American Survival Guide - - TABLE OF CONTENTS - By Joe Al­ton, M.D.

Life-sav­ing ba­sics of hem­or­rhage con­trol

Whether times are good or bad, ev­ery­thing from ev­ery­day ac­ci­dents to mas­sive dis­as­ters can cause in­juries and deaths. Some are nat­u­ral events, such as hur­ri­canes and tor­na­does; oth­ers are man-made, such as ter­ror at­tacks and ac­tive shoot­ers. Re­gard­less of how ca­su­al­ties are caused, it’s clear that many deaths oc­cur due to bleed­ing from trau­matic wounds. It’s even clearer that some deaths might be pre­vented by the quick ac­tion of nearby “Good Samaritans.” In mod­ern times, we have the ben­e­fit of emer­gency med­i­cal per­son­nel and high tech­nol­ogy. These as­sets, how­ever, aren’t al­ways just around the cor­ner. An in­jury caus­ing dam­age to a ma­jor artery can kill a per­son in just a few min­utes. If not treated im­me­di­ately, some vic­tims will be be­yond help by the time pro­fes­sional help ar­rives.

In sur­vival set­tings, the sit­u­a­tion is even worse: There is no am­bu­lance on the way or res­cue he­li­copter on the hori­zon. There might not even be a way to con­tact pro­fes­sion­als to get in­struc­tions for treat­ing an ac­ci­dent vic­tim.


There­fore, in­di­vid­u­als at the scene must act, of­ten with lim­ited sup­plies, if they are to save a life. For some­one who isn’t med­i­cally trained, it’s a ma­jor chal­lenge. Just see­ing a good amount of blood or a limb de­formed from trauma gives the av­er­age per­son pause and some­times in­duces a tem­po­rary men­tal paral­y­sis that could be fa­tal to the vic­tim. De­lay in ren­der­ing care makes bleed­ing con­trol, also called “hemosta­sis,” more dif­fi­cult.

The lack of blood vol­ume caused by trau­matic hem­or­rhage has var­i­ous ef­fects on the body based on the per­cent lost. The hu­man body con­tains 9 to 10 pints of blood. It can tol­er­ate the loss of a rel­a­tively small amount with lit­tle ill ef­fect. For ex­am­ple, you can do­nate a pint of blood—10 to 11 per­cent of your to­tal blood vol­ume—to the Red Cross ev­ery eight weeks.

Once you lose 15 to 30 per­cent of your to­tal blood vol­ume, how­ever, phys­i­cal signs be­come ap­par­ent. The pur­pose of red blood cells is to de­liver oxy­gen to, and re­move car­bon diox­ide from, the tis­sues of the body. When there are fewer of them, the cells must travel faster to pro­vide the same amount of oxy­gen. The heart must beat faster to ac­com­plish this goal, so you’ll no­tice a rise in the pulse rate. The body be­gins to feel a lack of oxy­gen, so the pa­tient breathes faster, as well. Skin be­gins to pale and is cool to the touch, and some ag­i­ta­tion might be noted. If bleed­ing is stopped, re­cov­ery may not re­quire blood trans­fu­sion.

From 30 to about 40 per­cent loss of blood vol­ume, the vic­tim’s abil­ity to com­pen­sate for the loss of red blood cells be­gins to reach max­i­mum ca­pac­ity. The vic­tim’s blood pres­sure be­comes hard to main­tain at nor­mal lev­els and drops, while the heart rate in­creases to the point that it might no longer be ef­fi­cient in pump­ing blood. The pa­tient be­comes con­fused, lethar­gic and might lose con­scious­ness.

Blood trans­fu­sion is usu­ally re­quired at this point. Be­yond 40 per­cent blood loss, the body can no longer com­pen­sate. Blood pres­sure, heart rate and res­pi­ra­tion drop, and death is im­mi­nent with­out ma­jor in­ter­ven­tion.


What can a med­i­cally un­trained in­di­vid­ual do to stop a ma­jor bleed?

For our pur­poses, we’ll as­sume the event that caused the in­jury has passed, and the care­giver is not per­son­ally in dan­ger at the mo­ment. Know­ing the level of dan­ger is im­por­tant, just as your per­sonal safety is your high­est pri­or­ity. If there is an ac­tive threat, you help no one by be­com­ing the next vic­tim.

First aid steps for any in­jury should be­gin with iden­ti­fy­ing your­self and re­as­sur­ing the in­jured per­son that you’re there to help. Just stat­ing who you are and your pur­pose will in­crease the chances the vic­tim will co­op­er­ate with your ef­forts. Ask sim­ple ques­tions such as, “What’s your name?” to get an idea of the level of con­scious­ness and to gauge the abil­ity to fol­low com­mands.

The pa­tient should be placed in the “shock” po­si­tion—that is, ly­ing supine (face up) with the legs el­e­vated above the level of the heart. This might make it more dif­fi­cult for the heart to pump blood out of the body. If the wound is in the chest or ab­domen, how­ever, bend the knees in­stead of rais­ing the legs.

