# Soooo you THINK you know your steps to control bleeding !!!!!



## dannios3 (Jan 12, 2011)

When I was in school which was about half a year ago they taught us that to control bleeding you had to

1. Apply direct pressure over the wound, with dressing 
2. If bleeding continues, apply more dressing 
3. If it continues, elevate 
4. If it doesn't stop use the nearest pressure point 
5. Finally if bleeding proceeds use a tourniquet 

However recently I heard that the steps have changed?!?!

Does anyone know ??


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## JPINFV (Jan 12, 2011)

I believe that the "official" steps removed elevate and pressure point.


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## vquintessence (Jan 12, 2011)

Where does ice fit into the equation?

But if you want a real neat & effecive trick for bleeding control: just stop the heart before going through any of those steps.


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## jjesusfreak01 (Jan 12, 2011)

vquintessence said:


> Where does ice fit into the equation?
> 
> But if you want a real neat & effecive trick for bleeding control: just stop the heart before going through any of those steps.



Can a reverse cardioversion be done? Shock the heart at just the right part of the rhythm so that it goes into vfib. Then control bleeding and shock again.


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## Adz (Jan 12, 2011)

I heard they are now:

Direct pressure with dressing

Pressure dressing

Elevation

Tourniquet

Treat for shock if necessary

EDIT

So you basically remove the pressure point step, going straight to tourniquet.


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## 18G (Jan 12, 2011)

Both elevation and pressure points were found not to be very effective which is why they were deemphasized. Direct pressure and tourniquet use are the primary methods for bleeding control. Of course you can use elevation... nothing say's that you can't.

The tourniquet is effectively your pressure point.


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## DesertMedic66 (Jan 12, 2011)

According to national testing it's just: direct pressure. If bleeding continues tourinquet. (sorry for bad spelling). And treat for shock.


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## Melclin (Jan 12, 2011)

Adz said:


> Treat for shock if necessary



What does that involve exactly?


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## DesertMedic66 (Jan 12, 2011)

For EMT-B it just involves elevate feet, blanket, and high flow O2.


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## dannios3 (Jan 12, 2011)

so acording to what the most of the guys said the only thing that changed was that they took out elevate and pressure point...


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## 18G (Jan 12, 2011)

My definition of "treat for shock"....

- Provide warmth (since decreased temp decreases clotting ability).

- Oxygen to increase pO2 to drive diffusion since oxygen carrying capacity may be decreased from loss of RBC's. 

- Keep patient calm as to reduce the metabolic demands of the already stressed body (decreased O2 consumption in a calm person). 

- Maintain perfusion with IV fluids to prevent acidosis and maintain oxygen delivery to the tissues - (blood clots poorly with low pH - yes, I know large volumes of NSS can actually cause acidosis).  

- Can try leg elevation if not contraindicated.

- Ultimately in traumatic shock with external hemorrhage... STOP THE BLEEDING.


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## Shishkabob (Jan 12, 2011)

If you're testing for NR, it's direct pressure followed by TQ.  No in between... if pressure can't stop it you don't fool around with anything else but TQs.

It's been that way since January-ish 09.


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## dannios3 (Jan 12, 2011)

Linuss said:


> If you're testing for NR, it's direct pressure followed by TQ.  No in between... if pressure can't stop it you don't fool around with anything else but TQs.
> 
> It's been that way since January-ish 08.



yeah i was wondering for the NR i didnt want to make a mistake..


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## DesertMedic66 (Jan 12, 2011)

And pressure dressing. It used to be: direct pressure, elevate, pressure point, pressure dressing, tourniquet, treat for shock. But now national just wants direct pressure, tourniquet, treat for shock.


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## Melclin (Jan 12, 2011)

*Right.*



18G said:


> My definition of "treat for shock"....
> 
> - Provide warmth (since decreased temp decreases clotting ability).
> 
> ...



You guys don't divide shock into say... hypovolaemic, cardiogenic, distributive and obstructive and then go from there? "Treat for shock" sounds like something out of our volly first aid 'curriculum'. "He got an awful fright so we treated for shock", "She fell down and flight of stairs and looks like death, so we treated for shock". Weird.


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## DesertMedic66 (Jan 12, 2011)

For paramedic I would say yeah you have to know what kind of shock. But for just EMT-B it's just "treat for shock". Our textbooks didn't talk about the different types of shock. It just said the usual signs and vital signs for shock and then how to treat it.


