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DrDom

FREE First Aid course specific to skydiving/PG - Feb 28, 2016; Newburyport, MA

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Greetings all!

Some of you may know me on here and others will not. Been a while since I've jumped (for many reasons) though I've been doing a lot of paragliding and paramotoring since. I was approached by a couple Paramotor/PG pilots recently to get some first aid information. It was going to be a small class and I managed to recruit a Paramedic instructor (with a ton of field experience) to help me put together a very basic first aid course specific to skydiving and paragliding.

It will be an "all welcome" type event if anyone wants to join. I have already reached out to Skydive Pepperill and Skydive New England to see if they are interested.

We will be covering everything from common medical issues you may see at your DZ/LZ, like basic diabetic emergencies, allergies and anaphylaxis, heart attacks, strokes, asthma, and more. We will then be doing a large bit on trauma related conditions including falls, hard landings, burns, blunt accident trauma, prop strikes, tree rescue injuries, basic bleeding and fracture care, head injuries, etc etc etc.

It will be interactive, we will have a lot of hands on practice, and hopefully teach you a lot of stuff you will hopefully never need to use. If you are interested please PM me on here and I'll add you to the list. It will start at 10am since I'm not a morning person ;)

If there are topics people are interested in, let me know.

I'm working on the POSSIBILITY of getting lunch catered... no promises yet. If anyone wants to fly to the place please let me know as Plum Island Airport is nearby!

--DrDom

ps- there is no merit badge or certificate for this, its just an informational course. Yes, we will go out drinking afterward. That is optional, though encouraged!
You are not the contents of your wallet.

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That sounds like an absolutely great idea. If anyone wants to head over from western Mass (I'm in Northampton), I'm open to provide a ride or whatever. It'd be both my husband and me.

Wendy P.
There is nothing more dangerous than breaking a basic safety rule and getting away with it. It removes fear of the consequences and builds false confidence. (tbrown)

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Former EMT-I here.

Just my 2 cents. Keep it really simple. Other than recognizing misc medical problems and calling 911 there is little that can be done and you don't want to fill people's head with a lot of confusing info they will probably never use and will forget the specifics of in a month or two.

Stick with direct pressure and basic tourniquet stuff (tourniquet for self use only, you can really mess someone up with that), keeping people very reclined (Semi-Fowler's position or supine) not moving people, etc.

A little bit of knowledge is dangerous when you don't appreciate the nuance of what is going on. What NOT to do is more important for lay responders than what to do. e.g. it is much easier to make things worse than make them better.

Be sure to explain the legal implications of doing anything not painfully obvious for would be samaritans. i.e. you use your shirt to apply direct pressure and someone gets an infection "not your fault," you put a tourniquet on someone and they lose the limb or die from an embolism, "your fault." Do anything you don't have a certificate for saying you have been trained to do (other than what is painfully obvious to everyone) and you have to take responsibility for your actions in court.

Recognition of the misc medical stuff is good for everyone but boils down to recline and call 911 or transport to a medical facility. Even for EMS, aside from some pretty specific issues and using specific equipment, we rarely "save lives" we simply prolong the dying long enough so that an ER or OR can do the saving.

The "do" list is short. The "do not" list is endless.

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Glad to hear there is some decent interest in this!

I have been taking a break from skydiving mostly because I started into Powered Paragliding after getting cold feet jumping. I'm not getting OUT of skydiving per se, but I needed some time to get my crap in order (and get my wife more supportive which she strangely has been of jumping... weird...) and get my head on so I could be in the game. One issue in the northeast is the climate, so once my pilot's license is done it will be easy for me to hop over to a warmer area and do a jump or two to keep current (or relatively so).

Anachronist is pretty spot on that this will be VERY basic. It will have some do's and dont's, though admittedly a good samaritan CAN put on a tourniquet to stop life threatening bleeding (it is covered in basic first aid courses and is considered "common knowledge", it has also been vetted in the courts but I digress). Realistically, the big things I'm hoping to have are basic injury care, but also a lot of medical "things you may not know about" to help people when they suddenly have their diabetic student start speaking jibberish, or their allergic friend gets sung by a bee. There is a lot of "common sense" that is not well known anymore since medical care is so available.

The course will be purely "practical magic" though we can go over lay responder CPR. New guidelines on compression only CPR is very widely accepted and buys time without complexity.

