A recent post on our EMT Review Facebook page was one of our favorites because of the discussion that ensued—thank you to everyone who participated. If you didn’t see it, here’s the question posted:
We will warn you that we love questions like this because they highlight the hazards of linear thinking in EMS—the belief that there’s one set way to apply the rules learned in class.
A small distinction is very important here. There are many ways to apply the concepts learned in class and that all of them are correct. As a matter of fact, this is what distinguishes the students who end up “getting it” from those who don’t.
Let’s look at the choices in the question:
a. Direct pressure. This is the traditional first step in bleeding control. Direct pressure might stop the bleeding, but it also would cause immense pain and potentially further vascular and nerve damage in a joint known for potentially serious vascular and nerve issues.
b. Pressure points. This answer isn’t an option, according to the latest trauma guidelines. There is no proof that using pressure points works—and there’s no time to waste with a severe hemorrhage.
c. Splinting. This might slow bleeding and will prevent further injury, but splinting is not a primary method of bleeding control.
d. Tourniquet. This will stop the bleeding, but will it do harm?
The value of this question lies in its realism: the way it mimics the street, where often there are no great answers, so you have to make the best choice. Hemostatic agents aren’t listed as a choice, but they might be an option.
So how do we bridge the gap between classroom-based concepts and scenario-based multiple choice exams—and the street? Let’s look at the basic rules we’re taught:
- We’ve been given set guidelines for bleeding control—basically, apply direct pressure first, then tourniquet.
- We’ve been told to minimize the movement of fractures by splinting them. Movement other than for necessary realignment is bad.
- In medicine, we should first do no harm.
If we take these rigid steps and transform them into guiding principles, the path seems clearer.
In this scenario, we would apply a tourniquet. Few locations are so remote that an EMT couldn’t get to a hospital in time to deal with the bleeding and save the limb (assuming it could be saved in the first place). This would spare the patient additional damage and tremendous pain. The choice here rests on a risk-benefit ratio—plus, with a motorcycle crash, we’d want to get moving anyway.
The 8th edition of PHTLS (p. 234) says:
Tourniquets had fallen out of favor because of concern about potential complications including damage to nerves and blood vessels and potential loss of the limb if the tourniquet is left on too long. None of these have been proven and, in fact, data from the Iraq and Afghanistan wars have demonstrated just the opposite.
What do you think? Should you apply pressure because that is the “first step”? Do you believe the risks involved in tourniquet application are more than or less than those of applying direct pressure over a deformed knee?
Answering questions like these is what EMS thinking is truly about—and what education should prepare students to do. It is much different from teaching the steps to control bleeding by following a skill sheet.