Code, Meet Trauma: Stop The Bleed!
Table Of Contents
It was a Thursday…
Actually, I don’t remember what day of the week it was, but it was at night. I was sitting in the squad room of the EMS station, where my partner and I, along with other EMTs, had just finished dinner. We were waiting for our next call, as the night was quiet. The squad room, as we affectionately call it, is where we come to check our trucks and equipment and try to grab a meal before the next call.
As EMTs, we work in a high-stress, fast-paced environment where the number of calls we receive can vary greatly. On some nights, we are slammed with emergency calls, while on others, it’s eerily quiet. This night was one of the quiet ones, and my partner, with his long blond surfer hair, a job shirt that was slightly too small for him, and a tendency to always draw the most exciting calls, was settling in for a nap.
In EMS, we use the terms “hot job” and “cold job” to distinguish between emergency calls. A hot job is a high-stakes or intense emergency call, such as a life-threatening situation. On the other hand, a cold job refers to a minor emergency call, such as a case of minor injuries or discomfort.
Just as we were getting comfortable, the tones from our radios and pagers, which function as an alarm system for dispatchers to alert EMTs of an incoming call, started blaring. The dispatcher reported a multiple-car crash with multiple injuries and people entrapped. This was the type of call, a hot job, that would test our training and experience, and we were eager to respond.
As Rescue technicians, a specialized team of EMTs trained to handle more complex and dangerous emergencies, such as vehicle accidents, rope rescue, or building collapse, we were ready for this challenge. The excitement was palpable as we sprang into action, responding to the scene of the accident and ready to provide the best medical care we could.
As we arrived, the scene looks something out of a movie. Three cars were involved, with intrusion into the patient compartments. For a total of 3 patients. One team was working on one of the vehicles, and my partner and I got another. My patient was an elderly man who was alert and talking to me. I asked him if anything hurt, and he started motioning at his leg. I could see that it was crushed by the steering wheel and impeded us from his rapid removal. As we tried to pry open the door, it was compressed between the two posts, and we would need to use hydraulic tools to free him. My partner and I suited up and started pulling tools off the truck. The “set” we take off is called peanut butter and jelly. 2 tools. A cutter and a spreader. Some will often refer to the spreader as the “Jaws of Life,” and I never liked that name. It's also a brand name for a tool company; if for anyone who knows the rivalry between Dewalt and x-brand tools, the same could be said for Holamatro. I love these tools, and our spreader, which can spread 10k pounds at the tips and opens to a whopping 32 inches, we call this tool the “honey badger” — because it doesn't care.
After taking an assessment, we knew we had to take the door off, and we may also have to perform a procedure called a dash roll. This is where you make some relief cuts near the A-post and behind the front strut to move the post away from the patient. Pretty standard stuff on an accident like this. These decisions were also made relatively quickly, which is important to remember later. With almost all non-verbal communication between my partner and I, we placed some protection around the octogenarian and went to work, first removing the door and then performing the dash roll. In the middle of these two moves, we now had a chance to assess the patient thoroughly. Day one EMT school is being able to perform Rapid Trauma Assessment. A drill we practice constantly to go head to toe with a victim and be able to assess life-threatening injuries. What a great catch this was. As I made my way down each of the patient's legs ( remember his legs are pinned by the steering wheel), the patient had also taken some shrapnel and was bleeding, however, was restricted by the pressure. If we didn't act fast, my patient could bleed out, or in fancy medical terms, hypovolemic shock. I reached into my partner's cargo pocket and pulled out his tourniquet. I fished it around the patient's legs and pulled very tight. Wound the TQ stick until I no longer noticed the blood rushing out of his thigh. If we had continued and rolled the dash, we would have taken all of the pressure off his leg, which could have led to him bleeding to death before we had time to react. A bleed like that can be fatal in three to four minutes. Without rapid intervention, he would have died.
But he didn't. Let me say it again. Stop the bleed. It saves lives.
A few years ago, I remember getting called to a car accident. This one was mid-day, and there was a reported CPR in progress. As my team and I rapidly made our way to the scene, we saw a bystander performing CPR on the sidewalk upon arrival. The patient had been the passenger and went unresponsive shortly after the collision. As we walked up, we noticed that there was a small pool of blood around the patient's arm, and upon further inspection, we found that there was also a larger pool of blood in the stepwell of the car. This seemed odd because the accident was not that severe, maybe one or two steps above a fender bender. The bystander was still doing what I would argue as great compressions under the circumstances. I started questioning where the blood was coming from because it didn't make sense. I started cutting away the sleeves of the patient. He was wearing an oversized down jacket, and this is one of the top 10 rules of EMS. “Never cut a goose down jacket.” Some rules are made to be broken as I cut away their sleeve, I found that the patient had a shunt in their arm that had been bleeding slowly. From this information, I could speculate that this had started before the accident. The human body has ~1.2–1.5 gallons of blood ( 5 liters ). Here's a little trick to estimate blood loss in the field in case you ever find yourself in need.
- “There was some bleeding” — It looks more dramatic than serious, likely < 500ml
- “There was a lot of blood” — It was dramatic and concerning, likely 500ml to 1L.
- “There was a s**t ton of bleeding” > 1L ( not good at all )
- “Oh, F**k” — The worst type of descriptor when talking about blood loss.
The patient was at a critical “Oh, F**k” level and in dire need of medical attention. I applied a tourniquet to the patient’s arm above the shunt to stop the bleeding. The reality of the situation was sobering, and the need for rapid transport and blood transfusion was evident.
The patient was loaded onto another ambulance and quickly transported to the hospital. Despite all heroic efforts, the patient did not survive. The after-action report revealed that the dispatch was correct, and the ambulance crews were on the scene within 5 minutes of being notified. Additionally, CPR was applied in the field, a rare occurrence that increased the chances of survival by over 20%. The entire process, from the time of the 911 call to the transfer of care to the hospital, was completed in less than 20 minutes, which is an exceptional timeline for this type of emergency call.
However, despite all the correct actions, the patient did not survive. The cause of death remains unclear ( I am not a medical examiner ), and the patient may have already lost too much blood before the arrival of EMS. Another possibility is that the excellent CPR continued to pump blood out of the patient, and the bleeding was not stopped quickly enough, leading to fatal consequences. This is purely speculative and based on limited information, but it highlights the importance of timely and effective medical interventions in emergencies. It highlights that even if you do everything correctly, your efforts are futile unless you stop the bleeding.
What the heck does this have to do with software?
As a senior software developer, I often apply my experiences as an Emergency Medical Technician (EMT) to software engineering. The idea of “stop the bleed” in software engineering is similar to its medical counterpart. In both cases, it’s about first identifying and fixing the most pressing issue. In software engineering, this means finding and fixing the problem degrading your system's health before it becomes a more significant issue. The mindset is always looking for the “why” because all the efforts made around it might lead to a negative outcome.
This adventure was to warm you up to the ideas and mindset of why stopping bleeding is so essential. It also wraps up our introduction to who I am and what this series will be about. In the following article, we will be talking about code quality. When it comes to code quality, having clean code is crucial for maintaining a healthy code base. However, maintaining code quality can easily be undone if others don’t follow the same guidelines. This can lead to a “bleed” in the code base, causing the efforts to maintain clean code to be impacted. Next time, we will dive into some stories about code quality, some more EMS stories, and some action items you can take to improve your code base's health. My goal here is to build a proactive mindset and a focus on code quality and best practices.
Disclaimer: The emergency calls described in this blog post have been slightly altered to protect the privacy of patients and emergency medical services (EMS) crews. The facts presented in this post may be based on actual calls or may have been combined for educational purposes.
