How Fast Can Someone Bleed Out? A Real Life Example with Video

I get asked often as a medical expert and host of this blog how fast someone can bleed out from a variety of injuries. When I say fast, I think many people are doubtful. I’ve said many times that all bleeding can lead to death if not controlled, whether venous or arterial.

Recently, Bo Johnson,  a friend of mine who is an ER nurse and avid outdoors man had a very close call with nearly bleeding to death. This story does have a happy ending (thank heavens.)

Bo was riding his bike to his children’s school while carrying a razor scooter in one hand. The scooter became caught in his bike and when he fell, his neck landed on the edge of the scooter, severing his right internal jugular as well as a large muscle. What follows is video of the bleeding before surgery that Bo graciously gave me permission to post here. WARNING: The following video is a graphic representation of active bleeding.

Photo Courtesy of Bo Johnson

Keep in mind, this is a large vein, and not an artery. However, the bleeding is still quite brisk and if uncontrolled would be deadly. If it had been arterial, the blood would be a brighter red in color and would spurt from the wound, and would be more difficult to control.

Bo spent two hours in surgery to repair the injury. The jugular vein could not be repaired so was tied off. The jugular vein on the other side of the neck will hopefully compensate. He spent one night in the hospital and should be back to work helping to heal others in about a month.

All who know Bo are so thankful that he is going to be okay after this freak accident. I personally publicly thank him for allowing me to share his story, video, and photo with you so you can see just how significant bleeding can be.

Speedy recovery, my friend.

Author Question: Gun Shot Wound/Severed Brachial Artery

Sandy Asks:

I am writing a scene where my heroine gets shot in the scuffle with the bad guy. If she’s shot in the brachial artery in her left arm, is it conceivable that she’d pass out and bleed a lot? Her firefighter hero is there and immediately rips off his shirt and balls it up to stop/slow the bleeding. He then uses a strip of fabric from another shirt to tie around that and then carries her to a waiting police car to get her to the hospital—in this case, an ER clinic.

How much danger is there of bleeding out? Is the pressure wrap enough? Can she survive? What would be the treatment? Surgery, I assume, and blood transfusions. Would she remain unconscious and for how long?

Jordyn Says:

Yes, it is conceivable that she would pass out and bleed a lot. The brachial artery will bleed briskly and quickly and without direct intervention she could bleed to death in a matter of minutes (3-6 min). I think both methods to control the bleeding need to happen quickly. The firefighter can direct a bystander to apply direct pressure while he fashions the tourniquet as he will have more experience. The tourniquet should be applied above the level of bleeding. After those two measures, I would have the firefighter continue direct pressure at the sight with a compression dressing. This will be better than continuing to hold direct pressure.

To your specific questions:

Without intervention, this character is in great danger of bleeding out. With immediate intervention, she should be all right.

I would do both the tourniquet and the pressure dressing.

Initial treatment by EMS would be to establish IV access very quickly and start supporting the fluid loss with IV fluids. A set of vital signs. Possibly oxygen if her heart rate is really elevated, her oxygen level is low, or she’s exhibiting any kind of distress.

Since she is being transported by a police car, these would then become the initial steps performed in the ER.

Upon arrival to the ER, labs will be drawn to check her blood counts. If low, then blood transfusion would be warranted. Repairing a severed artery will require surgery.

Whether or not the character goes unconscious depends on a lot of factors. A person can just pass out from looking at blood and the stress of being shot in addition to blood loss. If a person passes out from blood loss, they should regain consciousness as soon as their blood pressure is normalized either with IV fluids and/or blood transfusions.

You mention an “ER clinic”. I’m not quite sure what you mean by this, but a free standing ER, urgent care, or an “emergency” room outside a major hospital can have limitations in the type of care they can deliver. So, if it’s such a situation, the patient would need to be transferred to a larger hospital (for surgery, admission, etc).

Best of luck with this story!

911 S2/E2: Determining Death

In Episode 2 of this season’s Fox series 9-1-1, a devastating earthquake has hit LA county.

The team is searching for victims when they come upon a patient where only her lower legs are visible. The paramedic reaches down and assesses her pulse at her foot and determines that she’s dead. Time to move on.

Can you feel someone’s pulse in their foot? Yes, you can. He’s palpating what’s called the dorsalis pedis pulse.

Should it be used to determine if the patient is dead? To this, I would say no. The problem is, when the body goes into shock, it shunts blood toward the central aspects of your body to ensure blood flow to your vital organs so even though the person is alive, you may not be able to feel the pulses in the feet. This is why when checking for life, the use of central pulses is encouraged— for instance the femoral or carotid pulses. Also, this victim could just have two broken legs with compromised blood flow to her feet causing the lack of pulse.

However, I’m not going to give them too much grief for this. In a mass casualty situation, sometimes you do just need to move on and save who you can.

