Hemorrhage Control: Stopping the Bleed in EMS & Trauma

Massive hemorrhage is the leading cause of death in trauma, and EMS providers often have just seconds to intervene. In this episode, Erik and Matt discuss hemorrhage control techniques that save lives both in the field and in extreme environments. Whether you're a combat medic or an average citizen, it's important to know how to stop bleeding in a patient. Hemorrhage is the leading cause of death in trauma. Tune in as we discuss this simply but extremely important patient population. 

Transcript

Narrator: [00:00:00] Please be sure to like, share, and subscribe. 

Erik: I remember being so scared that first night in the tent. I did not sleep a wink. Well, no. The guy, it started bleeding out of his eyeballs. 

Narrator: You are listening to EMS With your hosts, Erik Axene and Matt Ball. 

Erik: Well, it's kind of like what we're talking about today. Yeah. Something that matters, something [00:00:30] that's, something we're going to actually use when we treat patients.

Yes. Because these are, these are emergencies that you may have seconds. 

Matt: That's right. 

Erik: And it really matters, I mean, you could be saving a life by doing something quickly here. 

Matt: Yeah, and this isn't even just for providers. I mean, this is for anybody at home. You know, if you come across up on a car wreck or something happens at the house and you know, you or a family member gets a severe cut, how do you manage that?

Because obviously we have to have blood in our bodies in order to survive. [00:01:00] All bleeding does 

Erik: stop eventually. 

Matt: Eventually, that's right. You end up being alive. That's right. Yeah. 

Erik: There are a lot of pearls of wisdom to learn here, uh, the lecture we just filmed, but yeah. Um, so what are we talking about?

Hemorrhage control. Good. Yeah. Hemorrhaging. Yeah. Bleeding out. Yep. 

Matt: Yeah. The number one cause of death in trauma. 

Erik: That's correct. Yeah. Yep. Hemorrhage. Yep. And most of the time, as we talked about in the lecture, it's, uh, torso injuries. That's right. Um, yeah. But extremities can be injured. Junctional areas can be [00:01:30] injured.

We'll talk about that. Anything. 

Matt: Yeah. Yeah. And I think, so the junctional, or the, the torso. You know, why do we bleed out so fast with our 

Erik: torso? Oh man, you got some big old vessels in there. It's all, like we talked about in the light board that we did. Bleeding out is typically not a pump problem. Bleeding out is usually a hose problem.

We have these blood vessels in our body and they deliver blood to perfused. And when you have an injury to part of your body, you're going to be injuring some of the [00:02:00] hoses and you, you know, if you're running a, uh, a large diameter hose out of a hydrant and you busted or car drove over and it's, it's hemorrhaging water, you're not going to generate much pressure at the pump, right?

So there are a lot of different problems, um, that can happen physiologically when we damage a blood vessel, but there are a lot of things that we can do to fix it. 

Matt: Yeah, it's a pretty, well, it's a relatively simple fix in theory that we to stop the bleeding, right? We have to close off that whatever it is that's leaking, right?

Just [00:02:30] like you said, with a hose, you got to shut down that line and then you've at least stopped the progression of the damage, right? And then you have to replace what you've lost, like we talk about in our lecture. And so that's That's the biggest thing, whether again, you're a EMT, a paramedic, a nurse, doctor, or a layperson, is if you see somebody that has significant bleeding, and talking about significant bleeding, and I'm sure you've seen this too, I'll never forget, one day we were called out.

to a hemorrhage call early in the [00:03:00] morning, four or 5 a. m. And we're going to this call and I'm reading the notes on the computer and it says, uh, daughter has a nosebleed and in the notes it says massive amount of blood and I'm like, okay, wow, you know, I mean, again, going back to our theory of there's small vessels in the nose, you know, but you can bleed a lot through your nose for sure.

I got a story to tell. Okay, perfect. So we show up. And this guy answers the door, and he's this big, muscled up, mean looking dude, right? And [00:03:30] he is frantic. He is freaking out. And I'm like, what's going on? Oh, my daughter's got this nosebleed. And we're like, okay, and then the wife comes down. She's got the daughter, and she's kind of holding pressure on the nose, and she's got her head tilted backwards.

And I'm like, okay, first off, let's not tilt her head backwards. You know, because then the blood goes down into your throat, all that stuff. So I'm like, just pinch it for now. He goes, her whole pillow was covered with blood. And we heard her crying. We went room and the whole pillow was just saturated with blood and I'm like, could you go get me the pillow so I can see for [00:04:00] myself how much blood we're talking about here?

And so, uh, while he's doing that, my partner's checking out the kid, you know, doing all that stuff. And this, I mean, this dude looked like an ex Navy seal. I mean, he just had this look like this dude probably knows what a lot of blood, he comes down and there's like three little drops of blood on the pillow.

And I'm like, I think she's going to be okay. You know, but, uh, it was funny. He probably didn't. say that. I did not say, no, I did say, I said, I think she's going to be okay. I said, this, this is, you know, I didn't, you didn't say you idiot. [00:04:30] I did. I fought it, but I didn't say it. Yeah, no. I mean, and I get it that when it's, when you're a dad, I don't care what your experience, when it's your little baby girl or baby boy, you're freaking out.

So no, we, she, you know, was fine, but it's 

Erik: studied this. We are really bad at estimating blood loss. Even 

Matt: us medical 

Erik: professionals, as much as we want to say, you idiot, we have been And we're really bad at estimating blood loss. 

Matt: Yeah. Didn't they pour it on the ground or something? Yeah. Yeah. They 

Erik: poured it on the ground.

Just, just a X amount of blood. I don't know how much it was honestly, but they went and asked medical [00:05:00] professionals to enter that scene to estimate the blood loss in the wherever, in the kitchen with all the blood everywhere. And the, the variety of estimations, 

Matt: It's kind of like palpating pulses or needle decompression all over the place.

Yeah, that's so funny. 

Erik: I had a patient with a bloody nose once and this guy came in, his nose was, you know, and honestly, 99 percent of blood bloody noses I can, I can take care of and send them home and they'll follow up sometimes with an ENT, sometimes I'll [00:05:30] just tell the kid to stop picking their nose or, uh, you know, it's really dry out.

site, keep it moist or, you know, or whatever, maybe stop your blood thinner today and, and see your primary care in the morning or whatever. But, uh, so it's a, uh, pretty common thing, but I had one guy that came in with a bloody nose and I will, you know, typically, you know, pressure for a little while, see if we can stop it.

But he was breathing, bleeding pretty, pretty heavily. I mean, it was a pretty impressive nose bleed and I've seen a lot of them. So to impress me was something. . [00:06:00] And so I thought, okay, well I'm gonna skip my typical, you know, Rin in the nose and weight and, and I'm actually, I'm gonna, I'm gonna pa I'm gonna put in the balloons.

Mm-hmm . So put in bilateral balloons in this guy's nose after s spraying with some rin after I cleared the, the blood or whatever. And, um, they hurt. Got 'em both in, pumped them up. The guys were pretty uncomfortable. And he's like, man, I'm, I'm bleeding. I can, I can feel it going down my throat. Feel 

Matt: it backing up.

Yeah. 

Erik: So we had a pretty impressive, uh, nose bleed. So we have, I. Put in some of the [00:06:30] shorter ones. I should have put the long ones in. So I went in and I put the long ones in and I really balloons for posterior bleeds. Okay. And, uh, and typically I, I, I, I went through all this without contacting my auntie and, uh, anyway, the guy.