Legally, there is VERY little you're liable for as a non licensed responder, which is good. In MA, NH, and ME I know the samaritan laws are broad and covering. They were recently revised because of lay responders (like police) now administering medications like Narcan...

Anyhow, yes, there are do's and do not's.
But the single most important thing is empowering people with knowledge. Knowing what to expect, what to do or not to do, and knowing when to call for help will help limit the fear and stress of an emergency. A cool head is the single most important tool in an emergency.

if people are going just email me at my work address: dmartinello[at]ajh.org
this way i can get a running tally and see if I can find a way to get us fed, coffee'd, and watered!
You are not the contents of your wallet.

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Tourniquets are a controversial subject. They were banned in Canada decades ago because of the risk of amateurs killing an otherwise healthy lower leg.
Tourniquets have returned to fashion because of all the traumatic amputations suffered by soldiers in Afghanistan and Iraq. Think roadside bombs big enough to flip over a 5-ton truck.
Tourniquets are really only wise if you understand how many minutes to tighten, how many minutes to loosen, total time you are allowed to apply a tourniquet, etc.
Short of a traumatic amputation, Canadian first aid instructors still direct pressure on wounds.

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Fortunately there will only be rare use and for most purposes EMS will be "close enough" though we will discuss austere environments as well as things they may want to stock like the CAT tourniquet which EMS and military use with great data behind it. It's hard to screw up as long as we know time placed.
You still have a couple hours to lower it if needed... We leave them on in ortho surgical procedures well over an hour at times
You are not the contents of your wallet.

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I was about to make the same comment. A lay person should never, ever, ever apply any kind of a tourniquet. I have been a aparamedic for 21 years and an ER nurse in a level 1 trauma center for 3 years as well. I've never applied or seen a tourniquet applied to anyone. Direct pressure. As hard as you can. Be careful not to damage the ends of vessels unless you really want to piss off a vascular surgeon in the process. For this kind of activity it's important to not move people around too much. Don't pull helmets off unless you don't have an airway. If you need to do CPR that is fair game. Life comes before all else. CPR is easy. All you need to do is chest compressions. No need to do rescue breath unless you actually know how. Which is hard to do and try to protect the C-Spine as much as you can. The biggest two things for me is call 911 immediately and move them as little as possible. If the person needs CPR from blunt force trauma, don't feel bad if it doesn't work. Blunt force cardiac arrest is fatal maybe 8 or 9 times out of ten. Ripped aortas, pneumothorax, hemothorax, etc... You could have a doctor right there and they couldn't save them. Which sucks terribly when it is your buddy, I know how that goes.

Edit - Tourniquets fell out of favor where I am a long time ago due to short transport times. The military does many, many things in the field that are not common in EMS systems yet because they can have some seriously long transport times even with a helicopter. I've seen a few traumatic amputations and we will clip off the vessels with sterile clamps if there is no hope of reattachment. Hopefully you never see that at a DZ ;)

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.......
Tourniquets ..............
You still have a couple hours to lower it if needed... We leave them on in ortho surgical procedures well over an hour at times

........................................................................................

Yes, my sole experience with a tourniquet was during knee surgery, but I was anaesthetized.

Otherwise, my experience with tourniquets is limited to conversations like this.
A few years back, some (Air Force) Canadian Search and Rescue Technicians were doing (parachute) refresher training at Pitt Meadows. I started discussing first aid with a CSAR Tech and the conversation got around to removing harnesses from wounded skydivers. He suggested leaving leg straps tight to reduce the risk of shock. He said that limiting blood flow to legs reduces the risk of wounded going into shock.

I only I clip chin straps and raise visors to ease breathing, but leave the helmet on to avoid aggravating neck injuries. Disconnecting a chest strap can also help breathing, but beyond that, I prefer to wait for ambulances.

Next question: what about suspended harness trauma if a jumper lands in a tree or wires or building?
I have recently sewn patches on a couple of BASE canopies that hung up on "objects."
Granted we see far fewer students in trees than during the 1970s. I have only needed to extract one student from a tree during this century. Fortunately, the land-owner provided a 30 foot 10 metre) ladder. I climbed the ladder, released the student's RSL, cutaway his main and ordered him to climb down the ladder. The student was not injured.

Another instructor and I struggled for 30 minutes to remove his main parachute from the tree. The worst part about the whole experience was all the "helpful advice" from onlookers who didn't know how to climb trees!
Grrrrrr!
What would you do if the student was hanging from a tree and bleeding?

