Bleeding from an injury can be quite alarming, particularly for a surfer in the water where assessing an injury and quantifying the amount of bleeding can be difficult. Any significant bleeding should prompt a return to shore to further assessment. Most hemorrhage can be controlled by applying pressure directly over the wound with gauze, a clean towel, or T-shirt. In a clinical setting, health care providers should wear gloves and protective eyewear, and use fingers or palm to press a stack of sterile gauze directly on to the area that is bleeding. If the wound is large enough, gauze packing should be placed directly into the wound. Pressure should be applied for 15 minutes before checking to see if the bleeding has stopped. A pressure dressing can also be made by placing a stack of gauze over a wound and applying a snug elastic bandage (e.g. Ace wrap) around the extremity or scalp. At the beach a plastic bag can substitute for gloves and a clean towel or T-shirt for gauze. A T-shirt cut in a spiral fashion into a long strip can be used in place of an elastic bandage.
It is very unusual that bleeding cannot be controlled with direct pressure. Rarely, however, as might be the case from an injury sustained by a shark bite, propeller strike, or deep fin cut, a tourniquet may be required in order to control hemorrhage. While uncontrollable hemorrhage is extremely rare, use of a tourniquet can be life-saving and one should not hesitate to use a tourniquet in the face of life-threatening bleeding. In the past, the use of tourniquets had been frowned upon due to concerns about limb ischemia and potential loss of limb. However, military experience in Iraq and Afghanistan have demonstrated the safety and efficacy of tourniquets in saving lives from extremity bleeding. Furthermore, tourniquets are routinely used by orthopedists in the operating room when performing hand surgeries to achieve a bloodless field and are often kept inflated for up to two hours without long-term complication. There has been a recent push by the American College of Surgeons to promote “Stop the Bleed” courses to teach by-standers techniques to prevent fatal traumatic hemorrhage by using direct pressure, hemostatic dressings such as “Quick ClotTM”, and tourniquets.
Tourniquets
Commercial tourniquets, such as the C-A-T, or SOFTT-W are widely available and cost $25 – $35 at the time of this writing. They apply a band of pressure about 1 inch (2.5 cm) wide, use a windlass to generate sufficient constriction, and can be self-applied. A manual blood-pressure cuff, kept inflated to above systolic pressure, is another effective tourniquet.
A well provisioned surfer’s first-aid kit should include a tourniquet and hemostatic gauze, but chances are good you won’t have these items readily available when needed. Simply wrapping a surfboard leash around an extremity is usually ineffective because without a windlass (see below) insufficient force is generated to fully collapse underlying arteries. If a tourniquet is only tight enough to obstruct venous, but not arterial flow, (as do elastic bands used to start an IV line) then increased venous pressure distal to the tourniquet will actually increase blood loss.
A functional tourniquet can be improvised using readily available materials. Non-stretch, pliable cloth such as denim, or a towel can be torn into a strip approximately 3 inches wide (7cm) by 3 feet long (90cm). A surfboard leash or rope is too narrow and will damage skin and nerves and a roof strap or belt is too stiff and difficult to tie. A wooden stick, pen, or screwdriver can be used as a windlass.
Credit: Surf Survival 2nd edition, Skyhorse Publishing
Tourniquet Application
Tourniquets should be sited about 2 inches (5cm) proximal to the wound. Do not place the tourniquet over any joints, as underlying vessels are not easily compressed. If necessary, place the tourniquet proximal to the knee or elbow. Document the time the tourniquet was placed by writing on the tourniquet if possible.
For an improvised tourniquet begin by wrapping the non-stretch material once around the injured extremity and tie a snug half-knot, as in the first part of a shoelace knot, as shown in the diagram above. Place the windlass across the half knot and tie a square knot over the windlass. Twist the windlass until the bleeding stops. Distal pulses should not be palpable, but most importantly the bleeding should stop. The windlass should then be secured with another strip of material or tape to keep it from unwinding.
Both commercial and improvised tourniquets will be uncomfortably tight if properly applied and will usually cause paresthesia in the distal extremity. If a tourniquet is to be used for more than 4 hours, loss of limb should be weighed against the possibility of loss of life. A potential solution is to loosen the tourniquet (while leaving it in place) to see whether bleeding has stopped or can be controlled with direct pressure.
Just as you can save a life with bystander CPR you may also save a surfer’s life if you “Stop the Bleed”.