Um, the blood stopped going down his throat, so I thought I'd gotten it. Right? Well, no. The guy, it started bleeding out of his eyeballs. Oh, gosh. Yeah, he, the, you know, the lacrimal duct are [00:07:00] connected to the nasal cavities. And, uh, they drain down into the Just wipe 

Matt: your eyes water when you get punched in the nose.

Yeah. Well, it's all connected. Yeah, yeah. Anyway, 

Erik: so he was literally bleeding out of his eyes and, uh, I, um, could not stop the bleed and, uh, I ended up, uh, contacting ENT. They came in and it ended up going to the cath lab. They embolized him. Oh, wow. Went to the cath lab to stop the bleed. It was a big posterior bleed and, uh, it had to, we had, [00:07:30] I mean, I can't stop that, right?

Yeah, yeah. 

Erik: So that's, uh, that was the worst nosebleed I've ever had. The guy literally bleeding out of his eyes. Um, that's crazy. I've never seen that before. And the ENT was pretty impressed too. No ENT with that. 

Matt: Oh yeah, with, who sees this 

Erik: every day, yeah. That's a good point, yeah. I actually got a medcom call not too long ago from one of my paramedics.

And we, uh, walked him through, you know, uh, saturating some gauze with TXA is, uh, that's not FDA approved use of TXA, but boy, we're finding 

Matt: a lot of things out [00:08:00] about TXA that it has used. Yeah, we had, uh, we got called to an e care one time for a hemorrhage, showed up and went in the room and the doctors and nurse, they weren't freaking out, but you could tell they were a little excited and walked into this room and this lady sitting there and she's got, you know, you can tell she's got stuff in her mouth.

And they've got two IVs, fluids, and I'm like, what's going on? Well, she had impacted wisdom teeth removed. She had a dry socket, popped a little artery. And they're like, we [00:08:30] cannot get this thing to stop bleeding. So first off, I was like, okay, well, let's shut down the IVs, right? Because we don't do that anymore.

We don't flood them out. So I'm like, let's shut down the IVs. Uh, and then, um, got her in the ambulance. And we had TXA and we were, uh, it was in our protocols to use it for nosebleeds, the gauze. So, but it wasn't in our protocols to do it for oral bleeding, which is actually 

Erik: one of the two FDA approved uses.

Oh, really? It's indicated FDA is [00:09:00] approved for two things. Maternal like OBGYN hemorrhage and dental. And it's not your protocol as well. 

Matt: This was also probably 10 years ago. This was a while ago. It's in there now 

Erik: for sure. Oh, 

Matt: yes, it is in there now. Yeah. So I called my medical director at the time and I was like, Hey, this is what I got.

And I said, is, is it okay if I, you know, do this? And he goes, Oh yeah, absolutely. And so that's what I did. I put it back there. I said, Hey, bite down on this. By the time we got to the ER, she had stopped bleeding. And so it really worked well. And so [00:09:30] I. That goes back to our hemorrhage control, like you have to consider where are they bleeding, you know, and there's a great diagram that I can maybe put up here that I found.

I love this diagram. I use it all the time when I'm teaching of how to stop bleeding, depending on where it's at. And so if it's an extremity, shoulder or hips down, tourniquet, tourniquet, right? And typically, as most people know, um, especially on a thigh or a leg wound, you probably are going to need to, right?

So for those providers, definitely 

Erik: usually need to, [00:10:00] 

Matt: yeah, Because again, you've got big hoses. 

Erik: Big hoses and a lot of tissue. 

Matt: Exactly. You've got to get through that tissue. So tourniquets on extremities, junctional areas, so shoulders, hips, things like that. That's where you'll use your combat gauze. Or there are junctional tourniquets 

Erik: too.

They're not commonly used, but they are. Israeli bandages. Yeah. 

Matt: Yeah. Things like that. Yeah. They're helpful, but still you can pack those. Still pressure basically. Exactly. And you can pack those and then put like an Israeli bandage over that. [00:10:30] Um, and one thing to keep in mind for our providers, EMTs, paramedics, if you have those type of injuries, if you don't, first off, if you have some sort of combat gauze, you want to pack that wound as deep as you can, as tight as you can.

And then if you run out of that gauze, just take some cling 

and 

Matt: you want to fill that hole up. And if you don't have combat gauze, just use the cling, take that out, you know, clean it and, and, uh, pack That wound is as well. The other 

Erik: thing worth mentioning now is the pelvic binder with [00:11:00] pelvic fractures, with traumas and unstable pelvis.

A pelvic binder can limit the amount. It doesn't stop the bleeding, but it can limit the amount of blood that can be bled into that cavity. Yes. Which is usually one to two liters. Um, any, you know, you don't put them in a binder. You run the risk of over bleeding and then getting close to that end stage of hemorrhagic shock.

We talked about, uh, how much blood. Can you bleed into the belly? Well, all of it, all of it. Uh, chest is big to, uh, hemi, you know, uh, uh, hemothorax of [00:11:30] some kind can be bad, but those torso bleeds, we can't really fix those. Uh, we might be able to help mitigate some of the bleeding, but, uh, it's, we got to get them to the place that they can get fixed quickly.

Matt: Yeah. And that's what most trauma is. You know, we've got to, you know, we preach all the time about like medical cardiac arrests or things like that, you know, stay away. We're not fixing, you know, most of the time in a medical cardiac arrest, it's a pump problem. Obviously, I'm not fixing that [00:12:00] problem. They probably need a cath lab, right?

Without 

Erik: you, their brain cells would die. But that's it. That's really the reason we're doing it. 

Matt: Yes, we're trying to keep the brain alive. 

Erik: And the best of, best of chest compressions are only given 20 to 30 percent cardiac output. And, uh, that might be enough to get them to the hospital where when the, they get the ROSC and get everything reperfused in the brain, we have it locked.

lost, um, too many brain cells and we can leave the hospital. 

Matt: Yeah. 

Erik: That's the goal. That's the end. That's the outcome measure [00:12:30] that really, and we, we, we're not talking about cardiac arrest, 

Matt: but, 

Erik: but, 

Matt: but there's so many points we could talk about, 

Erik: but as far as bleeding goes, uh, Early recognition is key. Early recognition is key and then stop in the bleed because you may not be bleeding from an extremity, right?

Right. Uh, you may be bleeding somewhere else and getting them to a place where they can get it stopped as quickly as possible as the key. You don't want to be dancing around on scene and realize, Oh no, we've been here for 10 minutes. They've been bleeding in their belly for 10 minutes. You may be in a world [00:13:00] of hurt and killing your patients.

Matt: That's right. Any of these skills you can do, you know, you can obviously on scene, I'm going to throw a tourniquet on real quick, but if I'm seeing squirting pulsatile flow of blood, bright red type blood, I know that's probably arterial and that turns up my brain. Time clock or you know, that's making it fat.

I got a move And so throw on a tourniquet and again tourniquets are simple to apply You know for you know, you should I [00:13:30] always not always but occasionally I will go into our bag that we carry on our cot in the ambulance And a lot of times, they'll only have one tourniquet in there, and I always have two in there.