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For what it is worth, here is my training about tourniquets, last updated in 2009 and in an EMT only class, so we didn't talk about the surgical application. Because not a lot of experimentation gets done, for obvious reasons, training varies depending on how the available information is interpreted and what other means (training, equipment, etc) are available to treat a problem. There is no 100% consensus in emergency medicine because not enough sound data exists. This problem was mentioned in the course, basically "this is the best info we have to go on." The same reason CPR procedures keep changing, new data=new method=new data, it is a continuous cycle. And why layperson CPR and EMT CPR aren't the same. The military is keen on it because it requires little training and is an absolute stop to bleeding that doesn't require constant attention, e.g. if someone's leg is blown off you can put a tourniquet on it and then proceeded to fight or transport them under less than ideal conditions and not have to worry about maintaining pressure. Not appropriate or necessary for most civilian situations.

Bottom line, use only to stop immediately life threatening bleeding that cannot otherwise be stopped with direct pressure. So the two scenarios that come up are amputation or severe laceration of an arm or leg.

The on-again off-again method is not advised for two reasons, first, if the bleeding is life threatening then you don't want to allow that to begin again to try and save a limb. The second is not only because of the tourniquet but because of clotting associated with the injury, you want to prevent an embolus, releasing the tourniquet increases the probability of one occurring.

The critical time quoted was 3 hours. After that time you begin having a much higher probability of losing the limb because of ischemia and thrombus, which also makes removing the tourniquet (which eventually has to happen) more dangerous.

We were told, you really only ever do it if losing the limb is an acceptable outcome, it is a last ditch effort to preserve life. Our standard of practice was if a tourniquet goes on, only a physician can remove it, just like a cervical collar.

Never used one, never saw one used, I can only convey what I was taught. I'm also not an MD so I can't comment on the validity of the principals I was taught, and can only accept them at face value.

My training was in Georgia at Valdosta Technical College in 2009 as part of a 1 year EMT-I course to include NREMT testing.

Personally, I would only ever use one if it was pretty obvious that I would bleed out before getting to a medical facility and accept that the limb would be lost.

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riggerrob


Yes, my sole experience with a tourniquet was during knee surgery, but I was anaesthetized.

Otherwise, my experience with tourniquets is limited to conversations like this.
A few years back, some (Air Force) Canadian Search and Rescue Technicians were doing (parachute) refresher training at Pitt Meadows. I started discussing first aid with a CSAR Tech and the conversation got around to removing harnesses from wounded skydivers. He suggested leaving leg straps tight to reduce the risk of shock. He said that limiting blood flow to legs reduces the risk of wounded going into shock.

I only I clip chin straps and raise visors to ease breathing, but leave the helmet on to avoid aggravating neck injuries. Disconnecting a chest strap can also help breathing, but beyond that, I prefer to wait for ambulances.

Next question: what about suspended harness trauma if a jumper lands in a tree or wires or building?
I have recently sewn patches on a couple of BASE canopies that hung up on "objects."
Granted we see far fewer students in trees than during the 1970s. I have only needed to extract one student from a tree during this century. Fortunately, the land-owner provided a 30 foot 10 metre) ladder. I climbed the ladder, released the student's RSL, cutaway his main and ordered him to climb down the ladder. The student was not injured.

Another instructor and I struggled for 30 minutes to remove his main parachute from the tree. The worst part about the whole experience was all the "helpful advice" from onlookers who didn't know how to climb trees!
Grrrrrr!
What would you do if the student was hanging from a tree and bleeding?



So there are some misconceptions I see in these statements. But again, refer to my training for presence or lack of validity, I certainly don't know it all. I am just regurgitating what I was taught. Tightening leg straps to prevent shock sounds like a bad idea, generally speaking you don't want to restrict blood flow unless you are stopping bleeding.

Shock (due to a loss of oxygenation) is a life saving physiological response that shunts blood to vital organs. The idea of "preventing shock" is because you don't want the person's condition to deteriorate to the point where it happens, but when it does, it can be life saving, it just means they are in deep doodoo. It is more an indication of the person's condition, not a "thing" that can be specifically prevented. If that makes sense. i.e. if you could "prevent shock" when it is necessary, then you would be doing harm, the "prevention" is keeping the overall condition from getting to that point.

As far as hanging in a harness THIS is a good read. It is generically referred to as "suspension trauma," I've also heard "harness syndrome" and falls into the broader category of "compartment syndrome."

