May 31, 2023
Our main question is how to differentiate between going to the DLS Link for Bleeding Control vs. going straight to a tourniquet with the link for “Severe limb injury with catastrophic hemorrhage evident.” Also, does the Academy have a specific definition for catastrophic hemorrhage?
Emergency Communications Williamson County, Texas (USA)
The meaning of the term “Catastrophic hemorrhage” in the MPDS® is necessarily subjective and how it may be described will vary among callers. The constant is that most people understand the general meaning of “catastrophic,” which is why it was chosen. Most of the time we have found it to be obvious, either at the initial description, i.e., “The machine nearly tore his leg off and the blood is pouring out of him!” or during direct pressure attempts when the caller adamantly complains that “It’s not working,” and the blood continues to flow or spurt heavily. The neck bleeding cases are even more rare, but both I have heard were quite obvious. One was a young lady who attempted suicide by slashing her throat, and the other was a post-op patient with sudden and severe bleeding following vascular neck surgery. Interestingly, this patient and family were instructed on how to control neck bleeding if this complication occurred, and the instructions they were given by the surgeon inspired the new revised instructions in the MPDS. You will note that the tourniquet and direct pressure instructions are linked so if there is any doubt, start with direct pressure and use the Protocol T link, if necessary. Or, if catastrophic bleeding is evident from the beginning, note the DLS Link option to apply pressure while a tourniquet is retrieved or constructed. And if uncontrolled and catastrophic hemorrhage from the neck is discovered, these instructions are immediately available within the direct pressure sequence. Fortunately, we now know that the application of a tourniquet to a limb is not as clinically problematic as it was once thought to be, and tourniquet use is being promoted internationally. The take-home from this is trust your judgment as an EMD, respect the fact that this decision is subjective as an ED-Q and give EMDs the benefit of the doubt, and don’t delay direct pressure instructions prior to the readiness of a tourniquet.
Hope this helps.
Brett A. Patterson
Chair, Medical Council of Standards International Academies of Emergency Dispatch®
Great question, Terri.
Regarding the term “catastrophic hemorrhage,” it means severe hemorrhage from injuries that can lead to death. While this is not always easy to determine, let’s start by making sure there is a clear description of the cause of the injury (the mechanism). The Case Entry query, “Tell me exactly what happened,” is the best way to find this out. Causes of catastrophic hemorrhage include, but are not limited to, injuries from:
• Power saws
• Falls through glass
• Industrial equipment
• Traffic accidents
• Boat propellers
• Gunshot wounds
• Shark attack
• Crushing injuries
• Other high-force trauma
The purpose of the DLS Link “Severe limb injury with catastrophic hemorrhage evident” is to get quick access to the Tourniquet Protocol (Protocol T) without having to complete all instructions on the X-5 and X-5b panels first. This is important when limb bleeding is so severe that time is critical—the patient is losing blood so fast that even a short delay from an unsuccessful attempt to control bleeding with direct pressure (X-5, X-5b) means a dangerously high volume of blood is lost. It's important to note here that tourniquets—especially the latest commercial types—are easy to apply quickly and are safe. There is very low risk of harming a patient by using a tourniquet. In my view, the EMD should not hesitate to use Protocol T in cases of limb amputations with severe bleeding, particularly when we know the cause of the limb injury is of extremely high force.
Associate Director of Protocol Evolution International Academies of Emergency Dispatch
I might add that if direct pressure is not working, they're probably not pushing down hard enough, or not over a wide enough area.
Jeff Clawson, M.D.