding.
So you want to alert 9-1-1 first. Then B, you want to identify the bleeding
to see where it's located. And there will be some steps to that which we'll go over.
And then finally C, compress. You're going to hold direct pressure to the bleeding to stop it.
So again, A: alert 9-1-1. B: identify the bleeding. And then C: compress it.
So in terms of alerting 9-1-1, it's very simple. You call 9-1-1,
you let them know where you're located and then you follow whatever instructions they provide you.
The 911 operator is your friend and they're there to help, so please listen to their instructions.
In terms of bleeding, sometimes it can be readily available where the
source of bleeding is. Other times, somebody could have a blood soaked piece of clothing
and you may have to remove that part of the clothing to identify where the bleeding occurs.
In terms of that you should look for, these signs to identify life-threatening bleeding.
And that would be continuous bleeding that you actively see coming from their body. Two:
a large volume of blood whether that's on them in terms of their clothes being soaked throughout
or a pool that you may see on the ground. And that pool of blood can be quite substantial sometimes,
so it's important to look for that as well. Another thing that you should be
on the lookout for is: are there multiple places the victim was bleeding? It could be that somebody
got into an accident and then they moved themself away from where there could be a pool of blood.
So you may want to check for that. And then also again their clothing may hide a large amount of
blood, so look them over from head to toe to see if there's soaking of the clothes. In terms of
identifying where bleeding is occurring, it's important to recognize there are three generalized
regions that we want you to remember. The first one is the extremities, or your arm
and your legs. The next region would be that of your junctions of your body,
which is your armpits, your neck
or your groin. And then finally, there's the torso or the body, which is your abdomen and your chest.
In terms of these areas, the first thing you can do is try to do is compress, although the
ability for that to effectively stop bleeding will depend on the location that we just talked about.
C stands for compression or holding direct pressure onto the wound. It's important to
first identify where the wound is located and that may require you to take off some of the clothes or
disrobe partially the person who you're holding pressure on. Once you identify the wound such as
this, you want to hold focused and direct pressure to the wound. This may even require a substantial
amount of force and may be uncomfortable at first for the person that you're doing this,
but you must remember, this is a life-saving maneuver so it's important. So you would hold your
direct pressure onto the wound. As you do that, if the bleeding stops, you should keep that direct
pressure, not removing the pressure until somebody from the emergency medical services or someone
else arrives. This is a life-saving maneuver and it's very important that you keep the pressure.
As we talked about, first identifying the wound is important to make sure that you're holding direct
pressure at the right spot. Once you've identified the wound, you then would either use one hand or
two hands to place firm direct pressure to the wound to make sure the bleeding is stopped.
If needed, you can use the adjunct of a shirt or some other piece of cloth to then push over
the wound and hold downward. Again, pressure should be held until first responders arrive.
The next important thing is that sometimes there are deep or large wounds where you're not able to
effectively press down or compress throughout the wound. For that, the technique of packing is very
important. Basically, what you will do is utilize a gauze or some sort of cloth to pack into the
wound as seen on this slide. Sometimes bleeding can come not from the surface of the skin but
the deeper levels of the wound and this will help you to put pressure on those areas that your hand
superficially does not press on when packing a wound. It's important to first identify the depth
of the wound then make sure that you continue to pack the wound until it's filled up the entirety
of the wound. This will help exert pressure on the deeper parts of the wound once you've packed
sufficiently into the wound, you would then go back to holding your manual compression.
Again, this will be done until first responders arrive. If you've been able to stop the bleeding,
this technique of packing is beneficial because it can be used in all the three areas of the
body that we discussed: the arms and legs, the neck, armpits and growing or junctional areas,
as well as the torso or the body. Another adjunct you can use if compression and packing doesn't
stop the bleeding is to use a tourniquet. A tourniquet is a device that you can place two or
three inches above the wound. This is only used on the arms and legs, but you cannot place it over an
elbow or the knees because of the bony prominence. Once you place the tourniquet you should tighten
it until the bleeding stops. It's important to realize that this may cause some initial pain or
discomfort for the person you're helping. But by stopping the bleeding, you're saving their life.
You should not remove a tourniquet once you've placed it until first responders have arrived
or the patient is in a hospital. Another important benefit to a tourniquet is you can apply it to
yourself or to others and it can be applied over clothing as well, so long as it's not too bulky.
Tourniquets, it should be restated, hurt. It is painful. You are causing enough pressure that
you will stop all blood flow to their arm or leg and so it will cause some pain. But again, you're
saving their life, so it's an important thing to do. It's important to remember: when placing
a tourniquet that is designed for your arms or your legs, you should not place it over the knee
joints or the elbow joint. In addition, it's not designed to be used for the other areas of the
body that we discuss, such as the junctional regions of the groin, our inguinal region,
the armpits, and most importantly, the neck. You should not use a tourniquet there. When
placing the tourniquet, you should first look to see there's a windless rod, a windless clip,
a place where you can put the time for when you put the tourniquet on, and then this velcro.