If you find yourself hanging in a harness and otherwise uninjured, do as much as you can to change your position, flex your legs to move blood around, and try and take the load off your legstraps as much as possible. 30 min seems to be when the danger starts. Granted skydiving harnesses seem to distribute the load much better than climbing or safety harnesses, so I would posit the time required to cause medical problems would be greater. But that also depends, are you 18 or 80, how good is your circulation anyway?

Other than that, get to the ground as quickly as possible and call 911 if the person is expected to be hanging for any length of time, which you probably should have done anyway.

My memory is fuzzy on this one but I think that unloading the harness is sufficient to cause problems related to suspension trauma, straps usually aren't tight enough to appreciably restrict blood flow when you are just sitting or reclined. Rapid transport is the best course of action after getting down, if it is going to be a really long transport then you don't want to make things worse by continuing to restrict blood flow with tight leg straps. If it is that bad and there isn't a heli involved, well sometimes you just get boned.

One thing good to take away from the reading is not to lay down completely flat after being suspended. Rather, reclined at about 30 degrees. Reclined at 30 degrees is pretty much good for everything, for the lay-responder I would say "when in doubt, recline at 30 degrees." This is not considering CPR and stuff like that.

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WOW! Great topics in here.
I really appreciate the weigh-in from our RN at the Level I.

Tourniquets are... fraught with controversy and both sides are both right and wrong at the same time. Emergency Care in hospital (trauma centers) are going to be different than "austere environments".

Some of our paramotor pilots and paragliders will be out VERY rural and maybe hours from care. Our skydivers may land off somewhere though usually a bit closer to home. Different events will be differently managed and I hope that the take-away messages will not be misunderstood. We will be spending a LOT (LOT!) of time on bleeding management. It is forseeable that someone could put an extremity through a spinning prop... controlling bleeding may need to be accomplished thorough tourniquet.

In the Army we were able to train combat responders with the proper and improper use of these. I am sure we can easily train this community as well. MOST, and I truly mean MOST, of the time these are unnecessary and some simple pressure is fine. But in shock it may be our only option. I know Pepperill is close to a major trauma hospital, Lebanon (SNE) is further. But both have great EMS. The paramotor pilots could be... well... miles into the woods and may not have radio contact to call for help. Someone may have to land to get help. Knowing how to tourniquet themselves or someone else could save a life. Knowing when NOT to do it will save limbs.

It is a tough topic and before the course I'll be sure to pull all the current literature, grab my wilderness medicine text, and talk to a few lawyers as well as trauma specialists other than myself for unbiased opinions... not to mention the instructor is a paramedic supervisor and can talk to regional options and the good Samaritan rules.

Trust me, none of this is being taken lightly and ALL opinions will be voiced... on all topics.

I encourage everyone to continue the discussion in here! This is brilliant, and often not talked about as much. All I ask is that we provide our opinions and experience like the adults we are. I've seen a few of these tourniquet and first aid discussions go south fast... most recently at a trauma surgeon conference where a riot nearly erupted in the place. We are better than that ;)

But this spirited discussion is excellent!
You are not the contents of your wallet.

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DrDom

WOW! Great topics in here.
I really appreciate the weigh-in from our RN at the Level I.

Tourniquets are... fraught with controversy .....We will be spending a LOT (LOT!) of time on bleeding management. It is forseeable that someone could put an extremity through a spinning prop... controlling bleeding may need to be accomplished thorough tourniquet. ..................

But this spirited discussion is excellent!



...............................................................................

We can agree with using a tourniquet after a propeller chops off an arm.

Can we agree that "ladies' sanitary products" may be useful for staunching bleeding from deep puncture wounds (e.g. gunshot)?

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riggerrob


...............................................................................

We can agree with using a tourniquet after a propeller chops off an arm.

Can we agree that "ladies' sanitary products" may be useful for staunching bleeding from deep puncture wounds (e.g. gunshot)?



I have seen a few gunshot wounds and none of them and none that I have heard of were not controllable with direct pressure. The ones I saw didn't bleed externally enough to even require gauze.

The military has apparently played with the idea and a device called XStat has been approved for use, but it is far from a tampon in actual function.

The bottom line is direct pressure. The second bottom line is don't shove anything into a puncture wound.

I spent about an hour looking for scientific literature on the use of tampons (or anything else) to plug a hole to stop bleeding, I found none. I also looked for scientific literature on the use of XStat, found very little and none on use on humans. (Basically they just established, yes it does absorb blood and isn't inherently toxic). But Xstat has limitations, it has to be removed within 4 hours, can only be used on extremities and the armpit or groin.