Always have two, because if I'm going into an apartment or off somewhere in a wreck, and I show up, one tourniquet might not be enough. So, tourniquets are very simple to use. Obviously, make sure, like we said in our lecture, you're using approved CAT style tourniquets. Um, or else they might fail when you need them to not fail.

But practice with them. You [00:14:00] know, if you're an EMT, because Another thing, and we talk about this a lot in our lecture, you know, if you work out in a rural environment or maybe if you work in a real urban environment and you have unfortunately a lot of violence, you know, and you see a lot of gunshot victims, maybe you're used to working trauma.

I know like in my department, we work in a subdivision of Dallas or in a suburb of Dallas. You know, we don't get a tremendous amount of trauma. I mean, we get car wrecks and things like that, but we don't get a tremendous amount of trauma. So tourniquet [00:14:30] placement is one of those skills that you need to practice.

Yeah. Get it out. Throw it on. So important. It's so important because like you said, when you need it on, it's got to be put on quickly. Yep. And, um, so we got to be proficient at that, but these, get them on, get them on the cot, get them in the back and go. You can start IVs in route, you know, if you're, especially if you're rural service.

You've really got to get moving or call for a helicopter, you know, to get them to a trauma center quickly, um, and then get them to you guys at the facility that can treat those. Don't take them [00:15:00] to a level four trauma facility, you know, I mean obviously follow your protocols. 

Erik: Yeah, unless they're unstable and they've gone into cardiac arrest, uh, there may be a reason to, to leapfrog it from a, the closest possible.

You 

Matt: have to get, yeah, because even a level four trauma center with a physician and nurses is going to be better than, Yeah. You know, an EMT and a paramedic in some rural area, they still have a lot more resources, but, um, and then torso, you know, we don't want to pack. I've seen this before. A lot of people think, Oh, well, I'll get the combat cause you get like an abdominal [00:15:30] GSW and people want to start packing that.

And that's a bad idea. You know, you can, 

Erik: yeah, the G those GSW, those, those wounds are usually pretty small and trying to pack it. It's, it's not, not yet. Not a good idea. It's not going to do much good. The damage actually, that cavitation wave through the damages, the tissues. I mean, you just got to get them to the surgeon and get them there as quick as And they're probably bleeding internally with the vessel injury that you're not going to be able to get near.

So, you know, mucking around with [00:16:00] trying to pack a little tiny hole. The damage is inside. Yeah. Um, anyway, So we, we, there are many causes for hemorrhage. And so when we were planning our lecture, we wanted to, you know, what are we going to focus on? Are we going to focus on MVCs, which is the most common for violence, stabbings, gunshot wounds, MVCs.

We went a whole other direction. We totally did. What did we 

Matt: do? Well, what did you do? I didn't do anything. You did it. Well, the idea, right, you know, 

Erik: was to do something that would be [00:16:30] interesting. And so we, we picked, uh, you know, of all the animals on the planet and all the situations, somebody could do 

Matt: that.

I can think of that would probably be, there's two animals I can think of that are scariest. But the environment of that one 

Erik: is the 

Matt: scariest. I 

Erik: think so. I mean, we learned a lot of sharks. Yeah. Is that not only are you not a fish and not a fast swimmer. That's not 

Matt: our natural environment. Yeah. 

Erik: We talked about this.

Michael Phelps swims five miles an hour. 

Matt: Five. Five. And you asked me, and I think I said like [00:17:00] 20 or 30. You know, I thought, oh, you know, Michael Phelps probably can motor. Nope. Five miles an hour. 

Erik: Yeah, and sharks, the great white sharks swim at 46 miles an hour. Oh my gosh. 

Matt: At, at one or two tons of weight. Hey, if 

Erik: I see, if I see a shark, 

Matt: I'm just going to swim to shore.

Well, and that's what you said is when you talked to the doctors out there, the shark experts, you're not going to see these things. 

Erik: No, they attack from underneath and behind. They're, they're expert hunters. They use their [00:17:30] electro reception to orient their mouth with your body, and, uh, they're 23 feet long.

Tons of thousands of pounds of muscle, five rows, 4,000 psi bite, five rows of. Two inch long, razor sharp daggers. Um, that alone created the, the recipe for massive hemorrhage. And we talked to the ER doctors that describe these wounds as more of like, it looks like a grenade blew up on the guy's shoulder.

We actually got to talk. [00:18:00] to a shark bite victim that was on Good Morning AmErika. That's right. And he agreed to be on our show and we got to interview him and he survived. He got bit by this great white left shoulder. He was actually a left handed pitcher. Yeah. Took out his left shoulder. Now the guy, he was such a brave, inspiring kid, wanted to go back and become a lifeguard.

Matt: Went right back in the water. You couldn't, I wouldn't get into a kiddie pool after 

Erik: being bit by a great white shark. I felt like such a wimp, as scared as I was out there. where [00:18:30] these people were bit and killed, um, multiple it's, you know, we learned that it's a great white nursery. 

Matt: This is in California, California, 

Erik: uh, just, uh, San Diego area, just north of San Diego was this beacon 

Matt: beach?

Well, there are multiple different 

Erik: beaches around the Delmar area. Encinitas, uh, but there's, um, these are where these bites had taken place. And it's just considered a great white nursery. We learned that from Dr. Lowe up at Cal state Long Beach. And we decided to go out swimming out there. And, and, uh, that [00:19:00] was one of the scariest things I've ever done.

You got to check out the video. If you haven't seen it, it's some of the footage we got was, uh, we held rattlesnake. We did a lot of crazy stuff. Oh, you did. This was not so. Yeah. That was. Not so. 

Matt: Yeah, because you'll survive a rattlesnake bite more than likely. It's going to suck, but you're probably going to survive it.

And, you know, I mean, I think, didn't he say, you have a greater chance of getting struck by lightning than getting bit by a shark? Wasn't that something like that? That's true. 

Erik: Yeah. I mean, the chances of getting bit by a shark were [00:19:30] really, really low. It's just. The thought of what was lurking in water. I couldn't see.

And I was, you know, you think about it, you got surfers out there that are getting bit or swimmers. They're moving around. 

Yeah. 

Erik: Um, I was sitting in the same spot. I was told to stay in the same spot. 

Matt: Thanks, Devin, Devin, 

Erik: because he was flying the drone over us. Getting some, we coordinated our lines, to line up with the audio recordings, you know, and so we had hand motions of when he was bringing the drone in and we've hand motions when we were ready and what 

Matt: was the [00:20:00] hand motion for hurry up?

Let's get this done. 

Erik: Uh, yeah, we were freaked out. Oh, actually I was freaked out. Dr. Schwartz, who is the medical director for San Diego out there. He was not freaked out. In fact, he was like hitting my leg. He 

Matt: would have gotten punched. Yeah. That is one of my, you know, I go backpacking, you know, and, uh, you know, like my wife is terrified of bears.

She doesn't like going out. And I'm like, I get it. Yeah. Like, I mean, you know, a [00:20:30] grizzly bear, you know, that would be terrifying. However, when I go backpacking, I usually carry something with me to keep me safe, you know? So I have that option. Plus I'm in my environment. on land. Dude, when you're in the water.

Erik: Yeah, you can run, maybe climb a tree. They can climb trees too, but at least you can get up in an area where you can defend yourself a little bit with your handgun or it better be a large caliber handgun. Otherwise you're just going to piss them off. 

