Author’s note: This is the fourth diary in a new series that I will post monthly, on medical topics related to emergency care. If you want to check out the first diary in the series, you can find it HERE, on the topic of “insider tips to improve your visit to the ER”. Some of these diaries will focus on the medical system or process, and some will be disease-specific. My goal , as your friendly neighborhood ER doc to the Daily Kos community, is to provide useful information for this community to stay healthy and get the best results from our medical system. I hope you find it helpful!
The scenario: 2 AM shooting dropped off by the ambulance
I’m on shift in the ER, seeing the usual array of patients — an elderly woman with abdominal pain, a young man who is waaay too drunk, a middle-aged man with chest pain. And then: the dreaded overhead call: “emergency room, emergency room. This is medic command. EMS bringing a young male GSW, vital signs unstable, ETA 5 minutes”. All of us drop whatever we are doing, quickly apologize to patients to whom we are talking, and briskly move to the resuscitation “bay”, a large room where we perform medical and trauma resuscitations. As the “attending physician” on duty (i.e., the supervising doctor) — I make sure that people are assigned to key roles (airway, monitor, IV access, primary survey) and that everyone is gowned and wearing facemasks. Suddenly, the EMS crew bursts through the door with a sweaty half-conscious young man, jeans soaked with blood. We get to work.
Gun violence and mass shootings
The shooting at Chabad synagogue in California was very close to home. I’m Jewish, and my kids go to Chabad Hebrew School where I live in Pennsylvania. So I decided to scrap the topic I was going to cover today, and instead share some insights into what can be done in the field, by the public, if someone is shot. Now, first some disclosures: I approach this topic with mixed feelings, because I really truly believe that prevention is the key here, not treatment. I can’t understand why we allow the 2nd amendment to overwhelm people’s safety and right to free assembly, and can’t understand why military-style high power weapons are legal (for useful data and charts on the U.S. gun violence issue, here is an evidence-based article for you). I also don’t want people to get the wrong sense that empowering the public with lifesaving skills is the panacea. Most people who get shot in the head or the chest will live or die regardless of what is done by the public in the first few minutes (and, alas, most will die). However — the vast majority of deaths from gun violence are from hemorrhage, and in a fraction of these (estimated at 10-20%), the primary injury is to a major blood vessel of a limb or abdomen where layperson interventions could limit bleeding and potentially save a life.
I hope you never ever are witness to a shooting. But if you ARE — here are some key things you need to know. If you want to know more about these items, there is an important new program from the American College of Surgeons known as the “Stop the Bleed” campaign — you can find out more on the Stop the Bleed website.
1. Your safety is first.
The interventions I will describe in this diary are not applicable if the environment is unsafe. What does this mean? Do not allow yourself to become a second victim if you can avoid it. EMS providers (and trauma receiving centers) want as few victims as possible, so if you are in a situation where a shooter is present, get out. Only when the environment is safe, should you attempt bleeding control on victims. This may sound harsh, or selfish, but the fewer victims, the more chance of concentrating efforts and saving those who are hurt.
2. Time is of the essence.
The next most important thing to recognize is that elapsed time is the enemy after a shooting takes place. Of course, calling 911 should be performed as soon as possible and the response from EMS (emergency medical services) should be prompt. What is also important is the elapsed time to a tourniquet, or direct pressure, or wound packing (the three key elements of bleeding control, described below). Time is so important, in fact, that it has been shown that direct police transport of shooting victims, if it can be done before ambulances arrive (usually police are first on scene), can save lives even though the police aren’t medical providers (see reference here). What can you do? Recognize that time is crucial. Don’t assume someone else called 911 — do it yourself. And if the scenario is safe, rapidly move to identify bleeding and doing your best to stop it.
3. Understanding blood vessels.
There are two basic kinds of blood vessels: arteries and veins. Arteries are the ones that matter in gun violence — they are high pressure muscular vessels that, when punctured, bleed briskly and are sometimes difficult to compress. Think about a garden hose that gets punctured in your back yard, spraying everywhere. Veins, on the other hand, are low pressure blood vessels that bleed much more slowly and are easy to compress. So the problem is therefore when a bullet punctures an artery. Especially a big artery like the radial artery (in the forearm) or the femoral artery (in the thigh). A limb arterial puncture is probably the most important type of injury for the Stop the Bleed campaign, and the interventions described below. Limb arterial injuries bleed like crazy, but a few simple moves could greatly slow the bleeding and improve the chance of survival.