As far as I can tell the tampon in a bullet hole is an anecdote from an unknown number of nameless medics in the military. I have no doubt that it has been tried, but it apparently hasn't been evaluated by any medical authority. It is also not part of any EMS training I am aware of, not to include military who's medic training I have very limited knowledge of.

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Yeah tourniquets are a popular topic in emergency medicine. If the limb is gone I understand. I would place place it proximal to the amputation to save as much leg or arm as possible. You can use a BP cuff and pump the shit out of it. Much better than using a wire or band since it is wider. In rural areas call 911 and tell them you want a helicopter now and explain why. I started out as a 911 dispatcher decades ago and if you told me traumatic amputation, I would just dispatch the helicopter with the ambulance. Rural areas are often volunteer based and have extended response time.

As for the leg straps. I don't find that to be terrible advice either way really. When I first became a paramedic we carried MAST pants on the ambulance. They are velcro "pants" you can slide on to a trauma victim and inflate the bladders to push blood to their core and to their brain saving the vital organs. The problem you will encounter with leg staps in place is the same as we encountered with MAST pants and we had to stop using them. When you get to the hospital the first thing they do is strip you naked and start assessing you. If you deflate the pants all at once, the systemic BP drops and guess what. Cardiac arrest ensues. Or some idiot cuts them with scissors and they deflate.

I have worked in 3 different EMS systems and they all have different equipment and rules. Some are much more progressive than others. So it's hard to reach a consensus. Instead of cutting off blood flow to the legs you can elevate them. Trendelenburg position, legs elevated is thought to work well but again i get mixed reviews from other RN's.

My best advice is if it's a skydiving accident make it clear to the 911 operator how serious the situation is. Some will just send the helicopter immediately and if your friend is hurt badly but still alive that can make all the difference in the world. The Golden Hour is still the rule all these years later. One hour from scene to the surgeon's knife.

Edit - Yeah they really did use tampons in the military for bullet wounds. Then they went to quick clot. Now they are back to a device that packs a wound with expanding cotton that looks kinda like a tube with little marshmallows in it. (I just realized that is XSTAT, I didn't know the name. The FDA just cleared it for use in humans in the US and it is not in use around here just yet). I bet that pisses off surgeons a bunch, but apparently it works very well. Bullet wounds don't always bleed a lot. If they do it is mostly internal so direct pressure on them has little effect in my experience. You need something sterile in the wound to stop it.

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Dopamine_Junkie

(I just realized that is XSTAT, I didn't know the name. The FDA just cleared it for use in humans in the US and it is not in use around here just yet). I bet that pisses off surgeons a bunch, but apparently it works very well. Bullet wounds don't always bleed a lot. If they do it is mostly internal so direct pressure on them has little effect in my experience. You need something sterile in the wound to stop it.



Just to illustrate the importance of conveying accurate information and part of the reason why the tampon thing is such a widespread idea. I spent a lot of time looking for scientific literature on EbscoHost as well as Google Scholar and other databases for using any type of plug to treat a puncture or gunshot wound. I found literally nothing, the data simply doesn't exist (including articles for treating gunshot wounds published by the military and authored by military doctors, tampons or "plugs" of any kind were never mentioned). Feel free to enlighten me, I obviously didn't search every scientific article ever written. (There were some papers on using gels or other specialized materials internally during surgery, but is not applicable for what we are talking about).

I also spent time searching for XStat specifically, which is easy because it is a proper noun. The only papers I found (the total of which were 3, one in French) only established that yes, it absorbs blood in a dead pig, and that the sponges aren't inherently toxic. So my point is, "apparently it works pretty well" has no evidence to support it. The FDA is basically allowing an experiment for a new treatment that might or might not work, or maybe stops bleeding but the little sponges cause other problems. XStat is also not good for use out in the bush without rapid transportation, protocol requires that it has to be removed within 4 hours, I can speculate as to why but I'm not 100% confident so I wont, and none of the info I found specified why.

Long story short, when we evaluate something for effectiveness it requires references and citations. Assumptions are often incorrect or at best only partially correct with considerable and numerous exceptions.