Placing it on yourself, you would first tighten the velcro to the point where the patient may have
some discomfort but most importantly all bleeding is stopped. Then you would turn the windless rod
and fasten it into the windlass clip like this, placing the velcro and the time written here
and then putting this final velcro over all of that to help secure it. There are many different
types of tourniquet that can be effective. And so this course does not purport that
one is superior to the other. These are some examples of tourniquets that can be useful.
Some of the recommended non-pneumatic ones, these are ones similar to what I use,
pneumatic meaning that they don't have air to blow up with pressure, are listed right here.
In terms of pneumatic options, the ones that do blow up with pressure or air, you can get one
of these tourniquets as an example. Now we need to talk about how you can stop bleeding for children.
Tourniquets can be used in even young children with the same technique and size. As you can see,
the tourniquet can get quite small, down to even the level of about a hand.
For young infants or very small children, the accepted way to stop bleeding would be to hold
pressure if you're unable to get a tourniquet on their extremity. For large and deep wounds
in children, you can still use deep packing technique and compression as you already learned.
Now we're going to go over some common questions that we receive. And the first one is what do
you do if there's an impaled object such as a knife? What we would recommend is not removing
the impaled object. Wait for emergency medical responders, because when you remove that object
you actually could cause substantial bleeding that the knife or impaled object
is currently tamponading or stopping the bleed. The next question is should you use
an improvised tourniquet. And this one is a little bit more difficult to understand.
While an improvised tourniquet is not ideal and it won't necessarily stop bleeding,
if that is the only thing you have it may be beneficial. Although the company line would be,
if you can get a tourniquet, use the tourniquet, not an improvised tourniquet.
Another question we commonly see is what about losing your arm or leg because of a tourniquet?
And the most important thing that I can put people at ease is, in terms of placing a tourniquet,
you actually have about six hours prior to when that tourniquet needs to be removed,
with the still the possibility that you can save the arm or leg where the tourniquet was placed.
So that's typically plenty of time in an urban setting. And if you were in the situation where
you're in an austere location and you have to take the choice of losing an arm or leg or
saving someone's life, I think we all would agree that saving the person's life is most important.
And that's what the tourniquet is doing. It's stopping life-threatening hemorrhage.
A common thing that we get asked is what about the pain? The person complained of so much pain
when I placed the tourniquet or when I was holding pressure and I want you to realize
that that's expected. And it's okay to tell the person that you're placing the tourniquet on,
this will cause a substantial amount of pain but this is saving your life. And typically
people will be understanding of that and also note that as soon as the emergency medical
services respond or the person gets to the hospital, we will give pain medicines to help ease
that pain. Some people ask what can you do for the person after you've already stopped the bleeding?
An important thing is that people can become very cold, especially when they've lost a substantial
amount of blood. This is where something like a rescue blanket can help. You can see that a
package this small can become something quite big. This allows you to wrap the blanket around
their entire body to keep them warm. Another question that we get commonly asked is what to do
if you place a single tourniquet and it does not stop the bleeding? What we recommend is trying to
place a second tourniquet, meanwhile not touching the first tourniquet or even loosening it,
so placing a second tourniquet higher up or more proximal and then seeing if that will stop
the bleeding. Once you have those two, if there were still ongoing bleeding,
you should go to direct compression to try and get it to stop. To summarize, it's important to
first and foremost remember your own personal safety. While we did not use gloves in this
scenario of this demonstration, in real life all of us use gloves and personal protective wear.
Then to remember your ABCs. First, A: alert 9-1-1. That's simply calling
the 911, listening to what the operator says, telling them where you're located. B: find the
bleeding. That can mean disrobing or taking off some of the clothes to identify the source of
the bleeding, then identify whether or not it is life-threatening bleeding. Life-threatening
bleeding can be signified by a large pool of blood away from the person, significant amount of blood
on them, active arterial bleeding or any signs of active bleeding, and also another sign can be
whether or not the person is confused, as confusion can be a sign of blood loss.
Once you've identified life-threatening bleeding, it's time to act and to do something to either
stop that bleeding or to mitigate it. The first thing you can do is, remember, compress. Direct
firm pressure onto the site of the wound. Also if it's a large wound you can pack the wound first,
then holding direct pressure. And then finally, if it's on the arms or the legs you
can use a tourniquet to stop the bleeding. Most importantly, whichever of these methods you use,
once you've stopped the bleeding, hold that pressure or keep that tourniquet on
until help arrives. I'm Dr. Nahmias, one of the trauma surgeons at UCI Health and on behalf of
me and all of our team, we thank you for taking the time to learn these life-saving techniques.