An adult can bleed to death in less than five minutes from a severe wound. Bystander intervention is critical to survival, but many people are afraid to help in the moment. On this anniversary of the 9/11 attacks, Dr. Jack Sava discusses the Stop the Bleed campaign, a national movement to teach people simple steps to save lives.
TRANSCRIPT
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: Thanks for joining us today. We're talking to Dr. Jack Sava, Chief of Trauma at MedStar Washington Hospital Center. Welcome, Dr. Sava.
Dr. Sava: Well, thank you.
Host: So, today we're talking about the Stop The Bleed campaign, a national effort to encourage bystanders to become trained and empowered to help in a bleeding emergency before professional help arrives. Dr. Sava, why is it so important that bystanders know what to do if they see someone bleeding?
Dr. Sava: Well, I think that the Stop The Bleed campaign has become important in a couple different ways. This campaign grew out of a tragedy, a mass shooting, and so the original idea of the Stop The Bleed campaign is that first responders, specifically police officers, should be able to stop bleeding with direct pressure and a few other means. But, quickly everybody realized that this doesn't just apply to a police officer in a mass shooting. It applies to all of our lives. We've all become accustomed to the idea that if we're on a subway platform and somebody has a cardiac arrest, that it would be great if we knew how to do CPR and save their life. So, the fact that everybody now is getting on board with doing CPR, but many people don't understand the very basics of how to stop bleeding, is a bit of a mismatch. And I think that's part of the impetus for the Stop The Bleed campaign is to bring the care of bleeding patients up to what we're trying to achieve with the care of patients who have had a cardiac event.
Host: What's the danger if somebody is bleeding--how fast can that person die from blood loss?
Dr. Sava: Well, people can die in seconds or they can die in hours, and some of the people who die in seconds are not going to be saved by pressure on the subway platform, and maybe, you know, some of the other people have time to get to the hospital, but what we're after is this big middle ground of people who have severe bleeding and what happens in the first hour is going to make a difference between them living and dying. I've seen over the years footage, as we all do nowadays, of people who have been bleeding from an arm or a leg, and have been in a crowd of people who didn't know what to do, and you can watch these people bleed to death. And it's a very moving experience for anybody, but for a trauma surgeon it's torture to watch people who are well intentioned, but don't understand that if they did one or two simple things, they could save that person. It's very hard to watch, and we see this play out in people who come in who probably had an opportunity to have somebody stop the bleeding before arrival in the hospital.
Host: I think as a population people are just almost trained to panic when they see blood, you know, worrying about their own safety. What are the precautions that an individual might be thinking about or what's going through their mind when they're watching this individual bleeding?
Dr. Sava: Well, I think that's a great point. I think we've all gotten messages about what matters over the years, and people, even at their best, might have a hard time balancing those different things about priorities, about what matters, and when they're under a lot of stress, they're not going to be thinking that clearly. So, what do I mean by what matters? Well, first of all, infection matters. In a very general sense, I think we all think that wounds have to be treated with sterile stuff, with certain types of gauze and medical equipment, other than that there's going to be an infection. So, first of all, one of the important things that we need to train people is if you're about to bleed to death, infection doesn't matter at all. It literally should be the furthest thing from your mind. Another thing that matters is pain. So, if I tell you, and we don't often talk about this, but if you see, uh, somebody with a big wound on their arm, the last thing, as an empathetic human being, that you're going to be inclined to do is to press on it. We're trying to say that as if it's common sense, but it's actually very counterintuitive to press on a wound. It seems cruel, but that requires, some, uh, some discipline, some, you know, some training, maybe some mental preparation because it can be hard to do. I think that's something that we in the medical profession get good at. We're used to thinking of pressing on a wound as a nice thing to do for somebody, even if it's uncomfortable for them. We, you know, we feel good about that, but I think to the bystander, that connection might not have been made, and so now you picture somebody--well, what if it's your child? Many of us have been through situations like giving a child medicine where you have to hold them down, and you all know that sometimes in a marriage there is one partner who can do that because they feel like they're doing something good, even though it's unpleasant, but some people just can't torture their own child that way, so that's something that is not so much a fact that they need to learn, but something they need to mentally rehearse, and they need to really embrace the idea that this has to happen, despite the fact that it could lead to an infection weeks later that could easily be treated with antibiotics, but also despite the fact that it might be very painful. Now, in the military, you know, they have protocols. In many cases, if somebody has a gunshot wound to the leg, the medic might be kneeling on it or standing on it. I mean, those are things again that are not in our normal course of activities.
Host: I can only imagine what that would feel like - you come up on somebody and they're already in pain, and putting additional pain on them - it's the right thing to do. So, if I were walking through a subway, for example, and I see an individual bleeding out of their arm or leg, walk me through what I should do for that individual.