4. Direct pressure and elevation.
This is the most important and straightforward maneuver — putting your hands (ideally, your palms) over the bleeding location with some form of padding (gauze from a first aid kit is ideal, of course, but a t shirt or towel can work as well) and pushing down, HARD. This is not a time to be gentle — a person who is shot will be in tremendous pain, and pushing hard on a wound will hurt more. Easier said then done, but tune out the victim and don’t be gentle. In many cases of bleed vessels, direct pressure can slow the bleeding quite a bit, and buy precious minutes for trained personnel to arrive and take over.
Another key part of this direct pressure approach is elevation. When possible, lift the limb above the victim’s body (in most cases, the victim will be lying on the ground, so propping up a leg or arm on a chair, or a stack of books, or a backpack is what I mean by this). This will somewhat lower the pressure in the affected vessel and also slow bleeding. Direct pressure is the more important of the two moves, which is why I list it first — but doing both together is important when feasible.
5. Use of a tourniquet.
Used arguably as early as the time of the Roman empire, tourniquets are bands that can be fastened or tied snugly around a limb to cut off / reduce blood supply to that limb and therefore limit bleeding from a downstream injury (known in the business as a “distal” injury — upstream is “proximal”, downstream is “distal” in medical terminology).
If a first aid kit (or ideally a Stop the Bleed kit from the American College of Surgeons) is available, it should contain a tourniquet for use. Without such a kit, a belt or necktie is another option. Anything on hand that can be tightly wound around a limb, at least for the minutes before EMS arrival, may be helpful. Tourniquets do require a bit of practice, so I strongly encourage you to interface with the Stop the Bleed campaign — you can organize a class for your school, workplace, or community group for example.
Could a tourniquet cause injury by cutting off blood supply? Definitely. On the other hand, could I save a life from a bleeding arterial injury? I have seen this with my own two eyes, and the scientific evidence also points to a resounding “yes”. I think the important thing is that a layperson’s tourniquet very likely won’t be on very long, minutes at the most — so I believe this is a classic instance of “don’t let perfect be the enemy of the good”. But if a tourniquet isn’t immediately available, don’t waste time searching for one or fashioning one — apply direct pressure and call for help.
6. Packing with hemostatic gauze.
Many Trauma kits for public installation, including the Stop the Bleed kits, contain special gauze packs that are impregnated with compounds that promote blood clotting. If you have such a kit, pushing this gauze into the injury site (known as “packing” a wound) can be an important addition to the maneuvers described above. However, it is important to have some training before you consider this move, for a number of reasons. I include it here for the sake of completeness. If your workplace or school has such a kit available, it would be good to become familiar with it and learn more about wound packing as an option.
Some closing thoughts on trauma care for gun violence
I have been an ER/trauma doc for 15 years, and have seen plenty of gun violence victims. Many have lived, some have died. I have told parents about their newly dead children, and spoken to police about the horrific scenes they witnessed. When I travel to other countries and interact with emergency physicians, which I do often, they are bewildered and amazed by what they hear about the U.S. experience. In Korea and Singapore, two countries I have visited often for my scholarly work, there are essentially no guns and almost no gun fatalities. So clearly the answer is NOT “Stop the Bleed” campaigns and trauma kits. Do I know what the answer is? Well, for one thing — we need to allow research into gun violence. There is currently essentially a “gag order” on the NIH and CDC that prevents research funding for gun violence topics, which is just plain awful. How can we find the answers if we can’t study it?
Here are some sites and resources that you might find helpful about gun trauma and hemorrhage care:
Dept of Homeland Security site for Bleeding education
Centers for Disease Control Statistics site for gun violence
CDC Injury Center website
I hope you have found this discussion helpful — and I will stick around to answer any medical questions you have about trauma, gun injuries or hemorrhage. I kindly encourage you not to start a pie fight about gun rights on this thread; it is not my intention or expertise to discuss gun policy. My personal opinion is we need to curtail gun rights substantially and get more guns off the streets, but I know some in our community may respectfully disagree with this opinion. Let’s talk medicine, and leave policy for another opportunity.