Matt: Yeah. Yeah. You don't want to [00:21:00] shoot them with a nine millimeter that will make them mad, but a shark.

You're not, there's nothing. 

Erik: Did I ever tell you the story when I went up to Northern British Columbia to go camping? 

Matt: Was this your Portage 

Erik: trip? Yes, yes. They used to call this lake, it's the Bowern Lakes is where I went. Wonderful trip. They used to call it the Bear Lakes because there's so many grizzlies up there.

And I remember when we were at the ranger station, they were telling us, you know, don't use deodorant. They smell that don't cook spiced meats or eat like onions. [00:21:30] Uh, don't brush your teeth, no soaps, no shampoos, just use the mud to wash off and stuff. And, um, the first night my uncle had bought kielbasa with onions.

I'm not joking. All the wrong food. All the wrong food. Took a shower. Sprayed some. 

Matt: You had some cologne on. Oh, I mean, I, 

Erik: I, uh, I was, I remember being so scared that first night in the tent. I did not sleep a wink. I don't blame you. I was so scared. And the next [00:22:00] night I'm like, okay, I'm getting sleep tonight.

Cause we got a cabin the second night. Yeah. It's like these cabins you can stay in. And I remember thinking, okay, tonight I'm sleeping and I'm just about to go to sleep. And this muskrat kind of climbs through the chimney of this cabin. On, I can see it on the table in there, this giant prehistoric looking mouse, rat, huge things trying to claw into our food supply.

I threw my shoe at it. I didn't sleep at all that night. I was imagining [00:22:30] this thing. You're terrified of the muskrat. Anyway, uh, being in the food chain though with that, I'm imagining those grizzly bears. Now they run about 40 miles an hour and I can run about, not that, and uh, that's scary too. But the sharks.

It's just terrifying. But back to hemorrhage though, when a shark bites someone, they're just, it's an explosive injury. Like those ER docs would describe like grenades, you know, it's you that, uh, when, um, remember the oh bleep [00:23:00] moment that Keane described? 

Yeah, 

Erik: he got bit, took out his left shoulder. His arm was disarticulated.

It wasn't detached yet. It was attached by soft tissue, but he saw the head of his humerus. I mean, he's looking at his arm and blood everywhere, squirting blood. I mean, and then the guy in the chiropractor says, Oh, yeah. 

Matt: Oh, 

Erik: and he It was saved, obviously, and uh, what a great story, but, but when these sharks bite, they cause massive tissue injury.

Yes. 

Erik: Massive tissue injury. I mean, they're biting [00:23:30] limbs off. Yeah. I mean, with a 4, 000 PSI bite. Yeah. That's the Hamilton. Oh yeah, right, right, right. So, so it's really important, uh, for these lifeguards who taught us how to use tourniquets to know how to stop the bleeding if they can or transport quickly to the place where they can get fixed.

That's right. And a lot of these folks die. 

Matt: Yeah, oh yeah. 

Erik: Massive hemorrhage. Because they get bit by, you know, you get bit in the leg, that femoral artery is going to bleed you out quickly if you don't get the bleeding stopped. Yep. And so that's, that's what's killing people out there. 

Matt: Yep. [00:24:00] Yeah, it's super important to know how to manage these patients as providers.

You know, again, pressure, you know, get, Put something on it quick, get some pressure on it fast, you know, you can makeshift tourniquets. There's all kinds of videos out there on if you can't, if you don't have access to a cat tourniquet, you know, you can do different things, but pressure stopped. You know, when I was in paramedic school, we did not, tourniquets were like, Oh no, you don't do that.

And 

Matt: it's so interesting how, you know. In medicine, things come [00:24:30] back around, you know, um, and now it's like, Oh yeah, you a hundred percent, you know, we had no tourniquets on our ambulances. That was a big no, no, you didn't do that because you were going to cause, you know, damage to the tissue and they were going to have to get it amputated.

And now it's like, no, no, they can keep them on for, you know, a certain amount of time. Um, but yeah, it's super important to know how to manage these patients, you know, and fluids, you know. Like you said in the lecture, replace what they lost. They didn't lose normal saline or LR, they lost blood. And so if you're, [00:25:00] you know, if you have access to blood, that's what they need.

Um, but you know, until they get the, the injury fixed, um, if you don't have it, you know, maybe you could call a flight team or something. They could come out or maybe a local department has it. Um. And then obviously if, if nobody has, if that's not an option, you got to go, you got to get them to a facility that has some blood.

Erik: What you said is probably the biggest pearl, uh, or morsel that we discussed in our lecture that's important to take away [00:25:30] in managing major hemorrhage. Some of the other things we talked about were recognizing the stage of hemorrhage that you're in. That could be important too. Uh, you know, the, the first thing that changes is the, the vasculature changes.

That's right. Very fast. First thing that changes, but it won't show up on your vital signs. Your vital signs will be normal. Um, when you start to see the vital signs change, your heart rate starts to go up first. Mm-hmm . And then the blood pressure eventually will come down when that compensation doesn't work anymore.

And then you start getting alter mental status. Now you're circling the drain. 

Yeah. 

Erik: So it's really [00:26:00] important to, to try to figure out with all the other complicating facts. is this person going into shock or not? It can be tough. Like we talked about the shock index, heart rate over the blood, systolic blood pressure.

But recognizing the signs of massive blood loss is another key thing we learned. We talked about TXA, some of the other things we can do besides tourniquets to stop bleeding, pressure. And then I think One of the other things that we talked about is the permissive hypotension. Yes. Another key. [00:26:30] Yes. 

Matt: Yeah, 120 over 80 is not necessary on massive trauma patients.

If you got a blood pressure of 90, I'm perfectly happy with that. Yep. 

Yeah. 

Matt: So don't get too crazy that, oh my gosh, we've got to give them fluid because their blood pressure is 90. Nope, they're good. 

Erik: The days of doing that, slamming a liter of fluid on a trauma patient should never be done again. That's, that's hurting people.

It's making their blood dilute. So it's blowing clouds fast and then it also causes increased leakiness of blood vessels. So it's, it's really not [00:27:00] recommended to do that and follow your protocols, obviously, but you know, I don't care what the protocols say. If they 

Matt: say give two liters of fluid in a trauma, then yeah, you need to relook at that for sure.

And again, for, you know, watch our hemorrhage lecture. We go into way more detail. There's two parts. It's a two hour lecture. And it's fun. We're out there risking our lives. Well, you are. Sharks. 

Erik: I wasn't crazy 

Matt: enough to go do that. 

Erik: You were with me in spirit. I can't remember, you helped me plan it, but there was something going on that you couldn't travel with.

Yeah, 

Matt: I [00:27:30] don't remember what it was. Devin and I talked 

Erik: about you at the time. 

Matt: That chicken didn't come out here with us. That's not what we said. That's what I would have said. 

Erik: No, 

Matt: that was a, it's a great lecture, very entertaining. And very informative and a really important topic because we need to know how to manage these patients pre hospital.

Erik: And I think what cool thing for me about that lecture was, I think it was like a, that's really, if you want to see what we're all about with education, we take great [00:28:00] content and we package it in an interesting It's more like a show, really. We have fun watching it. You learn a ton from experts outside of, you know, we're experts too in some ways, but getting the other experts out and it just made it so much fun.

If you haven't seen a lecture from us, you got to check it out, uh, axenece. com. Yep. We've got the link in our bios. We should be putting it up on the website shortly. 