Dr. Sava: Well, the first thing to do, the immediate response, should be to press on it hard and to press on it with whatever you can find. One of the things that I see is that people like to use a lot of cloth, for lack of a better word--a lot of gauze, a lot of, you know, giant shirts and so forth, and what that can tend to do is spread out the force well beyond where it's needed and diminish the actual pressure at the right, at the point where it's needed, so you need to, uh, get an idea of where the actual cut is, and obviously, if somebody had a whole pant leg soaked in blood, it's very easy to be very wrong about that, so in some cases it means cutting off a piece of clothing or removing clothing, or if other people have sort of layered on dressings and cloth all over the place, you've got to kind of figure out where the actual wound is if you're going to successfully manage it with pressure. So, first step is to apply pressure. Now, in many cases that stops the bleeding. Now, I think that usually a person pushing on a wound does a better job than a dressing. My advice would be, if you're pressing on something and it stops the bleeding, don't be in a hurry to try to turn that into a bandage that's wrapped. Just take a moment and be happy with your success, and keep your hand on there until help arrives.
Host: Dr. Sava, what should a person do if that direct pressure doesn't stop a person's bleeding?
Dr. Sava: If the direct pressure doesn't stop the bleeding, another alternative that you may have available to you is to use what we call a hemostatic dressing. That means a dressing that's built to stop bleeding. So, nowadays over the last 10 years we've developed gauze dressings that are coated with special substances that stop bleeding, and so if you have those, those can be very effective to put on or into the wound, and then reapply the direct pressure. Now, if those things don't work, on an arm or a leg, the next step is a tourniquet. Tourniquets have been around for a long time. There are commercially available tourniquets, and one of the missions of the Stop The Bleed campaign is to try to make these very readily available. Just like there's defibrillators now everywhere, we want there to be tourniquets, you know, in glass cases at every school and everybody's glove compartment, and so forth. The key thing about a tourniquet is it has to be above or upstream of where the wound is, so if you have a wound on your thigh and you put a tourniquet on your knee or on your calf, then that's obviously not going to help. So, tourniquets are very effective when there's room to get them between the wound and the torso.
Host: So, the goal of the tourniquet--could you explain a little bit about that?
Dr. Sava: What the tourniquet does is it stops all blood flow to the arm or to the leg. And you might think, oh, that sounds bad to not have any blood flow to your arm or your leg, and actually, yeah, if you had no blood flow to your arm or to your leg for 8 or 10 hours, that would be a problem for that arm or leg. And that gets us back to the question of pain because putting a tourniquet on effectively is not comfortable, so you have to kind of push through that. And basically, you have to tighten that tourniquet until it stops the blood flow, so there's a good kind of feedback about whether or not your tourniquet is working because the wound should stop bleeding. It's very simple and satisfying physics. We see patients very frequently now who have probably had their lives saved by tourniquets. And it's interesting because tourniquets were not as commonly used 15 years ago, so really one of the major lessons of the war and the conflicts recently has been that tourniquets really are lifesaving and it really is OK to have them on for a reasonable period of time. So, thankfully, we're now, over the last 5 or 10 years, seeing the emergency medical services providers putting on tourniquets in the field, and it's even trickling down to citizens, so we're seeing workplace accidents where somebody at the job site has applied a tourniquet, and people are coming in awake and alert and surviving, whereas before that they would have come in soaked in blood and perhaps dying.
Host: It seems so antiquated to, you know, to be a newer technology, you know, like people have done this for centuries. And how did it fall out of practice?
Dr. Sava: Yeah, it's interesting. There's a lot of things that are cyclical like that, but the reason it fell out of practice was the concern for having no blood flow to a limb for a period of time, so, you know, there were a number of cases where there were consequences because they were left on too long. And the fact is also sometimes you might put a tourniquet on and it might turn out not to be necessary, and so between some of them not being necessary and some of them being left on too long, there was a period of time where people became anti-tourniquet, but the war changed all that.
Host: How are you and your team here at MedStar Washington Hospital Center working to promote the Stop The Bleed campaign or these initiatives, globally or nationally?
Dr. Sava: Well, the Stop The Bleed campaign is great because it's organized into some very simple messages, um, what we're trying to teach. And so now there's a course of materials, there's a simulation mannequin leg that we use to teach the skills, and there's ... it's all been put together into a product or course that we can teach very quickly, in an hour or two of time, so we are now going out into the community, um, to teach this course to all types of people. I'm teaching it to my kids' school this fall, which has raised the interesting discussion of how young can you be to learn these skills. Now, my kids were … I was yelling at my kids about bleeding management probably from the age of 4 maybe? I mean, they ... I used to get a cut on my finger, and I am not, of course, very freaked out by minor cuts, so I would just let it bleed and call my kids and then say 'this is going to bleed until you stop it,' and then my wife would tell me that's inappropriate. So, but anyway, for the school kids, I think the country is trying to decide what age is appropriate. Now, first aid skills and CPR go down into middle school and beyond sometimes, but this is, you know, a little more scary, and so everyone's trying to decide that.
Host: So, if I want this training for myself, how would I contact you or what are the resources available?
Dr. Sava: You can google Stop The Bleed and you can find courses through the website. You can also contact any local trauma center will likely be teaching the course. This has become a big push on the part of the trauma surgeons of the country, so most trauma folks either are putting on courses or know about them.
Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.
