Severe bleeding and the tourniquet

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Scene 1 · Opening

23.20, the workshop. She was cutting sheet steel on the circular saw, you were outside with the compressor.

When you come in, she is sitting against the workbench, her right leg caught under a sheet that has tipped over.

The floor stains in a few seconds. This is a bleed, and there is nothing to wonder about.

Scene 2 · The pressure

The wound is on her thigh, partly under the steel. There is a clean folded rag on the workbench, within reach.

Your phone is in your pocket and there is nobody else here.

What do you do with the first second?

• Right move : I press straight away, directly, with the rag, with all my weight, and I lay her down.
  Direct pressure, before anything else : The guidance is plain: direct pressure applies to any wound bleeding heavily, and it is the simplest and most effective way to stop bleeding. Then lay the casualty down comfortably, on a bed, a sofa, or the floor if there is nothing else, to hold off the collapse that comes with losing blood.
• Mistake : I take my belt off and fit a tourniquet right now: it is bleeding too much.
  You have not even tried pressing : A tourniquet is for when direct pressure fails or cannot be done: that is its definition, and it assumes you tried. A tourniquet cuts off the blood supply to that part of the limb completely, and once it is on it must never be taken off without medical advice. You do not start there.
• Not the best choice : I go through the toolbox: there must be a proper tourniquet somewhere.
  Three size-twelve spanners and a tape measure : You already have what a tourniquet is made of: a strap and a piece of wood. But this is not the moment, and your hand is free.

Scene 3 · The pressure fails

You have been pressing for a minute and the rag has soaked through. The wound runs under the edge of the steel: you cannot reach half its length.

There is a length of webbing from a lashing strap on the workbench, and a piece of batten.

15 is on speakerphone on the floor and is telling you to keep going.

You cannot reach the wound and it is not stopping. What do you do?

• Right move : Pressure is impossible: I fit a tourniquet above the wound, between the wound and the heart.
  This is exactly the case the guidance provides for : If direct pressure on a bleed from a limb fails, because the bleeding carries on regardless, or cannot be done, in particular when the wound is out of reach, then you fit a tourniquet above the wound to stop the bleeding, between the wound and the heart.
• Mistake : I add a third layer of cloth on top and press harder.
  Your hand still is not reaching the wound : Piling on layers makes sense when the pressure is working but is not enough. Here the pressure is IMPOSSIBLE: part of the wound is out of reach, and the guidance names that exact case as an indication for a tourniquet. Pressing next to the wound compresses nothing.
• Mistake : I put the strap below the wound, towards the knee and the foot.
  The blood arrives from above : The tourniquet goes ABOVE the wound, between the wound and the top of the limb, that is to say between the wound and the heart. That is where the blood is coming from. Below it, you are squeezing a section that is receiving nothing any more.

Scene 4 · The tourniquet

The webbing is four centimetres wide and a metre and a half long. The batten is fifteen centimetres.

Her thigh, her knee, her calf. You have to choose where the strap goes, and the guidance has an answer.

Where do you fit it, and with what?

• Right move : The wide webbing, two turns, 5 to 7 centimetres above the wound, on the thigh, never over the knee.
  On muscle, never over a joint : The guidance describes both the kit and the place: a strong strip of fabric, not elastic, 3 to 5 cm wide and at least 1.50 m long, a bar 10 to 20 cm long, two turns around the limb, ideally 5 to 7 centimetres above the wound, between the heart and the wound, and never over a joint.
• Mistake : I put the strap over the knee, it is the narrowest part of the leg.
  Never over a joint : That ban appears twice in the guidance, right next to the description of how to fit one. A joint has none of the muscle bulk that lets you squeeze the vessels shut: you are tightening on bone and tendon, the bleeding carries on, and you wreck a knee as well.
• Mistake : I take some thin electrical wire from the box, it will bite far harder.
  It cuts the skin and stops nothing : The guidance gives dimensions, and not at random: a strong strip of fabric, not elastic, 3 to 5 centimetres wide. A thin cord concentrates all the force on one line, it slices the surface tissue without squeezing the deep vessels. The guidance also rules out elastic tourniquets.

Scene 5 · Tightening

Two turns, a knot, the batten slipped underneath, a second knot over it. You start to twist.

On the third turn she screams. On the fourth, the bleeding stops.

She is screaming and it has stopped bleeding. What do you do?

• Right move : I hold the tension, even though the pain is severe, and I lock the bar off.
  The guidance foresaw this moment, and it foresaw your reaction : Twist the bar so as to tighten the tourniquet until the bleeding stops, then hold the tension yourself, even though the pain it causes is severe, or by any means available if you have to free yourself up. The tourniquet is working if the bleeding has stopped. If it carries on, you tighten it further.
• Mistake : I ease it back half a turn, she is in too much pain and it is not bleeding now.
  It starts again at once : The guidance anticipates this exact move: the rescuer holds the tension even though the pain it causes is severe. And once it is on, a tourniquet must never be taken off without medical advice. The pain of a tourniquet is the price of a limb and a life.
• Mistake : I lay her jacket over the tourniquet, she is shivering and it will cover it up.
  Nobody can see whether it is holding any more : The guidance asks you to leave the tourniquet visible wherever possible. And it adds: if the casualty is covered completely to prevent hypothermia, the tourniquet has to be checked regularly and often. A hidden tourniquet is one the crew will not see when they walk in.

Scene 6 · The wait

The tourniquet is tight, locked, visible. She is lying down, very pale, and she is cold.

The dispatcher says seven minutes. The floor is not staining any more.

Seven minutes, and the bleeding has stopped. What do you do?

• Right move : I cover her but leave the thigh and the tourniquet clear, I talk to her, and I touch nothing else.
  Cover the casualty, not the tourniquet : The two instructions go together: protect the casualty from the cold and warm her if she needs it, and leave the tourniquet visible wherever possible. You also write down the time the tourniquet went on, on the tourniquet or on her, so you can pass it to whoever takes over. You reassure her by talking to her regularly, you watch for signs of things getting worse, and you call back if her condition changes.
• Mistake : It has stopped bleeding: I will loosen it to give her leg back before they get here.
  It comes back at once, and harder : Once the tourniquet is on, it may be loosened only on a doctor's instruction. A tourniquet cuts off the blood supply to that segment of the limb completely: the decision to release a total compression belongs to a team that can deal with what follows. This is not excessive caution: it is the only rule there is.
• Mistake : It looks badly placed to me: I will loosen it and move it a bit higher.
  In between the two, nothing is compressing anything : A tourniquet does not get moved: it may be loosened only on a doctor's instruction. If it is working, meaning the bleeding has stopped, it is in the right place. If it is not, the guidance says to TIGHTEN it further, not to shift it, and if need be to fit a second one between the first and the top of the limb.

Scene 7 · The crew

Four people come in with a board and an orange bag. The first look goes to the thigh, and they see the tourniquet straight away: that is why you leave it visible.

They do not touch it. They put a drip in, they roll her onto the board, and they take her away with the batten still locked off.

You pressed for a minute, tightened a strap, and held a piece of wood for seven minutes. That was the whole thing, and it was the hardest in the game.