Yeah. 

Erik: So just keep an eye on it. Well. See you on the next one. Be safe out there.[00:28:30] 

Narrator: Thank you for listening to EMS, the

Erik and Matt Show.

Hemorrhage Podcast
===

Narrator: [00:00:00] Please be sure to like, share, and subscribe. 

Erik: I remember being so scared that first night in the tent. I did not sleep a wink. Well, no. The guy, it started bleeding out of his eyeballs. 

Narrator: You are listening to EMS With your hosts, Erik Axene and Matt Ball. 

Erik: Well, it's kind of like what we're talking about today. Yeah. Something that matters, something [00:00:30] that's, something we're going to actually use when we treat patients.

Yes. Because these are, these are emergencies that you may have seconds. 

Matt: That's right. 

Erik: And it really matters, I mean, you could be saving a life by doing something quickly here. 

Matt: Yeah, and this isn't even just for providers. I mean, this is for anybody at home. You know, if you come across up on a car wreck or something happens at the house and you know, you or a family member gets a severe cut, how do you manage that?

Because obviously we have to have blood in our bodies in order to survive. [00:01:00] All bleeding does 

Erik: stop eventually. 

Matt: Eventually, that's right. You end up being alive. That's right. Yeah. 

Erik: There are a lot of pearls of wisdom to learn here, uh, the lecture we just filmed, but yeah. Um, so what are we talking about?

Hemorrhage control. Good. Yeah. Hemorrhaging. Yeah. Bleeding out. Yep. 

Matt: Yeah. The number one cause of death in trauma. 

Erik: That's correct. Yeah. Yep. Hemorrhage. Yep. And most of the time, as we talked about in the lecture, it's, uh, torso injuries. That's right. Um, yeah. But extremities can be injured. Junctional areas can be [00:01:30] injured.

We'll talk about that. Anything. 

Matt: Yeah. Yeah. And I think, so the junctional, or the, the torso. You know, why do we bleed out so fast with our 

Erik: torso? Oh man, you got some big old vessels in there. It's all, like we talked about in the light board that we did. Bleeding out is typically not a pump problem. Bleeding out is usually a hose problem.

We have these blood vessels in our body and they deliver blood to perfused. And when you have an injury to part of your body, you're going to be injuring some of the [00:02:00] hoses and you, you know, if you're running a, uh, a large diameter hose out of a hydrant and you busted or car drove over and it's, it's hemorrhaging water, you're not going to generate much pressure at the pump, right?

So there are a lot of different problems, um, that can happen physiologically when we damage a blood vessel, but there are a lot of things that we can do to fix it. 

Matt: Yeah, it's a pretty, well, it's a relatively simple fix in theory that we to stop the bleeding, right? We have to close off that whatever it is that's leaking, right?

Just [00:02:30] like you said, with a hose, you got to shut down that line and then you've at least stopped the progression of the damage, right? And then you have to replace what you've lost, like we talk about in our lecture. And so that's That's the biggest thing, whether again, you're a EMT, a paramedic, a nurse, doctor, or a layperson, is if you see somebody that has significant bleeding, and talking about significant bleeding, and I'm sure you've seen this too, I'll never forget, one day we were called out.

to a hemorrhage call early in the [00:03:00] morning, four or 5 a. m. And we're going to this call and I'm reading the notes on the computer and it says, uh, daughter has a nosebleed and in the notes it says massive amount of blood and I'm like, okay, wow, you know, I mean, again, going back to our theory of there's small vessels in the nose, you know, but you can bleed a lot through your nose for sure.

I got a story to tell. Okay, perfect. So we show up. And this guy answers the door, and he's this big, muscled up, mean looking dude, right? And [00:03:30] he is frantic. He is freaking out. And I'm like, what's going on? Oh, my daughter's got this nosebleed. And we're like, okay, and then the wife comes down. She's got the daughter, and she's kind of holding pressure on the nose, and she's got her head tilted backwards.

And I'm like, okay, first off, let's not tilt her head backwards. You know, because then the blood goes down into your throat, all that stuff. So I'm like, just pinch it for now. He goes, her whole pillow was covered with blood. And we heard her crying. We went room and the whole pillow was just saturated with blood and I'm like, could you go get me the pillow so I can see for [00:04:00] myself how much blood we're talking about here?

And so, uh, while he's doing that, my partner's checking out the kid, you know, doing all that stuff. And this, I mean, this dude looked like an ex Navy seal. I mean, he just had this look like this dude probably knows what a lot of blood, he comes down and there's like three little drops of blood on the pillow.

And I'm like, I think she's going to be okay. You know, but, uh, it was funny. He probably didn't. say that. I did not say, no, I did say, I said, I think she's going to be okay. I said, this, this is, you know, I didn't, you didn't say you idiot. [00:04:30] I did. I fought it, but I didn't say it. Yeah, no. I mean, and I get it that when it's, when you're a dad, I don't care what your experience, when it's your little baby girl or baby boy, you're freaking out.

So no, we, she, you know, was fine, but it's 

Erik: studied this. We are really bad at estimating blood loss. Even 

Matt: us medical 

Erik: professionals, as much as we want to say, you idiot, we have been And we're really bad at estimating blood loss. 

Matt: Yeah. Didn't they pour it on the ground or something? Yeah. Yeah. They 

Erik: poured it on the ground.

Just, just a X amount of blood. I don't know how much it was honestly, but they went and asked medical [00:05:00] professionals to enter that scene to estimate the blood loss in the wherever, in the kitchen with all the blood everywhere. And the, the variety of estimations, 

Matt: It's kind of like palpating pulses or needle decompression all over the place.

Yeah, that's so funny. 

Erik: I had a patient with a bloody nose once and this guy came in, his nose was, you know, and honestly, 99 percent of blood bloody noses I can, I can take care of and send them home and they'll follow up sometimes with an ENT, sometimes I'll [00:05:30] just tell the kid to stop picking their nose or, uh, you know, it's really dry out.

site, keep it moist or, you know, or whatever, maybe stop your blood thinner today and, and see your primary care in the morning or whatever. But, uh, so it's a, uh, pretty common thing, but I had one guy that came in with a bloody nose and I will, you know, typically, you know, pressure for a little while, see if we can stop it.

But he was breathing, bleeding pretty, pretty heavily. I mean, it was a pretty impressive nose bleed and I've seen a lot of them. So to impress me was something. . [00:06:00] And so I thought, okay, well I'm gonna skip my typical, you know, Rin in the nose and weight and, and I'm actually, I'm gonna, I'm gonna pa I'm gonna put in the balloons.

Mm-hmm . So put in bilateral balloons in this guy's nose after s spraying with some rin after I cleared the, the blood or whatever. And, um, they hurt. Got 'em both in, pumped them up. The guys were pretty uncomfortable. And he's like, man, I'm, I'm bleeding. I can, I can feel it going down my throat. Feel 

Matt: it backing up.

Yeah. 

Erik: So we had a pretty impressive, uh, nose bleed. So we have, I. Put in some of the [00:06:30] shorter ones. I should have put the long ones in. So I went in and I put the long ones in and I really balloons for posterior bleeds. Okay. And, uh, and typically I, I, I, I went through all this without contacting my auntie and, uh, anyway, the guy.

