Neck pain; apply cervical collar, put on backboard (but not anymore).
Chest pain; administer aspirin, deliver supplemental oxygen (but not always).
Mantras and EMS protocols evolve over time as research reveals new best practices and standards of care. In the trauma world, tourniquets used to be a last-resort option, but now they’re almost synonymous with a bandage. By all means, there’s an absolute benefit to their appropriate application, but the key word here is “appropriate.”
Whether you’re testing the critical thinking abilities of your new EMTs or putting your seasoned paramedics into a practical skills scenario environment, I challenge you to throw a bit of a curveball at them. Develop a scenario that only requires direct pressure and bandage support, and see if they start (and stop) with the basics, rather than escalating right away to the advanced.
These scenarios aren’t designed to trick providers, but to challenge their critical thinking and appropriate skill deployment, rather than automatic worst-case scenario diversion. After all, direct pressure, trauma dressings and bleeding control agents still have a place in hemorrhage control.
Scenario No. 1: Exsanguination
Begin with a major hemorrhage patient scenario.
Scenario: A windowpane fell from a skylight window on a construction site of a new home. The glass created multiple, deep lacerations to both of the patient’s lower extremities. Blood is both oozing and spurting.
This patient needs damage control resuscitation, and he clearly needs a tourniquet. In fact, he needs two ... and now!
He’s hypotensive, tachycardic, pale and mumbling his words. He’s experiencing severe hemorrhagic shock – he’s “circling the drain.”
This scenario calls for double tourniquets, IV fluid bolus, tranexamic acid (TXA) or even blood products, stat!
Scenario No. 2: Moderate hemorrhage
Taking these scenarios in a digressive fashion, transition into your next call right after your providers’ adrenaline is flowing and tourniquet use is front of mind. They’ll likely be expecting this scenario to require a tourniquet, as well.
Scenario: The stab wound to your patient’s upper extremity (located quite proximal) is producing some moderate oozing of blood. It’s located too high on the arm for a tourniquet and it’s not severe enough to indicate its application.
Providers should be worried about a major vein injury, perhaps the axillary vein. There’s not a lot of pressure or intensity produced by the bleeding, but it’s still certainly noticeable (and requires rapid management). Ask what options they have to control the bleeding – 5x9 inch trauma dressings, hemostatic gauze or direct pressure.
What if the bleeding continues – what is their plan B?
Scenario No. 3: Chest injury
For the final scenario, make your providers critically think, deductively analyze and rationalize this case to come down to one obvious solution: utilizing a chest seal.
Scenario: The patient has a gunshot wound penetrating the chest wall.
Trauma and pressure dressings, alone, won’t work here. Tourniquets certainly aren’t indicated. Hemostatic agents: maybe, but, a chest seal: absolutely.
On the advanced and progressive end, once initial bleeding control measure have been taken, the use of ultrasound may aid your providers in accurately diagnosing a pleural effusion and the development of a tension pneumothorax. In this case, they could watch their needle being guided toward the pleural lining.
If point-of-care ultrasound (POCUS) isn’t an option, or even needle decompression, for that matter, then a great BLS option could be applying a chest seal. Remind providers that completely sealing the chest could lead to the build-up of pressure (and a narrowing pulse pressure, increased dyspnea, absent unilateral lung sounds, jugular vein distention, etc.). Using a chest seal, moreover, allows them to create a seal around the injury all while allowing for excess pressurized air to “burp” outward, rather than build up inward.
Each of these scenarios presents with its own unique set of complications, indications for appropriate device application and methods for hemorrhage control. Instruct providers to start with direct pressure. If that doesn’t work, apply more pressure. If that doesn’t work, or if the bleeding is too severe upon their arrival, they should not pass Go … not collect $200 … just go straight to damage control resuscitation.
