Your Red Bags: Stop The Bleed – Part 1, by Philip J. Goscienski, M.D.

When the shooting stops but the bleeding doesn’t, are you really prepared?

Approximately 40,000 Americans die every year from injuries that result in severe bleeding, a condition that can drain life away in as little as four minutes. The massacre at Sandy Hook, Connecticut on December 14th, 2012, was a tipping point. In that dreadful event twenty students, all only six or seven years old, and six staff members were gunned down by Adam Lanza, who had earlier murdered his mother and subsequently took his own life. Shortly thereafter members of the American College of Surgeons, the Department of Defense, the FBI, and other experts convened in Hartford, Connecticut and formed the Hartford Consensus. And so Stop the Bleed was born.

Hemorrhage is a major factor in trauma-related deaths and Emergency Medical Services are almost never available in a timely manner. Experience on the battlefields of the Middle East as well as civilian catastrophes convinced the leaders of the Stop the Bleed program that there were immediate steps that could be taken to stem bleeding and that these measures were simple enough for civilians to learn and to apply effectively. The result is that Stop the Bleed has become the most rapidly-deployed lifesaving public health measure in the history of medicine.

Mass shootings garner massive headlines and deservedly so but most of us will never encounter such an injury. Most deaths from hemorrhage result from accidents in the workplace and the nation’s roadways. In fact, the life that you are most likely to save is your own or that of someone you love. The home can be a deadly place. An errant kitchen knife, a whirring circular saw blade, or a fall into a glass patio door or a window are among the most common causes of life-threatening bleeding. Further, because such an event can occur at a distance from a medical facility or in a TEOTWAWKI situation where a firearm injury is quite possible, it’s even more imperative to master the skills described here.

One of the earliest discussions at regarding this matter came in a post by Hugh James Latimer on May 25th, 2017. Several other writers have contributed to this topic. What follows is a description of the Stop the Bleed program, the skills involved, pitfalls in their execution, what materials are needed to prevent severe blood loss and where to find them. I have also described the Red Bag, designed for likely targets of deranged or ideologically driven individuals: houses of worship, schools, and business establishments where multiple injuries have occurred in recent

Stop the Bleed: basic elements

Emergency responders ensure that a victim must be “trauma naked”: you can’t manage a wound that you can’t see. Cut or tear away clothing that might obscure the source of bleeding. When a life is in the balance modesty takes a back seat. In a firearm injury, always assume that there is an exit wound as well as an entry wound. The exit wound is almost always larger and bleeds more severely but both entry and exit wounds might have to be managed simultaneously. Take the time to examine both the front and the back of each extremity as well as the back and front of the chest and abdomen.

Putting on gloves to prevent your becoming infected wastes precious seconds and the risk of acquiring HIV or hepatitis is vanishingly small, especially if your own skin is intact. Don’t worry about causing an infection if your hands aren’t clean. Contamination with dangerous germs is possible but antibiotics are available later if they are present. When a knife or bullet penetrates clothing and skin it carries bacteria into the wound so any attempt at preventing contamination is pointless.

It is not unusual for a stabbing victim to still have the knife handle protruding from the body. DON’T PULL IT OUT! It may be preventing more bleeding.

The basics: pressure, packing, and tourniquets.

Pressure. Compressing the tissues above and around the damaged vessel will often stop bleeding. Your bare hands may be all you have in the first few seconds. A couple of paper towels might be handy but a cloth object is better. If you use a towel or an article of clothing, place only enough of it against the wound so that you don’t obscure bleeding that might be continuing. Press with both hands – hard! If the bleeding stops don’t let go until the emergency responders arrive. Specifically, resist the temptation to see if the bleeding has stopped! Expect to apply continuous pressure for at least 15 minutes. If the bleeding has not stopped because of your pressure, you will be able to see it. That’s one more reason to use only as much fabric as necessary between the wound and your hands. If the fabric becomes saturated, place more on top, and keep the pressure on. Do NOT remove the first dressing or fabric. If bleeding continues, move on to the next step.

In case of a head injury, if the skull bone beneath the wound is broken, intense pressure is not only not necessary but it may push a bone fragment into the brain. Scalp wounds bleed a lot but they are not life-threatening.