Um, the blood stopped going down his throat, so I thought I'd gotten it. Right? Well, no. The guy, it started bleeding out of his eyeballs. Oh, gosh. Yeah, he, the, you know, the lacrimal duct are [00:07:00] connected to the nasal cavities. And, uh, they drain down into the Just wipe 

Matt: your eyes water when you get punched in the nose.

Yeah. Well, it's all connected. Yeah, yeah. Anyway, 

Erik: so he was literally bleeding out of his eyes and, uh, I, um, could not stop the bleed and, uh, I ended up, uh, contacting ENT. They came in and it ended up going to the cath lab. They embolized him. Oh, wow. Went to the cath lab to stop the bleed. It was a big posterior bleed and, uh, it had to, we had, [00:07:30] I mean, I can't stop that, right?

Yeah, yeah. 

Erik: So that's, uh, that was the worst nosebleed I've ever had. The guy literally bleeding out of his eyes. Um, that's crazy. I've never seen that before. And the ENT was pretty impressed too. No ENT with that. 

Matt: Oh yeah, with, who sees this 

Erik: every day, yeah. That's a good point, yeah. I actually got a medcom call not too long ago from one of my paramedics.

And we, uh, walked him through, you know, uh, saturating some gauze with TXA is, uh, that's not FDA approved use of TXA, but boy, we're finding 

Matt: a lot of things out [00:08:00] about TXA that it has used. Yeah, we had, uh, we got called to an e care one time for a hemorrhage, showed up and went in the room and the doctors and nurse, they weren't freaking out, but you could tell they were a little excited and walked into this room and this lady sitting there and she's got, you know, you can tell she's got stuff in her mouth.

And they've got two IVs, fluids, and I'm like, what's going on? Well, she had impacted wisdom teeth removed. She had a dry socket, popped a little artery. And they're like, we [00:08:30] cannot get this thing to stop bleeding. So first off, I was like, okay, well, let's shut down the IVs, right? Because we don't do that anymore.

We don't flood them out. So I'm like, let's shut down the IVs. Uh, and then, um, got her in the ambulance. And we had TXA and we were, uh, it was in our protocols to use it for nosebleeds, the gauze. So, but it wasn't in our protocols to do it for oral bleeding, which is actually 

Erik: one of the two FDA approved uses.

Oh, really? It's indicated FDA is [00:09:00] approved for two things. Maternal like OBGYN hemorrhage and dental. And it's not your protocol as well. 

Matt: This was also probably 10 years ago. This was a while ago. It's in there now 

Erik: for sure. Oh, 

Matt: yes, it is in there now. Yeah. So I called my medical director at the time and I was like, Hey, this is what I got.

And I said, is, is it okay if I, you know, do this? And he goes, Oh yeah, absolutely. And so that's what I did. I put it back there. I said, Hey, bite down on this. By the time we got to the ER, she had stopped bleeding. And so it really worked well. And so [00:09:30] I. That goes back to our hemorrhage control, like you have to consider where are they bleeding, you know, and there's a great diagram that I can maybe put up here that I found.

I love this diagram. I use it all the time when I'm teaching of how to stop bleeding, depending on where it's at. And so if it's an extremity, shoulder or hips down, tourniquet, tourniquet, right? And typically, as most people know, um, especially on a thigh or a leg wound, you probably are going to need to, right?

So for those providers, definitely 

Erik: usually need to, [00:10:00] 

Matt: yeah, Because again, you've got big hoses. 

Erik: Big hoses and a lot of tissue. 

Matt: Exactly. You've got to get through that tissue. So tourniquets on extremities, junctional areas, so shoulders, hips, things like that. That's where you'll use your combat gauze. Or there are junctional tourniquets 

Erik: too.

They're not commonly used, but they are. Israeli bandages. Yeah. 

Matt: Yeah. Things like that. Yeah. They're helpful, but still you can pack those. Still pressure basically. Exactly. And you can pack those and then put like an Israeli bandage over that. [00:10:30] Um, and one thing to keep in mind for our providers, EMTs, paramedics, if you have those type of injuries, if you don't, first off, if you have some sort of combat gauze, you want to pack that wound as deep as you can, as tight as you can.

And then if you run out of that gauze, just take some cling 

and 

Matt: you want to fill that hole up. And if you don't have combat gauze, just use the cling, take that out, you know, clean it and, and, uh, pack That wound is as well. The other 

Erik: thing worth mentioning now is the pelvic binder with [00:11:00] pelvic fractures, with traumas and unstable pelvis.

A pelvic binder can limit the amount. It doesn't stop the bleeding, but it can limit the amount of blood that can be bled into that cavity. Yes. Which is usually one to two liters. Um, any, you know, you don't put them in a binder. You run the risk of over bleeding and then getting close to that end stage of hemorrhagic shock.

We talked about, uh, how much blood. Can you bleed into the belly? Well, all of it, all of it. Uh, chest is big to, uh, hemi, you know, uh, uh, hemothorax of [00:11:30] some kind can be bad, but those torso bleeds, we can't really fix those. Uh, we might be able to help mitigate some of the bleeding, but, uh, it's, we got to get them to the place that they can get fixed quickly.

Matt: Yeah. And that's what most trauma is. You know, we've got to, you know, we preach all the time about like medical cardiac arrests or things like that, you know, stay away. We're not fixing, you know, most of the time in a medical cardiac arrest, it's a pump problem. Obviously, I'm not fixing that [00:12:00] problem. They probably need a cath lab, right?

Without 

Erik: you, their brain cells would die. But that's it. That's really the reason we're doing it. 

Matt: Yes, we're trying to keep the brain alive. 

Erik: And the best of, best of chest compressions are only given 20 to 30 percent cardiac output. And, uh, that might be enough to get them to the hospital where when the, they get the ROSC and get everything reperfused in the brain, we have it locked.

lost, um, too many brain cells and we can leave the hospital. 

Matt: Yeah. 

Erik: That's the goal. That's the end. That's the outcome measure [00:12:30] that really, and we, we, we're not talking about cardiac arrest, 

Matt: but, 

Erik: but, 

Matt: but there's so many points we could talk about, 

Erik: but as far as bleeding goes, uh, Early recognition is key. Early recognition is key and then stop in the bleed because you may not be bleeding from an extremity, right?

Right. Uh, you may be bleeding somewhere else and getting them to a place where they can get it stopped as quickly as possible as the key. You don't want to be dancing around on scene and realize, Oh no, we've been here for 10 minutes. They've been bleeding in their belly for 10 minutes. You may be in a world [00:13:00] of hurt and killing your patients.

Matt: That's right. Any of these skills you can do, you know, you can obviously on scene, I'm going to throw a tourniquet on real quick, but if I'm seeing squirting pulsatile flow of blood, bright red type blood, I know that's probably arterial and that turns up my brain. Time clock or you know, that's making it fat.

I got a move And so throw on a tourniquet and again tourniquets are simple to apply You know for you know, you should I [00:13:30] always not always but occasionally I will go into our bag that we carry on our cot in the ambulance And a lot of times, they'll only have one tourniquet in there, and I always have two in there.

Always have two, because if I'm going into an apartment or off somewhere in a wreck, and I show up, one tourniquet might not be enough. So, tourniquets are very simple to use. Obviously, make sure, like we said in our lecture, you're using approved CAT style tourniquets. Um, or else they might fail when you need them to not fail.

