Common Tread

Ask the doc: How to handle impalement injuries

Aug 21, 2017

“Better out than in” is a general rule of thumb for everything except impalement injury.

Editor's note: Warning. Some readers may consider the photos in this story to be graphic.

As is usual, Common Tread readers sensed a hot topic and dove right into the impaled branch discussion after the upload of the off-road rider who impacted a downed tree limb. Of course, one of the injured rider’s compatriots captured it all for our viewing and commenting pleasure. What followed in the video was, to the medical professional in me, both the textbook opposite of ideal management and at the same time representative of a common “instinctive” reaction.

The video clip raises three issues:

  1. What to do with the impaled object
  2. The rational use of tourniquets
  3. How to address a bleeding wound as a bystander

Here we go.

First, leave the impaled object in place! No good can come of pulling it out. Only blood, and often lots of it. The object often plugs its own hole in an artery or a vein and is its own best bandage. Think of it like the little Dutch boy with his finger in the hole in the dike.

What if the object is large and makes movement awkward or difficult? Trim it and secure it. EMS does this for people who have been impaled on fences or stop sign poles and then transports them to the Emergency Department. ROK straps or other cords commonly used to hold on to gear are great stabilizers, as are belts, a shirt cut into strips, and even vines, if there are any to be found.

sign post impalement
Yes, it is possible to be impaled by the post of a stop sign and live to tell the tale and have it photographed by your surgeon. Photo by Dr. Lewis Kaplan.

Clearly, wood that is as thick as that pictured in the video would need to be sawed — not a fun prospect for the injured victim. Many handheld multitools have a saw blade that could be used to trim the limb. Do stabilize the impaled object at the entry point to the skin and then just above where you intend to cut it off. This prevents movement that could cause additional injury, and of course, pain. As has been noted, “pain lets you know you are alive.” I can think of more enjoyable ways that I would prefer to be reminded, thank you. Power tools are excellent for trimming impaled objects, but are generally not handy, at least not on my bike. If you are fortunate enough to be close to a home, help might be closer than you think.

Worst-case scenario: The only time to pull it out

But what if you are remote, the object is large, you have nothing with which to trim it and you chose to ride solo? Oh, and by the way, you have no cell phone service, or a satellite-based GPS Tracker with SOS messaging device. (This is why you should always bring a buddy, even if the buddy is electronic! If you are from New York City, everything below northern New Jersey qualifies, I think, as remote; especially the Pine Barrens.) What to do?

This may be one of the exceedingly few times you may need to pull it out — but not without the right aids at hand: a procoagulant dressing and a tourniquet. Remember the emergency kit we talked about in an earlier article? This is when you need it!

Make sure that you are not standing (if at all possible) so that you do not risk falling in a few moments when you remove what is stuck in you. First, position the tourniquet above the impaled object. Second, open the procoagulant dressing and have it ready to pack into the space left behind when you pull out the offending object.  You are now ready to quickly pull it out and rapidly pack the space with the procoagulant gauze and secure it in place. If that stops the bleeding, great. You are lucky. Remember, this is an extreme approach if and only if you are alone, cannot call for help, and must self-extricate but the object is too large for you to move about without trimming it, and you cannot trim it. Otherwise, allow me to reiterate: Leave it in place.

knife impalement
If you've been stabbed in the back — literally, not figuratively — don't remove the knife. Photo by Dr. Lewis Kaplan.

The truth about tourniquets

If the dressing fails to control your bleeding (a little staining on the dressing is OK), it is tourniquet time. It is also tourniquet time if you have a lot of bleeding around the impaled object. Tourniquets have previously received a bad wrap (unable to resist that one). Prior notions linked tourniquet use to the absolute need for limb loss and were viewed as a tool of Lucifer. All ye who read herein, abandon those outdated and totally wrong notions.

Tourniquets significantly reduce blood loss (shocker), result in limb salvage (a new thought), and save lives (the overall goal). Once the tourniquet is tightened enough to stop blood flow below where it is placed (no pulse below it — yes, you should check), do not let it down. This is far worse than keeping it up, as any restored arterial blood flow can wash lots of the byproducts of your living but oxygen-starved tissue back into your venous circulation. All of them make you sick, can decrease your blood pressure, raise your heart rate and can even create an abnormal cardiac rhythm. All of this would be considered bad.

The value of tourniquets is underscored by broad support for their use from layperson courses such as B-CON (Bleeding Control) and STOP the Bleed, to a recommendation from the American Red Cross Scientific Advisory Committee (disclosure: I was part of that panel). They are a prominent part of police and EMS training across the United States (disclosure: I spearheaded that trend as part of a regional SWAT team) and are standard issue in the military, in particular in the wake of Improvised Explosive Device traumatic amputation. In every circumstance, their use saves lives.

How to prepare yourself to help

As a bystander (i.e. not a medical professional), and perhaps a riding buddy, bleeding control is a key skill to have in the event of a one-person or multi-person disaster, or mass casualty events like the one we just saw in Barcelona. Direct pressure is the mainstay, but knowing how to apply a manufactured tourniquet, or how to improvise one, is a learned skill. The Federal Emergency Management Agency (FEMA) as well as others have courses that specifically focus on bystander disaster management skills (yes, part of that one too) in an effort to cultivate a “culture of competence” in the wake of natural disasters and violent extremism.

I am fairly certain that none of the riders in the video has taken any of those courses.  How about you?