Packing. The best material is rolled gauze, which should be in your first aid kit, or hemostatic gauze if it is available. This verbal description will have to suffice but you can find numerous videos online that describe it. While holding the roll of gauze in one hand use the index finger of the other hand to pack the gauze into the wound to its depth, maintaining pressure with your fingertip toward the heart. That’s where the bleeding is coming from.

Use as much gauze as it takes to fill the wound cavity. When it’s full, press what remains against the surface of the wound and press hard. The gauze mesh will help the blood to clot and for bleeding to stop but it might not. Continue to apply firm pressure until help arrives.

Note that you can’t pack an abdominal or chest wound but you can still apply pressure on the outside. These injuries require surgical intervention. A bullet or knife blade that penetrates the lung can lead to an accumulation of air under pressure, a tension pneumothorax. That complication is beyond this discussion but it does not develop instantaneously. In the several minutes before professional responders arrive you should cover a chest wound. A specifically designed chest seal is preferred but a makeshift seal to cover the wound(s) will do until the professionals arrive.


“The tourniquet should no longer be the last choice for hemorrhage control – it should be the first choice.” Peter T. Pons, M.D., from: Stop the Bleed: 8 pitfalls to avoid in hemorrhage control, September 8, 2017, Trauma System News

There is a good deal of false lore regarding tourniquets. Until we sent our military forces to the Middle East, using a tourniquet was considered an extreme measure because of the fear that it might lead to gangrene or loss of the limb. Battlefield experience has shown that a well-designed and properly placed tourniquet can be safely left in place for two hours or even longer without causing long-term damage.

Every American soldier now goes into battle carrying at least one tourniquet. Some tactical uniforms have built-in tourniquets and some combatants go onto the field with one loosely in place on each arm and leg. If bleeding and tissue damage are severe consider using a tourniquet immediately instead of using pressure or packing. It is no longer a last resort but there are some caveats.

There are several types of tourniquets on the market but they share some common features such as proper width (at least one inch) and a windlass, a metal (preferably) or plastic pencil-shaped rod that is used to tighten the band. At maximum tightness, the windless is held in place with a C-shaped clasp.

Place the band about two inches above the bleeding wound and tighten it with the windlass until bleeding stops. This can cause extreme pain and it’s not unusual for the victim to beg for it to be released, but to cave in makes it more likely that the victim will die.

Tourniquet tips

When placing it on the extremity be sure to have the windlass facing you so that you can turn it easily and lock it in place. Never place the tourniquet over a joint. It just won’t work because the artery cannot be compressed if it is surrounded by bone. The arterial supply to the foot and ankle may lie between the two long bones of the lower leg where it might not be compressed by a tourniquet. Place the tourniquet above the knee.

If bleeding continues, place a second tourniquet above the first (closer to the heart) and apply it the same way. (Yes, the second one will hurt too.)

Bleeding from the large limb of an obese or muscular victim is more likely to require a second tourniquet.

Applying a tourniquet is not as easy as it looks. After all, those folks demonstrating it on YouTube have had lots of practice. Persons who have never placed a tourniquet almost never do it effectively the first time. Even with training, in a true emergency you will be fumble-fingered and slow.

Our fighting men are trained to place a tourniquet on themselves using one hand and many have done so in actual combat. To apply it swiftly and well actually takes four hands, two to apply pressure to the still-bleeding wound and two more to get the tourniquet in place.

Improvised tourniquets. You have probably heard of someone’s life being saved when a rope, wire, or electrical cord stopped the bleeding if a regular tourniquet was not available. What you probably did not hear was that the victim – thankfully still alive – now has a nerve injury as a consequence. In a dire emergency, use what’s available, but a better choice is something wider such as a necktie, a scarf, a sleeve cut from a shirt, a strip of bedsheet, a section of a woman’s skirt, etc. A leather belt might work but there’s no way to keep it tightly in place when you let go. If you use an improvised tourniquet you can also improvise a windlass using a sturdy rod-like item at least as big as a ballpoint pen. Expect that it might break – again referring to the oft-quoted “two is one and one is none” principle.

(To be concluded tomorrow with details on packing your Stop The Bleed bag, in Part 2.)