But practice with them. You [00:14:00] know, if you're an EMT, because Another thing, and we talk about this a lot in our lecture, you know, if you work out in a rural environment or maybe if you work in a real urban environment and you have unfortunately a lot of violence, you know, and you see a lot of gunshot victims, maybe you're used to working trauma.

I know like in my department, we work in a subdivision of Dallas or in a suburb of Dallas. You know, we don't get a tremendous amount of trauma. I mean, we get car wrecks and things like that, but we don't get a tremendous amount of trauma. So tourniquet [00:14:30] placement is one of those skills that you need to practice.

Yeah. Get it out. Throw it on. So important. It's so important because like you said, when you need it on, it's got to be put on quickly. Yep. And, um, so we got to be proficient at that, but these, get them on, get them on the cot, get them in the back and go. You can start IVs in route, you know, if you're, especially if you're rural service.

You've really got to get moving or call for a helicopter, you know, to get them to a trauma center quickly, um, and then get them to you guys at the facility that can treat those. Don't take them [00:15:00] to a level four trauma facility, you know, I mean obviously follow your protocols. 

Erik: Yeah, unless they're unstable and they've gone into cardiac arrest, uh, there may be a reason to, to leapfrog it from a, the closest possible.

You 

Matt: have to get, yeah, because even a level four trauma center with a physician and nurses is going to be better than, Yeah. You know, an EMT and a paramedic in some rural area, they still have a lot more resources, but, um, and then torso, you know, we don't want to pack. I've seen this before. A lot of people think, Oh, well, I'll get the combat cause you get like an abdominal [00:15:30] GSW and people want to start packing that.

And that's a bad idea. You know, you can, 

Erik: yeah, the G those GSW, those, those wounds are usually pretty small and trying to pack it. It's, it's not, not yet. Not a good idea. It's not going to do much good. The damage actually, that cavitation wave through the damages, the tissues. I mean, you just got to get them to the surgeon and get them there as quick as And they're probably bleeding internally with the vessel injury that you're not going to be able to get near.

So, you know, mucking around with [00:16:00] trying to pack a little tiny hole. The damage is inside. Yeah. Um, anyway, So we, we, there are many causes for hemorrhage. And so when we were planning our lecture, we wanted to, you know, what are we going to focus on? Are we going to focus on MVCs, which is the most common for violence, stabbings, gunshot wounds, MVCs.

We went a whole other direction. We totally did. What did we 

Matt: do? Well, what did you do? I didn't do anything. You did it. Well, the idea, right, you know, 

Erik: was to do something that would be [00:16:30] interesting. And so we, we picked, uh, you know, of all the animals on the planet and all the situations, somebody could do 

Matt: that.

I can think of that would probably be, there's two animals I can think of that are scariest. But the environment of that one 

Erik: is the 

Matt: scariest. I 

Erik: think so. I mean, we learned a lot of sharks. Yeah. Is that not only are you not a fish and not a fast swimmer. That's not 

Matt: our natural environment. Yeah. 

Erik: We talked about this.

Michael Phelps swims five miles an hour. 

Matt: Five. Five. And you asked me, and I think I said like [00:17:00] 20 or 30. You know, I thought, oh, you know, Michael Phelps probably can motor. Nope. Five miles an hour. 

Erik: Yeah, and sharks, the great white sharks swim at 46 miles an hour. Oh my gosh. 

Matt: At, at one or two tons of weight. Hey, if 

Erik: I see, if I see a shark, 

Matt: I'm just going to swim to shore.

Well, and that's what you said is when you talked to the doctors out there, the shark experts, you're not going to see these things. 

Erik: No, they attack from underneath and behind. They're, they're expert hunters. They use their [00:17:30] electro reception to orient their mouth with your body, and, uh, they're 23 feet long.

Tons of thousands of pounds of muscle, five rows, 4,000 psi bite, five rows of. Two inch long, razor sharp daggers. Um, that alone created the, the recipe for massive hemorrhage. And we talked to the ER doctors that describe these wounds as more of like, it looks like a grenade blew up on the guy's shoulder.

We actually got to talk. [00:18:00] to a shark bite victim that was on Good Morning AmErika. That's right. And he agreed to be on our show and we got to interview him and he survived. He got bit by this great white left shoulder. He was actually a left handed pitcher. Yeah. Took out his left shoulder. Now the guy, he was such a brave, inspiring kid, wanted to go back and become a lifeguard.

Matt: Went right back in the water. You couldn't, I wouldn't get into a kiddie pool after 

Erik: being bit by a great white shark. I felt like such a wimp, as scared as I was out there. where [00:18:30] these people were bit and killed, um, multiple it's, you know, we learned that it's a great white nursery. 

Matt: This is in California, California, 

Erik: uh, just, uh, San Diego area, just north of San Diego was this beacon 

Matt: beach?

Well, there are multiple different 

Erik: beaches around the Delmar area. Encinitas, uh, but there's, um, these are where these bites had taken place. And it's just considered a great white nursery. We learned that from Dr. Lowe up at Cal state Long Beach. And we decided to go out swimming out there. And, and, uh, that [00:19:00] was one of the scariest things I've ever done.

You got to check out the video. If you haven't seen it, it's some of the footage we got was, uh, we held rattlesnake. We did a lot of crazy stuff. Oh, you did. This was not so. Yeah. That was. Not so. 

Matt: Yeah, because you'll survive a rattlesnake bite more than likely. It's going to suck, but you're probably going to survive it.

And, you know, I mean, I think, didn't he say, you have a greater chance of getting struck by lightning than getting bit by a shark? Wasn't that something like that? That's true. 

Erik: Yeah. I mean, the chances of getting bit by a shark were [00:19:30] really, really low. It's just. The thought of what was lurking in water. I couldn't see.

And I was, you know, you think about it, you got surfers out there that are getting bit or swimmers. They're moving around. 

Yeah. 

Erik: Um, I was sitting in the same spot. I was told to stay in the same spot. 

Matt: Thanks, Devin, Devin, 

Erik: because he was flying the drone over us. Getting some, we coordinated our lines, to line up with the audio recordings, you know, and so we had hand motions of when he was bringing the drone in and we've hand motions when we were ready and what 

Matt: was the [00:20:00] hand motion for hurry up?

Let's get this done. 

Erik: Uh, yeah, we were freaked out. Oh, actually I was freaked out. Dr. Schwartz, who is the medical director for San Diego out there. He was not freaked out. In fact, he was like hitting my leg. He 

Matt: would have gotten punched. Yeah. That is one of my, you know, I go backpacking, you know, and, uh, you know, like my wife is terrified of bears.

She doesn't like going out. And I'm like, I get it. Yeah. Like, I mean, you know, a [00:20:30] grizzly bear, you know, that would be terrifying. However, when I go backpacking, I usually carry something with me to keep me safe, you know? So I have that option. Plus I'm in my environment. on land. Dude, when you're in the water.

Erik: Yeah, you can run, maybe climb a tree. They can climb trees too, but at least you can get up in an area where you can defend yourself a little bit with your handgun or it better be a large caliber handgun. Otherwise you're just going to piss them off. 

Matt: Yeah. Yeah. You don't want to [00:21:00] shoot them with a nine millimeter that will make them mad, but a shark.

You're not, there's nothing. 

Erik: Did I ever tell you the story when I went up to Northern British Columbia to go camping? 

