Some years ago, while working for an air ambulance, me and an experienced paramedic responded to a pedestrian-vs-car accident. A young female was out driving when she had a flat tire. As she opened the rear compartment to get the spare tire, a second car slammed in. Our patient was wedged between the cars.
On our arrival we saw that our patient had suffered horrendous lower leg injury with bilateral open fractures and massive tissue injury. I noted some pools of blood on the scoop stretcher and some bloody gauze over her legs, but there was no visible active bleeding. The patient was a bit pale but seemed alert and was talking. While her injuries were severe, the scene didn’t seem too desperate to me. Slow and steady wins the race.
As I went to assess the patient I became a lot more concerned. She was indeed pale but also diaphoretic. While she was talking, she was confused and not making sense at all. Her pulse frequency was 160bpm. Radial pulses were absent. Her carotid pulse was thready and barely palpable. She was was bleeding to death.
As I looked up to brief the paramedic about the urgency I saw that he, without saying anything, as the very first thing he did on our arrival, had already applied two tourniquets.
This case annoyed me.
I had failed to recognise how the patient was bleeding out, right in front of me, while the paramedic instantly knew what our top priority and immediate action should be.
We are constantly discussing TXA, prehospital blood transfusions, tourniquets, pressure points, Reboa and what not.
None of which is going to help us much if we don’t actually recognise lethal bleeding when it is right there staring at us.
We tend to underestimate bleeding
We tend to think of major haemorrhage as glorious, arterial, pulsating, gushing fountains of blood. But obviously, unless we work as combat medics, we rarely see this type of bleeding in the field or ED.
Most of these patients will have bled out and died long before EMS gets to them. Long before we see them in ED.
Lethal bleeding in my context is more likely to be a quiet affair. It is the slow and insidious stealth haemorrhaging from thousands of microscopic vessels. It is the slowly growing red splotches on the bandages that eventually leaks and hides under the ambulance blankets or seeps into the ground.