Hemorrhage Control – What Aunt Flow Didn’t Know
Every now and again, this bad recommendation surfaces. I actually saw this printed in an emergency veterinary book recently which prompted me to finally write this article. It’s time to bust this myth.
I think it was the 2008 SOMA conference and the medic’s were presenting their combat medical vignettes. A medic was presenting his casualty vignette when it started going something like this: “…so I stuck my finger in the wound, and it…no shit…, it felt like a vagina.”
At which point, the entire audience of about 500 collectively looked at their neighbor and asked “did he actually just say that?”. And then he continued: “…so I put a tampon in it.”
I’m sure almost everyone that has ever received ‘tactical medical’ training, and many that haven’t, has probably heard this advice in some form. Back in 2000 during my EMT ambulance practicum, noticing there were no big field dressings like the Army issued me, I asked my preceptor ‘if we get a really big bleeder, what do we have to use?’ to which he answered ‘probably the diapers’.
Enter critical thought.
To start with, let’s define exactly what the issue is I’m addressing in plain language. Often, so called “subject matter experts” will give the advice, that to treat massive hemorrhage, tampons, sanitary pads and even diapers are acceptable and effective ‘bandages’. The qualification they give is that they are designed to ‘soak up blood’.
I’ve said it before, and I’ll say it again; if you’re ‘soaking up blood’, you aren’t controlling hemorrhage. You are only keeping the floor clean. When someone asks the question ‘how much blood can this bandage soak up?’, they are completely missing the point, and don’t fully understand hemorrhage control.
Sanitary Pads and Diapers
Let me first address sanitary pads and diapers. These are specifically engineered and manufactured to soak up blood and urine and hold it in ‘keeping you dry’. They rapidly wick fluid away from the surface.
If you consider the way blood clots in a wound, this actually works against what you are trying to accomplish. Effective hemorrhage control is to tightly pack gauze up against the damaged vessel, and inside the wound, and hold it under pressure. Medical gauze is specifically designed for this purpose. It puts a significant amount of ‘surface area’ in the form of the gauze fibers in the area where the blood is leaking out. The (manual) high pressure is to minimize this leaking out by squeezing the damaged blood vessel(s) closed. Blood flow is slowed, and with the clotting factors in the blood activated, it becomes sticky, and hopefully sticks to the gauze fibers and all their surface area. With pressure maintained and minimal movement and disruption, hopefully, eventually a clot will form within the matrix of gauze fibers, over the hole in the damaged vessel(s) that will hold and prevent further hemorrhage.
Place a sanitary pad or diaper on a wound and it doesn’t put surface area in the form of gauze fibers in the wound. Rather, it actually wicks the blood away, almost sucking it out of the wound, leaving no clotting or clotted blood present in the wound to seal it. The blood is wicked into the core and clots inside the pad and away from the damaged vessel where it is actually needed to adhere to, to form the plug. Not the best conditions to promote clotting. So the next time someone tells you to use these devices, please educate them on the difference between their great theory of hemorrhage control, and the reality of physiology, physics and the design of these products.
Tampons
The other adjunct I’ll address is the tampon. The theory is that tampons soak up blood so they should be good for hemorrhage control. After all, that’s what they are designed for isn’t it? They come on a stick that seems like it should fit into a bullet wound track, so why wouldn’t it be effective in a gun shot wound for hemorrhage control.
If you understand ballistics, you know that when tissue is struck with a high velocity projectile, the kinetic energy transfer causes both a permanent and temporary cavity. Those cavities also disrupt tissue planes which creates access to potential spaces for blood to pool in internally, as well as following the permanent wound cavity out the entry and exit wound (if an artery is damaged).
Medical gauze sold for packing wounds is usually around 4 inches x 12 feet (144 inches). And a typical gunshot wound will easily eat that entire roll and possibly then some.
Does anyone know how much gauze is in a tampon? I didn’t, so I opened one up. I needed to soak it in water as it was compressed extremely tight and trying to open it dry, just pulled off little pieces. Little pieces that if they became loose and lost in a wound would be great infection beds.
A tampon is made of two 2 inch x 4 inch pieces of gauze-like material and a little string. And that’s it other than the applicator. Compare that to 12 feet of medical gauze.
Compare this to the volume that comes in one gauze package.
A tampon is not designed to stop bleeding. It is not designed to clot blood from a wound. And I absolutely refuse to entertain any jokes whatsoever regarding the natural physiology of the female body. This is serious and respectful business. The bleeding source is not the vagina, but rather from the uterus, and blood flows out through the cervix then the vagina. The tampon is deigned to soak and hold a small amount of blood. The required function is very different. In the presence of a damaged artery, two 2″x4″ pieces of gauze is like throwing a rock at a tank.
Let me leave you with this advice on managing massive traumatic hemorrhage; soaking blood does not equate to stopping bleeding. Once you get past that, you’re on your way to really understanding how clotting, and hemorrhage control works. You need to provide surface area (gauze fibers), including pro-coagulants and or muco-adhesives if available, in and against the actual wound, specifically the damaged vessel that is the source of the bleeding, under pressure, for an adequate duration, so that the minimal amount of blood that does leak out forms a stable clot.
If you need to improvise, a cotton T-shirt can’t be beaten, except by a bamboo T-shirt. Leave the diapers, sanitary pads and tampons alone or else you could be ‘doing more harm’.
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Originally Posted by SeriousStudent
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