Matt: Was this your Portage 

Erik: trip? Yes, yes. They used to call this lake, it's the Bowern Lakes is where I went. Wonderful trip. They used to call it the Bear Lakes because there's so many grizzlies up there.

And I remember when we were at the ranger station, they were telling us, you know, don't use deodorant. They smell that don't cook spiced meats or eat like onions. [00:21:30] Uh, don't brush your teeth, no soaps, no shampoos, just use the mud to wash off and stuff. And, um, the first night my uncle had bought kielbasa with onions.

I'm not joking. All the wrong food. All the wrong food. Took a shower. Sprayed some. 

Matt: You had some cologne on. Oh, I mean, I, 

Erik: I, uh, I was, I remember being so scared that first night in the tent. I did not sleep a wink. I don't blame you. I was so scared. And the next [00:22:00] night I'm like, okay, I'm getting sleep tonight.

Cause we got a cabin the second night. Yeah. It's like these cabins you can stay in. And I remember thinking, okay, tonight I'm sleeping and I'm just about to go to sleep. And this muskrat kind of climbs through the chimney of this cabin. On, I can see it on the table in there, this giant prehistoric looking mouse, rat, huge things trying to claw into our food supply.

I threw my shoe at it. I didn't sleep at all that night. I was imagining [00:22:30] this thing. You're terrified of the muskrat. Anyway, uh, being in the food chain though with that, I'm imagining those grizzly bears. Now they run about 40 miles an hour and I can run about, not that, and uh, that's scary too. But the sharks.

It's just terrifying. But back to hemorrhage though, when a shark bites someone, they're just, it's an explosive injury. Like those ER docs would describe like grenades, you know, it's you that, uh, when, um, remember the oh bleep [00:23:00] moment that Keane described? 

Yeah, 

Erik: he got bit, took out his left shoulder. His arm was disarticulated.

It wasn't detached yet. It was attached by soft tissue, but he saw the head of his humerus. I mean, he's looking at his arm and blood everywhere, squirting blood. I mean, and then the guy in the chiropractor says, Oh, yeah. 

Matt: Oh, 

Erik: and he It was saved, obviously, and uh, what a great story, but, but when these sharks bite, they cause massive tissue injury.

Yes. 

Erik: Massive tissue injury. I mean, they're biting [00:23:30] limbs off. Yeah. I mean, with a 4, 000 PSI bite. Yeah. That's the Hamilton. Oh yeah, right, right, right. So, so it's really important, uh, for these lifeguards who taught us how to use tourniquets to know how to stop the bleeding if they can or transport quickly to the place where they can get fixed.

That's right. And a lot of these folks die. 

Matt: Yeah, oh yeah. 

Erik: Massive hemorrhage. Because they get bit by, you know, you get bit in the leg, that femoral artery is going to bleed you out quickly if you don't get the bleeding stopped. Yep. And so that's, that's what's killing people out there. 

Matt: Yep. [00:24:00] Yeah, it's super important to know how to manage these patients as providers.

You know, again, pressure, you know, get, Put something on it quick, get some pressure on it fast, you know, you can makeshift tourniquets. There's all kinds of videos out there on if you can't, if you don't have access to a cat tourniquet, you know, you can do different things, but pressure stopped. You know, when I was in paramedic school, we did not, tourniquets were like, Oh no, you don't do that.

And 

Matt: it's so interesting how, you know. In medicine, things come [00:24:30] back around, you know, um, and now it's like, Oh yeah, you a hundred percent, you know, we had no tourniquets on our ambulances. That was a big no, no, you didn't do that because you were going to cause, you know, damage to the tissue and they were going to have to get it amputated.

And now it's like, no, no, they can keep them on for, you know, a certain amount of time. Um, but yeah, it's super important to know how to manage these patients, you know, and fluids, you know. Like you said in the lecture, replace what they lost. They didn't lose normal saline or LR, they lost blood. And so if you're, [00:25:00] you know, if you have access to blood, that's what they need.

Um, but you know, until they get the, the injury fixed, um, if you don't have it, you know, maybe you could call a flight team or something. They could come out or maybe a local department has it. Um. And then obviously if, if nobody has, if that's not an option, you got to go, you got to get them to a facility that has some blood.

Erik: What you said is probably the biggest pearl, uh, or morsel that we discussed in our lecture that's important to take away [00:25:30] in managing major hemorrhage. Some of the other things we talked about were recognizing the stage of hemorrhage that you're in. That could be important too. Uh, you know, the, the first thing that changes is the, the vasculature changes.

That's right. Very fast. First thing that changes, but it won't show up on your vital signs. Your vital signs will be normal. Um, when you start to see the vital signs change, your heart rate starts to go up first. Mm-hmm . And then the blood pressure eventually will come down when that compensation doesn't work anymore.

And then you start getting alter mental status. Now you're circling the drain. 

Yeah. 

Erik: So it's really [00:26:00] important to, to try to figure out with all the other complicating facts. is this person going into shock or not? It can be tough. Like we talked about the shock index, heart rate over the blood, systolic blood pressure.

But recognizing the signs of massive blood loss is another key thing we learned. We talked about TXA, some of the other things we can do besides tourniquets to stop bleeding, pressure. And then I think One of the other things that we talked about is the permissive hypotension. Yes. Another key. [00:26:30] Yes. 

Matt: Yeah, 120 over 80 is not necessary on massive trauma patients.

If you got a blood pressure of 90, I'm perfectly happy with that. Yep. 

Yeah. 

Matt: So don't get too crazy that, oh my gosh, we've got to give them fluid because their blood pressure is 90. Nope, they're good. 

Erik: The days of doing that, slamming a liter of fluid on a trauma patient should never be done again. That's, that's hurting people.

It's making their blood dilute. So it's blowing clouds fast and then it also causes increased leakiness of blood vessels. So it's, it's really not [00:27:00] recommended to do that and follow your protocols, obviously, but you know, I don't care what the protocols say. If they 

Matt: say give two liters of fluid in a trauma, then yeah, you need to relook at that for sure.

And again, for, you know, watch our hemorrhage lecture. We go into way more detail. There's two parts. It's a two hour lecture. And it's fun. We're out there risking our lives. Well, you are. Sharks. 

Erik: I wasn't crazy 

Matt: enough to go do that. 

Erik: You were with me in spirit. I can't remember, you helped me plan it, but there was something going on that you couldn't travel with.

Yeah, 

Matt: I [00:27:30] don't remember what it was. Devin and I talked 

Erik: about you at the time. 

Matt: That chicken didn't come out here with us. That's not what we said. That's what I would have said. 

Erik: No, 

Matt: that was a, it's a great lecture, very entertaining. And very informative and a really important topic because we need to know how to manage these patients pre hospital.

Erik: And I think what cool thing for me about that lecture was, I think it was like a, that's really, if you want to see what we're all about with education, we take great [00:28:00] content and we package it in an interesting It's more like a show, really. We have fun watching it. You learn a ton from experts outside of, you know, we're experts too in some ways, but getting the other experts out and it just made it so much fun.

If you haven't seen a lecture from us, you got to check it out, uh, axenece. com. Yep. We've got the link in our bios. We should be putting it up on the website shortly. 

Yeah. 

Erik: So just keep an eye on it. Well. See you on the next one. Be safe out there.[00:28:30] 

Narrator: Thank you for listening to EMS, the Erik and Matt Show.