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## Adz (Jan 12, 2011)

Melclin said:


> You guys don't divide shock into say... hypovolaemic, cardiogenic, distributive and obstructive and then go from there? "Treat for shock" sounds like something out of our volly first aid 'curriculum'. "He got an awful fright so we treated for shock", "She fell down and flight of stairs and looks like death, so we treated for shock". Weird.



When I'm reviewing the call to further educate myself, but it doesn't matter on scene because it doesn't change my treatment options as an EMT-B.


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## JPINFV (Jan 13, 2011)

Melclin said:


> You guys don't divide shock into say... hypovolaemic, cardiogenic, distributive and obstructive and then go from there? "Treat for shock" sounds like something out of our volly first aid 'curriculum'. "He got an awful fright so we treated for shock", "She fell down and flight of stairs and looks like death, so we treated for shock". Weird.



For someone who doesn't carry a monitor, can't start an IV, and is limited essentially to oxygen and oral glucose (some places allow albuterol), what exactly are you expecting an EMT to do for cardiogenic, distributive, or obstructive shock?


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## Melclin (Jan 13, 2011)

JPINFV said:


> For someone who doesn't carry a monitor, can't start an IV, and is limited essentially to oxygen and oral glucose (some places allow albuterol), what exactly are you expecting an EMT to do for cardiogenic, distributive, or obstructive shock?



I don't really care to start an argument about EMT education and scope and so forth, I was just surprised to hear that sort of first aid terminology pop up and thought it might mean something else when used by actual healthcare providers. I don't really see knowing the types of shock as being advancing your education. I see it as the foundation... In the sense that it hadn't really occurred to me that it could be reduced to a simpler concept and still be correct. I suppose 'correct' is a relative term. 

It seems also that the idea has made its way through to the P level as well. Building on advanced first aid rather than just starting from scratch with the real story seems sort of counter productive to me.


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## JPINFV (Jan 13, 2011)

To be fair, they were at a minimum mentioned, and not much more, during my EMT training, but, yea... not really emphasised.


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## MrBrown (Jan 13, 2011)

We no longer teach pressure points however, like the Heimlich, will be used in common practice for some time yet.

Recently the CAT tourniquet was introduced here at our Technician (BLS) level and has been very effective so far.


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## lightsandsirens5 (Jan 13, 2011)

18G said:


> Both elevation and pressure points were found not to be very effective which is why they were deemphasized. Direct pressure and tourniquet use are the primary methods for bleeding control. Of course you can use elevation... nothing say's that you can't.
> 
> The tourniquet is effectively your pressure point.



Yea. In fact in my county, if direct pressure is not appreciatively effective, you go strait to a tourniquet.


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## dannios3 (Jan 13, 2011)

mhmmmm well i will keep all this in mind like i said i just wanted to make sure bc i dont want to make a mistake on the NREMT-B exam


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## Sandog (Jan 13, 2011)

All the NREMT skill sheets can be found here.
https://www.nremt.org/nremt/about/exam_coord_man.asp


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## usafmedic45 (Jan 13, 2011)

Honestly, if you have more pressing concerns (airway?) and not enough help, skipping the direct pressure and going straight to a tourniquet for significant hemorrhage from an extremity would be a good idea.


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## Veneficus (Jan 13, 2011)

Melclin said:


> What does that involve exactly?



it is a 120 hour course, some have upped it to 150.

It could take 120 hours to explain the physiology of shock. Then there would be no time for learning how to use a spineboard.


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## Shishkabob (Jan 13, 2011)

usafmedic45 said:


> Honestly, if you have more pressing concerns (airway?) and not enough help, skipping the direct pressure and going straight to a tourniquet for significant hemorrhage from an extremity would be a good idea.



That's what we have.  If we think the bleeding is severe enough, they get a CAT right off the bat.  After we establish stability in other stuff, we can go back and remove the tq.


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## Sam Adams (Jan 13, 2011)

Linuss said:


> If you're testing for NR, it's direct pressure followed by TQ.  No in between... if pressure can't stop it you don't fool around with anything else but TQs.



NR? I'm not familiar with that abbreviation.


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## jjesusfreak01 (Jan 13, 2011)

Adz said:
			
		

> Treat for shock if necessary





Melclin said:


> What does that involve exactly?



