Glass, an Anticoagulant, and a Towel He Keeps Lifting
A 41-year-old woman was carrying a glass tabletop when it shattered against a door frame. She has a deep cut on the inside of her right forearm. Her partner is calling and says blood is running, not dripping, through two bath towels and has pooled on the kitchen floor. She is pale and sweaty and says she feels dizzy and wants to lie down. She takes apixaban, started last year after a pulmonary embolism. She is awake and answering, breathing fast. The cut happened about six minutes ago. The partner has been holding a towel on the wound but says he keeps lifting it to check whether it is still bleeding. The flat is on the third floor with no lift.
1. Which key questions establish the severity of this bleeding, and where does this call land on the determinant scale?
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Questions that separate a plaster job from a haemorrhage:
- Is the bleeding controlled with the pressure you are applying right now, or is it still coming?
- Is it pouring or spurting, or soaking through as fast as you put cloths on?
- How big is the pool on the floor? Is it spreading?
- Is she pale, clammy, confused, or drifting off?
- Is she breathing fast?
- Does she take any blood thinners - warfarin, apixaban, rivaroxaban, clopidogrel?
- What cut her, and how deep does it look?
Determinant: uncontrolled bleeding, blood running through two towels, a pool on the floor, a patient who is pale, sweating and dizzy, and an anticoagulant on board is a life-threatening haemorrhage - the high-acuity level of the bleeding protocol, not a minor laceration. Dizziness and pallor are the earliest hypovolaemia signs she will show before she decompensates.
The single most controllable factor in this call is the partner lifting the towel. That is what the pre-arrival instructions must target first.
What the EMD does not do: guess the volume, diagnose shock, or downgrade because she is still talking. Talking is not the same as stable.
2. Give the pre-arrival instructions for controlling this haemorrhage, including what to say about the towel he keeps lifting.
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Sequence:
- Put on anything you can as a barrier - gloves, a plastic bag, a clean nappy bag.
- Firm, continuous pressure directly on the wound with the cleanest cloth you have - and press hard, harder than feels polite. Use your body weight.
- Directly address the checking: Do not lift the cloth to look. Every time you lift it you break the clot that is forming. Leave it down until the paramedics are there.
- If it soaks through, do not take it off - put another layer on top and press harder.
- Lift her arm up above the level of her heart and keep pressing while you do it.
- Have her lie flat. Keep her warm with a blanket or coat. Nothing to eat or drink.
- Talk to her and tell me if she stops answering, or if her breathing changes.
On a tourniquet: only if local protocol directs it, only for extremity bleeding that pressure will not control, and the time must be recorded. On a limb where firm pressure is working, a tourniquet adds harm.
Delivery: one step at a time, confirm each. He is panicking, so keep the sentences short and take control of the pace.
3. The partner reports the bleeding has slowed, but she now says she feels faint and that everything is going gray. What is the priority, and how should the call be closed?
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Priority shifts from bleeding to perfusion.
- Keep the pressure on - slowed is not stopped.
- Lay her flat and, if there is no leg injury, raise her legs to protect the blood pressure. If she is pregnant or you suspect a spinal injury, do not.
- Keep her warm - a blanket, a coat, whatever is in reach. Cold worsens deterioration.
- Keep her talking, and watch breathing and responsiveness while the partner presses.
- Do not let her stand up to go to the door, and do not give her anything to drink.
- Update the responding unit: bleeding slowed, now showing faintness and visual change, third floor, no lift.
PDIs for a third-floor flat with no lift:
- Unlock and prop the front door, turn on the stair light.
- Clear a path and send someone to meet the crew at the entrance if a second person is available.
- Gather the apixaban box, the medication list, and her ID.
Closure: confirm the address and callback number back to him, tell him not to hang up until you say so, and stay on the line as the coaching presence - the compression of the call is what is keeping the partner focused on holding pressure.