Author Question: Stab Wound to the Abdomen in a Young Girl

Loinnir Asks:

There’s a scene in my story where one of the main characters, a short and slightly underweight 13 year old, is stabbed in the abdomen (I was thinking the epigastric region) with a 4-5 inch blade which is almost immediately ripped out by the perpetrator. Around 25-30 minutes pass before she arrives at the hospital (she is transported by car, not an ambulance as the witnesses don’t have any way to call one).

So, I was wondering how likely she is to survive, the type of treatment and expected length of recovery, and what would the protocol be for the witnesses (her five friends, all minors)?

Jordyn Says:

Thanks for sending me your question.

I think the biggest risk in an underweight (thin child) being stabbed with a 4-5 inch blade (which is fairly long) in the epigastric region is hitting the descending aorta (or one of the large veins). Particularly if the blade is pulled out, there would be little to stem the bleeding. Of course, it would depend on the angle and depth of the blade but this would be one of the more concerning injuries. If the blade is angled up, you could also hit the diaphragm, a lung, and possibly the heart. Angle the blade to the side and you have the spleen on the left and the liver on the right.

Biggest risk of death for this victim would be hemorrhage. Considering she is being transported by car versus ambulance, she would die in just a few minutes if her descending aorta or heart were hit. A lung injury could be survivable if care is given within thirty minutes depending on how much of the lung is deflated.

If you want her to live, I would also avoid hitting the liver or spleen on either side as she would bleed to death before getting to the hospital.

Getting stabbed in this area could also injure the small intestine. This is probably the more survivable injury. It would require surgical repair and a short hospital stay if the surgery went well and there was no other damage. They would have to ensure her bowels were working, she was passing gas, and could tolerate food and fluids before discharging home.

Medical treatment in the ER for a stab wound would be a set of vital signs, continuous monitoring of ECG, oxygen levels, and breathing. IV placement (likely two—one in each arm in the antecubital space), normal saline fluid boluses, labs (particularly those that measure blood levels and organ function of the abdomen) and blood if needed. They’ll check her urine for blood and if she’s menstruating she will get a pregnancy test. She would likely get x-rays of her chest and abdomen as well as a CT scan of her abdomen checking for injuries. Antibiotics would likely be warranted if her intestine had been perforated. Then to the OR to repair any injuries.

I’m not sure what you’re asking as far as the five minor witnesses. I checked with my brother who works in law enforcement and he said there are no legal issues in interviewing a juvenile witness. If your question is concerning medical care, I don’t see a reason for these kids to be evaluated if they are uninjured. At the scene, they would likely be held until parents arrived to pick them up.

Best of luck with this novel.

Author Question: What Kind of Car Accident Matches these Injuries?

Mary Asks:

I have a couple questions. My young adult characters (a total of six— four of them intoxicated) were involved in a car accident. The two sober ones were in the first vehicle. My plan was to have the driver suffer from a broken wrist, maybe a bump on the head, nothing too serious (this can change if it needs to). If he is that okay would it be unrealistic to have his passenger hit her head hard enough to lose consciousness and suffer memory loss when she wakes up? I was thinking of including pretty severe amnesia, but as for the other four characters, would their level of intoxication let them walk away with little to no injuries, or would they still arrive in the ER with at least the unconscious passenger?

Jordyn Says:

There are so many variables in car accidents that you could basically do whatever you wanted, but I’ll give you some guidelines.

If you want the injuries to be less severe, I would not have a very serious car accident. For instance, your two sober characters in the first car should not be traveling probably over 45mph. Are there air bags in the car? Did they deploy? Typically they’ll deploy in a front end collision. Now air bags are not like soft little pillows when they inflate so facial injuries are not uncommon with air bag deployment so your driver breaking his wrist (if he were bracing the steering wheel in anticipation of the accident upon impact) with a bump on his head would be reasonable if he were seat belted into the car.

The sober passenger— I’ve never really seen “pretty severe amnesia” in head injuries unless the brain injury was very significant (like brain swelling, bleeding requiring intubation, medical coma, etc). This could be achieved if this passenger was not wearing a seat belt and maybe came up over the top of the air bag into the windshield. Or, for some reason, the air bag failed to deploy and they hit the dash board or they’re driving an older car without air bags.

Generally people with amnesia related to a “simple” concussion will remember what happened to them in a few hours— generally after sleeping so everything can “reset” itself. Most often, in the ER, we observe them until they are at their “neurological baseline” which means they basically have to be the same way they were before the accident as far as knowing who they are, where they are, and what time it is, and somewhat remember what happened. Also, their physical symptoms will have to be improved (little to no headache, no repetitive vomiting or nausea, good motor function, and can walk with little to no dizziness).

So to have “pretty severe amnesia” which I think you mean to have the amnesia to persist over days or weeks then I think this character would need a more severe head injury— which could probably be achieved if the passenger went through the windshield because she wasn’t wearing a seat belt.