Massive fluid boluses with at least 3 IVs, vasoconstrictors, all holes plugged up, and MAST trousers. If their BP isn't at least 200 systolic, then you aren't treating the shock correctly.


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## lightsandsirens5 (Jan 13, 2011)

jjesusfreak01 said:


> Massive fluid boluses with at least 3 IVs, vasoconstrictors, all holes plugged up, and MAST trousers. If their BP isn't at least 200 systolic, then you aren't treating the shock correctly.



Please, please tell me you are being sarcastic. 

Cause in my county we are supposed to maintain them at 75-90 systolic.


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## lightsandsirens5 (Jan 13, 2011)

Sam Adams said:


> NR? I'm not familiar with that abbreviation.



National Registry


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## Sam Adams (Jan 13, 2011)

lightsandsirens5 said:


> National Registry



Righto. A little more obvious than I was thinking...


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## Tanker299 (Jan 13, 2011)

Types of shock were not only mentioned during my recently finished EMT-B class but subsequently, and quite stringently, tested upon as part of the module testing.
The question was raised (to my dismay) during class why we needed to know the different types of shock if we couldn't do anything about them other than simply "treat for shock".

The instructor answered in the most polite fashion he could muster "It provides a solid foundation when you know these differences and will help you and your patient should you want to make a living at this."


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## dannios3 (Jan 13, 2011)

in my bls class we learned the diffrent types of shock and how to notice wich ones they are so even tho we may not be able to treat with drugs or what not at least we know what to expect and of course how to treat with bls care


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## 18G (Jan 13, 2011)

In the context of the discussion I thought it was assumed we were all talking about hypovolemic/hemorrhagic shock.


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## NomadicMedic (Jan 13, 2011)

jjesusfreak01 said:


> Massive fluid boluses with at least 3 IVs, vasoconstrictors, all holes plugged up, and MAST trousers. If their BP isn't at least 200 systolic, then you aren't treating the shock correctly.



I thought the new standard was 260 systolic.

Hmm. I better get my protocol book out. 

Permissive Hypertension = "Sir, I'm gonna make your blood peressure *really* high. Is that okay? I need your permission. Sir? ... Sir?"


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## Akulahawk (Jan 13, 2011)

vquintessence said:


> Where does ice fit into the equation?


It normally doesn't. There are times that it does, but in EMS, the times you'd see that ice makes a difference would be pretty rare. Seriously, it'd take a while to explain when it's going to make a difference and when it won't.


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## akrall83 (Jan 14, 2011)

vquintessence said:


> Where does ice fit into the equation?



You throw the amputated limb in it


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## hocomedic (Jan 14, 2011)

my teacher said:

apply pressure with your hand(yes gloved) and a bandage under your hand

if bleeding continues elevate and apply more bandages

if it still continues, apply tourniquet and treat for shock.


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## juxtin1987 (Jan 15, 2011)

I feel bad for the OP on this thread, he was aiming for a simple Q&A about NREMT Standards and started a discussion of the common "You took a 100 hour course and couldn't POSSIBLY know anything" debate. Some of us "100 Hour Coursers" Have spent upwards of 2000 hours doing our own research and education as to have the foundation that all medical professionals should build upon. Not to mention if you take the proper approach to a 100 hour course as i feel i did you can take away from it more than enough to be considered a qualified EMT-B level care provider. What do i mean by this you may ask... well, my class met for 3 hour sessions 2x per week, my study group met for 5+ hour sessions 1-2x per week, i personally spent 4-5 hours every evening researching the Physiology associated with what was being taught to me at the Basic Level, and volunteered in the local ED every saturday and sunday for 12 hour shifts each day because a textbook doesn't explain to you the smell of death and the nature of the beast that is emergency medicine. I agree that it is rather unfortunate that the only thing offered for EMT-B students is a 100 hour course (At least in my area), but until the system changes, the new-hires will always be green unless they're actually driven to be a healthcare provider. 

P.S. To reply to this post, and many future/past posts concerning NREMT standards, the best option in regards to what protocols/proceedures are for testing standards is to check with the NREMT direct protocols prior to taking your exam. My class was outdated with not only Bleeding Control, but aslo outdated in AED use so make sure you check the NREMT Registry before testing.