I think the propagation of the tampon idea and XStat is that it seems logical at a surface level of evaluation, is simple, offers a quick fix to a big problem, and is kind of funny (the tampon part anyway). Those are all things that make urban legends spread. Could XStat be an amazing new tool for treating bleeding? Maybe. Could it be a disastrous failure? Maybe. There is simply not enough (zero) data to support either of those assumptions.

I would posit XStat has very limited applications and is more a clever marketing scheme to try and sell millions of units to the US military. Even if the military says "lets try it" the XStat company will make millions, even if it is a failure in the long run. The hype is almost certainly greater than the actual benefit. The fact that they got FDA approval without clinical trials raises my eyebrows. But I am more familiar with the FDA process of approving pharmaceuticals, not mechanical devices, so it could be normal, I don't know. What I do know is that the FDA is not an altruistic organization and a tremendous amount of lobbying by private interest is involved making the validity of FDA approval questionable all together.

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Anachronist

***
...............................................................................

We can agree with using a tourniquet after a propeller chops off an arm.

Can we agree that "ladies' sanitary products" may be useful for staunching bleeding from deep puncture wounds (e.g. gunshot)?



I have seen a few gunshot wounds and none of them and none that I have heard of were not controllable with direct pressure. The ones I saw didn't bleed externally enough to even require gauze.

The military has apparently played with the idea and a device called XStat has been approved for use, but it is far from a tampon in actual function.

The bottom line is direct pressure. The second bottom line is don't shove anything into a puncture wound.

I spent about an hour looking for scientific literature on the use of tampons (or anything else) to plug a hole to stop bleeding, I found none. I also looked for scientific literature on the use of XStat, found very little and none on use on humans. (Basically they just established, yes it does absorb blood and isn't inherently toxic). But Xstat has limitations, it has to be removed within 4 hours, can only be used on extremities and the armpit or groin.

As far as I can tell the tampon in a bullet hole is an anecdote from an unknown number of nameless medics in the military. I have no doubt that it has been tried, but it apparently hasn't been evaluated by any medical authority. It is also not part of any EMS training I am aware of, not to include military who's medic training I have very limited knowledge of.

Not the "ladies sanitary product" that came to my mind. The "other ones" are large, sterile (presumably), absorbent pads.
Perfect for applying direct pressure to a serious wound.

My ex-wife had a habit of carrying one or two in the glove box or center console of her car. I never minded if she put one in mine. I even carried one in a pocket on my motorcycle jacket.

Having a band aid is "nice" but pretty useless in the event of a serious injury. Having a sanitary pad handy could, under the right (or wrong) circumstances, save someone's life.
"There are NO situations which do not call for a French Maid outfit." Lucky McSwervy

"~ya don't GET old by being weak & stupid!" - Airtwardo

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We carry basically that on ambulances. Big "trauma pads" that are just sterile absorbant pads to put pressure on the wounds. Things may have changed in the 3 years since I went to nursing so I can only speak from my past 21 years of experience as a medic. Over that time things changed rapidly and constantly, the reason we have continuing education requirements.

As for the person above you, I understand the scientific method and peer reviewed articles. After all I have Cell and Molecular Biology and Biochemistry degrees on top of the rest of my education. Were you in the US military and were you a medic? I work with several nurses that were army medics and navy corpman. You would be surprised at what they use in the field that is basically experimental. A significant portion of what paramedics use in the field today came from the military and their research because they deal with trauma like gunshot wounds on a regular basis. I could go several months without a GSW just because calls are random. We did not place anything in a wound forever. Then we tried some quick clot type interventions but the surgeons didn't approve because they have to dig it out of the wound trying to repair a bleed. Anyway, you keep steering this thread way off topic. None of this matters for a first aid class for people with no medical training. I mean do people get shot a lot at your DZ or something? This seems to be a case of you being insitent you are right because you searched for peer reviewed data. That's fine with me, I don't care. Go back to the topic.

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I would not put a tampon in. You don't know what is in there or how deep it goes. Plus, if someone is shot at your DZ there are likely bigger scene safety issues.

You can use ANYTHING CLEAN (or dirty if that's all you have) to apply direct pressure to bleeding.

If you take the class we can go over all this ;)

Maybe I'll get the curriculum and share it with anyone who wants to add with it and teach it remotely.

We use the term "FOAM", Free Online Access to Medicine. Its kind of like crowdsourcing or open-source education. If I can get enough people around the country interested maybe we can create a database of lectures; or you can just pay me to fly out and teach!

ha... in a perfect world, eh?
You are not the contents of your wallet.

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