Ex­pose the wound(s) so you can see their full ex­tent, prefer­ably with an EMT shears or a ban­dage scis­sors, which are de­signed to avoid ac­ci­den­tal in­jury. Don’t di­rect the vic­tim


to re­move their own clothes; move­ment could cause ad­di­tional in­jury if there are frac­tures or might cause un­nec­es­sary de­lay in treat­ment if the in­jured party is not fully alert.

Once you’ve cut away cloth­ing and re­moved loose de­bris over the wound, eval­u­ate the in­jury.

Is there an en­try wound from a pro­jec­tile? Is there an exit wound? (Be aware that exit wounds are de­pen­dent on the po­si­tion of the vic­tim at the time of in­jury and not al­ways di­rectly op­po­site the en­try wound.) Is there a large ob­ject em­bed­ded in the wound, such as a knife? Ob­jects stuck in the wound should not be re­moved, be­cause do­ing so might pro­voke more bleed­ing. Don't probe the wound with, say, your fin­ger. Your job is to stop the hem­or­rhage.

If there are gloves avail­able, put them on. Use some kind of bar­rier to try to stop the bleed­ing—

prefer­ably a ster­ile ban­dage—or at least a clean cloth. This will pro­tect both the vic­tim and the care­giver. Press the dress­ing firmly with your palm, one hand over the other, on the bleed­ing wound. Keep your arms straight, ap­ply­ing pres­sure di­rectly over the wound it­self. Many wounds will cease ooz­ing sim­ply with the ap­pli­ca­tion of di­rect pres­sure. In large ex­trem­ity wounds, con­cen­trate your ef­forts clos­est to the torso.

In cir­cum­stances for which di­rect pres­sure fails to stop the hem­or­rhage, your ban­dage will soak through, mak­ing it clear that a more-ag­gres­sive re­sponse is needed. The place­ment of a tourni­quet 2 to 4 inches above the wound (be­tween the wound and the heart) is in­di­cated for ar­te­rial or other life-threat­en­ing hem­or­rhages. Ar­te­rial bleed­ing can be iden­ti­fied by the pres­ence of bright-red blood spurt­ing from the wound.

If you see this or a sig­nif­i­cant pool­ing of blood on the ground, plac­ing a tourni­quet should be the first course of ac­tion. Al­though tight­en­ing a belt or ban­danna around a bleed­ing ex­trem­ity might suf­fice, com­mer­cial tourni­quets such as the CAT


(Com­bat Ap­pli­ca­tion Tourni­quet) and SOFT-T (Spe­cial Op­er­a­tions Forces Tac­ti­cal Tourni­quet), among oth­ers, are likely to be more ef­fec­tive.


An open wound should be packed tightly with dress­ings. In the April 2017 is­sue of the Jour­nal of Emer­gency Med­i­cal Ser­vices (JEMS), Dr. Peter Tail­lac and EMT-P as­so­ciates Scotty Bol­leter and A.J. Height­man put forth their rec­om­men­da­tions for the pack­ing of hem­or­rhagic wounds with plain and/or spe­cial blood-clot­ting gauze such as Quik­clot, Celox and oth­ers. The Amer­i­can Col­lege of Sur­geons (of which I am a re­tired fel­low) found these spe­cial­ized “hemo­static” ban­dages to be ef­fec­tive in 90 per­cent of cases.

If you’re us­ing reg­u­lar ban­dages and need to place more to achieve hemosta­sis, don’t re­move the old ones; sim­ply pack the added ban­dages firmly on top. With blood-clot­ting gauze, how­ever, old gauze should be re­moved so you can see where the bleed­ing ves­sel is. The hemo­static dress­ing should be packed di­rectly where the bleed­ing orig­i­nates.

Pack­ing of wounds is use­ful in many sit­u­a­tions, but not all. Wounds of the neck are prob­lem­atic, for in­stance, due to the risk of com­press­ing air­ways and af­fect­ing the pa­tient’s abil­ity to breathe. Pack­ing in­juries in the ab­domen, pelvis and chest might not be ef­fec­tive due to the deep na­ture of the bleed­ing ves­sels. This is one rea­son that in an off-grid set­ting, the death rate (called “mor­tal­ity”) from these wounds is so high. For ex­am­ple, sta­tis­tics from the Civil War put mor­tal­ity rates for ma­jor in­juries in these re­gions at close to 70 per­cent—a fig­ure that might also be ex­pected in long-term sur­vival sce­nar­ios.

Ac­cord­ing to Dr. Tail­lac’s team, proper pack­ing of wounds with plain or hemo­static gauze should in­clude the fol­low­ing steps:

Quickly and ag­gres­sively ap­ply di­rect pres­sure with a gloved hand, a clean dress­ing or cloth—or even the knee or el­bow—while break­ing out your sup­plies.


Find the ex­act source of the bleed­ing. Tightly (and I mean, tightly) pack the wound cav­ity as deeply as you can while con­tin­u­ing to ap­ply pres­sure di­rectly on the bleed­ing ves­sel. Al­though hemo­static gauze is best, suf­fi­cient pres­sure with plain gauze might be enough in some cases.