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## micosabeh (Jan 24, 2011)

Well for me, first I control it by direct pressure (gloves), elevate, add gauze/pad then using splint then tourniquet as last option then treat for shock.. for some who asking why for treat for shock meaning the amount of blood that loss during the management of bleeding is already enough to knock-out the patient that is why treating for shock is done after doing tourniquet.. 

Using pressure points perhaps, not applicable, for me, to use as one of the control bleeding due to invasion of privacy


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## sredish (Jan 25, 2011)

dannios3 said:


> When I was in school which was about half a year ago they taught us that to control bleeding you had to
> 
> 1. Apply direct pressure over the wound, with dressing
> 2. If bleeding continues, apply more dressing
> ...



a lot of the textbooks still teach this, they haven't been updated but the instructor has the responsibility to update the student.  what they have all said is correct.  direct pressure then if unmanageable, straight to TQ.


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## Niccigsu (Jan 18, 2012)

This comes straight out of the AEMT book: 
1.Apply direct pressure over the wound. Elevate the injury above the level of the heart if no fracture is suspected.
2. Apply a pressure dressing.
3. If direct pressure with a pressure dressing does not control bleeding, apply a tourniquet above the level of the bleeding.


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## Fish (Jan 18, 2012)

dannios3 said:


> When I was in school which was about half a year ago they taught us that to control bleeding you had to
> 
> 1. Apply direct pressure over the wound, with dressing
> 2. If bleeding continues, apply more dressing
> ...



Apply pressure
Apply Gause
Apply more
Turniqut


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## JPINFV (Jan 18, 2012)

Wait... all bleeding stops... eventually.


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## DesertMedic66 (Jan 18, 2012)

Everywhere teaches it differently. I know some places that teach cold packs to stop bleeding. 

I like and use: direct pressure with gauze, then more gauze, then elevation, pressure point, pressure bandage (usually a BP cuff works well) and then the tourniquet.


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## SanDiegoEmt7 (Jan 19, 2012)

18G said:


> In the context of the discussion I thought it was assumed we were all talking about hypovolemic/hemorrhagic shock.



Right? On a question about bleeding control that's what one would expect.

But someone's always gotta get on the soapbox.  Either way the first aider isn't going to be able to figure out the difference and doesn't have the tools to treat anything accept, spurting red stuff.


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## Shishkabob (Jan 19, 2012)

Funny story.  A patient sliced his cephalic vein open.  Fire arrives, sees blood, freaks out, puts on gauze.  Blood continues.  Fire freaks out more, slaps on 3 separate TQs.  Blood continues.  Fire totally loses it and packs on the quikclot bandages.  Blood continues.

We arrive, pull out a BP cuff, get odd looks (Stupid Paramedics wanting a blood pressure while the patient bleeds? HA!), slap on BP cuff, pump up, and... voila!  No more bleeding.


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## JPINFV (Jan 19, 2012)

Fornicating veins, how do they work?


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## mycrofft (Jan 19, 2012)

NRretty well covered.

Quote above:
"For someone who doesn't carry a monitor, can't start an IV, and is limited essentially to oxygen and oral glucose (some places allow albuterol), what exactly are you expecting an EMT to do for cardiogenic, distributive, or obstructive shock?"
Ans: _*GO faster.*_

Pragmatic answer: Do the official stuff. If you fail to get bleeding to stop, you are usually not pressing hard enough. If you do not have a tourniquet and pressure still won't stop it, a pressure point is a last ditch but it ties you in place and is so hard to do properly that it rarely works anyway. A tourniquet may be your ticket, but, if applied too loosely, will accelerate bleeding through collateral circulation and due to venous/arterial pressure differential. Elevation of the injury works for things like nosebleed and minor cut finger; ice will help a really minor booboo but will also reduce swelling and reduce pain; elevating legs to counter shock is too minor and enough elevation would push the viscera into the diaphragm since the pt is upside down and draining like a stuck pig. (The leg up deal is an old last-ditch thing and like a resisted Valsalva maneuver good for fainting/syncope).
If you slapped on a combine dressing like most "ABD" 's/5X9's, you can hasten clotting by slapping on a regular gauze pad first; the combine dressing is designed to absorb, so the blood/clot is in the dressing and not on the wound unless you have put-on beaucoup pressure.


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## NYMedic828 (Jan 19, 2012)

Here in NY it has changed to direct pressure, pressure dressing, tourniquet.