The drunk kids— with an offset front end collision of around 45 mph and they were all seat belted into the car with air bag deployment then I could see them walking away with little to no injures. Likely, EMS would transport them to the ER for a medical exam because 1) they are minors (I’m assuming under 18) and 2) they’re drunk and could be responsible for an accident. The police might be interested in a legal blood alcohol levels which can be very tricky (for instance, our ER doesn’t do them. We’ll do a medical one, but this isn’t released to the police). Now, could a prosecutor later obtain those medical records through the courts? Probably with a warrant.

Hope this helps and best of luck with your story.

Author Question: Gunshot Wound Near Clavicle

Sarah Asks:

In my novella, the main character is shot directly below the left clavicle by a sniper rifle. The bullet misses the bone, but would it have hit the subclavian artery or another artery? And if so, how long would it take for her to bleed out? She receives medical help from an off-duty paramedic within three to five minutes. Thanks!

Jordyn Says:

I reviewed a couple of anatomy pictures and the subclavian artery appears to sit higher and slightly above the clavicle or collar bone. When looking at anatomy photos, red indicates arteries (as they are taking oxygen rich blood away from your heart to the rest of your body) and blue indicates veins (bringing oxygen poor blood to your heart and lungs for more oxygen).

That being said, the left chest has all sorts of major veins and arteries. A bullet can always miss these structures— we all hear those rare stories, but I generally encourage authors to stick to the right chest for a more believable scenario if they want the character to live. Ultimately, it is your choice.

The subclavian vein, which is nestled under the artery, could definitely be nicked or severed by a gunshot wound to this area (either the right or left side). Central lines are often placed to the subclavian vein which is accessed just benenath the collar bone.

If the bullet hits the subclavian artery, the character would bleed out fairly immediately— in roughly under two minutes without any medical intervention. Your paramedic arriving in three to five minutes would likely be too late. Direct pressure to the area will help. It is hard to stem bleeding from an artery this size, but pressure could help delay the onset of death for another few minutes.

If the bullet hits the subclavian vein, the bleeding will still be brisk but could be more easily controlled with pressure than bleeding from an artery.

If you want an injury that will bleed, but would likely be survivable, I would pick the subclavian vein with people at the scene immediately applying direct pressure to the gunshot wound.

Hope this helps and best of luck with your story!

Dr. Strange Should Know Better

If you haven’t seen the movie Dr. Strange, you have been warned that this blog post will contain spoilers to the movie.

Dr. Strange, released in 2016 as part of the Marvel Universe, features a stereotypical, obnoxious, arrogant, and rich neurosurgeon. He is greatly skilled, but is known to turn down patients in order to keep his perfect surgical record. Unfortunately for the character, he is in a terrible car accident and both his hands sustain multiple fractures that cause permanent nerve damage and therefore lead to the end of his promising career.

Dr. Strange is like many patients when the medical establishment can’t offer complete healing. He begins to investigate alternative/investigative medicine for treatments. He hears from a physical therapist that a patient with a complete spinal fracture is up and walking around. Dr. Strange responds to this by saying, “Show me his file.”

I’ve said all along in this blog that medical people in films, television, and novels can do bad things. Your job as the writer is to let the reader know that you know that the character is misbehaving in his role. This allows the reader to know you’ve done your research and they can trust you as an author.

Dr. Strange asking for this patient’s chart if flat out a HIPAA violation. He never cared for the patient and he has no right to know what’s in his medical record. There are consequences for HIPAA violations and having the character suffer these is a great way to add tension and conflict to the story.

A second medical violation in the movie is the treatment of Dr. Strange’s chest wound. He suffers a blade wound to the chest and transports himself back to his old hospital to be treated by a colleague. There are a few problems with this scene.

Problem #1: That there is a sterile operating room in the ER. No, this isn’t standard. Can sterile procedures be done in the ER? Yes, but not a sterile operation as in the OR.

Problem #2: Wrong ECG rhythm. Dr. Strange has diagnosed himself with a pericardial tamponade. A cardiac tamponade is where fluid is collecting in the sack around the heart thereby impinging on the heart’s ability to pump blood.

The rescue procedure for this is a pericardiocentisis— or removal of the fluid from around the heart. His love interest confirms the diagnosis by percussing his chest. This is probably the least reliable way of diagnosing this problem. Any well equipped ER should have some sort of bedside ultrasound to aid in the diagnosis. The ECG monitor first shows a rhythm of bradycardia— the heart beating too slowly. This again is one of the least likely rhythms related to this condition.

Problem #3: Wrong placement of the needle. In the movie, the doctor is shown placing the need straight into the chest. It should be at an angle pointed to the left shoulder which this nifty video on You Tube shows.

Problem #4: Shocking asystole: I’ve blogged a lot on this. You cannot shock asystole. It won’t improve the outcome for the patient and is contraindicated. First treatment is high quality CPR and a dose of epinephrine or adrenaline. Also, this is not the correct paddle placement for defibrillation. It should be just to the right of the patient’s sternum and over the apex of the heart or more to the left side. They also cannot be placed over clothing.

Problem #5: OR is next. Most likely a patient like this with penetrating trauma to the chest would likely go to the OR, or at least some follow-up radiology studies. Not just stitched up and sent on his way.