Uti­liz­ing the pres­ence of nearby bones to pack against might be use­ful in cer­tain wounds. If there is a knife em­bed­ded in the wound, keep it in place and pack around it as best you can un­til you can get the vic­tim to a more-con­trolled set­ting.

Main­tain pres­sure on the packed wound for at least three min­utes and see if the bleed­ing has abated. If you’re suc­cess­ful in stop­ping the hem­or­rhage, cover the wound se­curely with a pres­sure dress­ing such as the Emer­gency Ban­dage (also called the Is­raeli Bat­tle Dress­ing), OLAES Ban­dage or an­other brand. These are de­signed specif­i­cally to keep pres­sure on the in­jury and con­trol bleed­ing if placed cor­rectly.

At one point or an­other, the vic­tim should be trans­ported to where fur­ther care can be pro­vided, whether it’s a hos­pi­tal or, in a sur­vival sce­nario, wher­ever the bulk of your med­i­cal sup­plies is. Keep in mind that the jostling that might oc­cur dur­ing this process could cause bleed­ing to re-start. Splint­ing the wound will im­mo­bi­lize it and help decrease move­ment that could dis­turb your pack­ing or tourni­quet place­ment. Com­mer­cial splints such as the Struc­tural Alu­minum Mal­leable (SAM) can be bent or cut into shape to con­form to the in­jured ex­trem­ity.


A com­mon is­sue that oc­curs in ma­jor hem­or­rhages is the loss of body heat. Keep­ing a per­son warm is dif­fi­cult when they are ly­ing on the cold ground, so a bar­rier of some sort be­tween the ca­su­alty and the ground will help. A My­lar or other blan­ket should be used to cover the per­son, as well.

Cov­er­ing the vic­tim of a bleed­ing wound to main­tain warmth does not mean your vig­i­lance is no longer nec­es­sary. It’s im­per­a­tive to fre­quently re­assess the wound. Don't re­move the gauze or ban­dage, how­ever, un­less blood is ob­vi­ously seeping through.

Of course, hav­ing a med­i­cal kit con­tain­ing the es­sen­tial items (listed in the side­bar above) makes this process much eas­ier. How­ever, sim­ply hav­ing med­i­cal sup­plies is not enough. You should prac­tice, for ex­am­ple, us­ing the tourni­quet in your kit so you are pro­fi­cient in its use.

I’ll ad­mit that the like­li­hood you’ll have to save the life of some­one bleed­ing to death to­mor­row, next week or next month might be small. Nev­er­the­less, over the course of a life­time in these un­cer­tain times, hav­ing the knowl­edge and sup­plies to stop bleed­ing makes sense.

Add in your chil­dren’s life­times, and I think you’ll agree it’s time we in­still a cul­ture of med­i­cal pre­pared­ness in our cit­i­zens. If a dis­as­ter leaves us with­out mod­ern med­i­cal care, have no doubt: Lives will be saved.



Re­mov­ing a knife em­bed­ded in the body could worsen bleed­ing, so leave it in place un­til pro­fes­sional treat­ment can be ac­cessed.

Any in­jury that re­sults in sig­nif­i­cant blood loss should be treated as quickly as pos­si­ble to en­sure the best chance for a full re­cov­ery.

h Rapid ac­tion by those at the scene might have saved lives in this car ac­ci­dent.

h Above: In longterm sur­vival sce­nar­ios, don’t ex­pect to see this on the hori­zon.

i Top: By­standers must act quickly when some­one re­ceives a sig­nif­i­cant bleed­ing in­jury. In other words, they should not con­tinue to sim­ply stand by. i Near right: Tightly pack dress­ings di­rectly on the bleed­ing blood ves­sel to get it to stop bleed­ing.

Vic­tims of hem­or­rhagic wounds lose vi­tal body heat and should be kept warm dur­ing and after their in­juries are be­ing treated.

i Near and far right: The time the tourni­quet is ap­plied to the wound site should be doc­u­mented.

i Far right: By it­self, di­rect pres­sure might be able stop bleed­ing in some wounds. (Note that pres­sure is ap­plied with the palm—not the fin­gers or heel of the hand.)

i EMT shears are de­signed to al­low ex­po­sure of a wound with­out cut­ting the vic­tim.

h Near left: If not treated, ar­te­rial bleed­ing can kill in min­utes, mak­ing it es­sen­tial to in­clude tourni­quets in your kit.

h Far left: A woman re­ceives first aid from a by­stander after be­ing hit by a car. (Photo: Paul J. Richards/afp/getty Im­ages)

It is im­per­a­tive that ev­ery­one in your group trains to learn the proper use of tourni­quets and other med­i­cal sup­plies.

h Near left: U.S. sol­diers from the 10th Moun­tain Di­vi­sion prac­tice first aid tech­niques at the for­ward op­er­at­ing base in Ghazni, Afghanistan, in 2013. (Photo: Getty Im­ages)

h Far left: In sur­vival sit­u­a­tions, a ded­i­cated hos­pi­tal tent should be es­tab­lished, if pos­si­ble. The larger your group is, the more im­por­tant this fa­cil­ity is.

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