We used to be of the mindset that once we put on a tourniquet the pt is going to lose the limb distal to it. This turned out to be entirely untrue as a limb can go from 5-12 hours without blood supply depending upon what text you read. 

It is more important to maintain a sufficient hemodynamic by controlling a major bleed than the possible extended loss of a limb that more than likely can be repurfused by time of surgery.


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## Sandog (Jan 19, 2012)

NYMedic828 said:


> Here in NY it has changed to direct pressure, pressure dressing, tourniquet.
> 
> We used to be of the mindset that once we put on a tourniquet the pt is going to lose the limb distal to it. This turned out to be entirely untrue as a limb can go from 5-12 hours without blood supply depending upon what text you read.
> 
> It is more important to maintain a sufficient hemodynamic by controlling a major bleed than the possible extended loss of a limb that more than likely can be repurfused by time of surgery.



I think the original fear of a tourniquet (Tk) was necrosis (cell death) due to massive acidosis buildup and release of acid throughout the body when Tk removed, but with the use of alkaline injections prior to removal, this is no longer a concern.


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## NYMedic828 (Jan 19, 2012)

Sandog said:


> I think the original fear of a tourniquet (Tk) was necrosis (cell death) due to massive acidosis buildup and release of acid throughout the body when Tk removed, but with the use of alkaline injections prior to removal, this is no longer a concern.



The "Rescue Medics" here in NYC actually have sub protocols that allow them to give sodium bicarbonate to victims with crush syndrome for an extended period while being extricated.


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## mycrofft (Jan 19, 2012)

Tourniquets (TK's) cost limbs because improvised and older commercial ones were too narrow and crush tissue circumferentially. However,as they say, "life or limb"...
True urban legend: broken bottle fight in a bar, guy has neck cut. Another drunk takes off his belt and tries to make a tourniquet. Because it was a leather belt and holes were too near the tip, he failed with the TK, but succeeded in putting lots of pressure on the bleeder, and the guy lived. (related by Omaha firefighter, 1979).


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## Veneficus (Jan 19, 2012)

You mean its not:

1. epi soaked gauze
2. epi injection
3. Bovie
4. preformed metal clamp
5. sutures
6. make a flap
7. cut the offender out


Damn... No wonder I can't pass NREMT-B :unsure:


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## mycrofft (Jan 19, 2012)

1. Find the source of bleeding by touch (it's dark and raining),
2. Jam your finger into the hole.


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## Tigger (Jan 20, 2012)

Veneficus said:


> You mean its not:
> 
> 1. epi soaked gauze
> 2. epi injection
> ...



Mmmm love me some blanching with my hockey players.


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## mycrofft (Jan 20, 2012)

Be like an old timer fighter, put ALUIM on it. (Hydrated potassium aluminum sulphate).

Two years ago every other reply would have been about clotting chemicals OTHER than the common stypic pencil (alum).


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## Veneficus (Jan 21, 2012)

mycrofft said:


> Be like an old timer fighter, put ALUIM on it. (Hydrated potassium aluminum sulphate).
> 
> Two years ago every other reply would have been about clotting chemicals OTHER than the common stypic pencil (alum).



I thought stypic pencils were only used by barbers?

There is always a new gadget or technological device that is going to allow medics to save the world.

Unfortunately none of those things ever seems to be a book that details most of that overpriced crap is just a waste of money.


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## TLettuce (Jan 22, 2012)

Linuss said:


> Funny story.  A patient sliced his cephalic vein open.  Fire arrives, sees blood, freaks out, puts on gauze.  Blood continues.  Fire freaks out more, slaps on 3 separate TQs.  Blood continues.  Fire totally loses it and packs on the quikclot bandages.  Blood continues.
> 
> We arrive, pull out a BP cuff, get odd looks (Stupid Paramedics wanting a blood pressure while the patient bleeds? HA!), slap on BP cuff, pump up, and... voila!  No more bleeding.



BP cuffs... definitely one of the more under-appreciated tools on the rig.


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## Brandon O (Jan 25, 2012)

JPINFV said:


> For someone who doesn't carry a monitor, can't start an IV, and is limited essentially to oxygen and oral glucose (some places allow albuterol), what exactly are you expecting an EMT to do for cardiogenic, distributive, or obstructive shock?



Well, it might be nice to have ALS for these... whereas for the hemorrhagic they're gonna have to dive through my open window as I pass.


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