Stop the Bleed Faster
By Johnathon Miranda
No one wants a patient to die—but losing one because of outdated priorities is unacceptable. A patient can die from multiple critical conditions, including:
- Bleeding: 2-5 minutes (massive hemorrhage)
- Lack of air: 3-6 minutes (brain damage starts at ~4 minutes)
- Shock: 10+ minutes (depends on severity)
Yet, many EMS protocols still default to airway, breathing, circulation (ABC) protocols—even when a patient is actively bleeding out. In trauma, massive hemorrhage kills way faster than airway compromise. Tactical medicine adapted to this long ago, but civilian EMS has been slow to follow. Today, we’re going to fix that.
Rethinking Trauma Care: Bringing Tactical Medicine to EMS
To close the gap (or at least shrink it) between tactical medicine and civilian EMS, we need to rethink and reevaluate our trauma care. The traditional ABCs work in most cases, but in trauma, they can cost precious seconds when a patient is bleeding out while some medics are focused on textbook-perfect care. Tactical medics figured this out a long time ago: The concept of bleeding control comes first. That’s why they slap on a tourniquet without hesitation and pack wounds aggressively instead of wasting time securing an airway on someone who's about to bleed out anyway. A tourniquet, in the eyes of a tactical medic, is the first line of defense for massive hemorrhage, not the last intervention.
EMS needs to adopt that same mindset. Hemorrhage is responsible for 30% to 40% of trauma-related deaths, with 33% to 56% of these fatalities occurring in the prehospital setting.1 This highlights the critical need for EMS to adopt a proactive approach to hemorrhage control. Prioritizing rapid hemorrhage control isn't just about training on dummies to pass the NREMT skills portion—it's about changing the culture. Agencies, EMS schools, and instructors need to stop teaching hesitation and start teaching action. If we want better survival rates, EMS protocols must evolve. Tactical medicine has already proven what works—it's time civilian EMS caught up.
Why STOP THE BLEED® Must Be Mandatory for EMS
Despite uncontrolled bleeding being the No. 1 preventable cause of trauma death, STOP THE BLEED® certification is still not a national requirement for EMS providers. That’s not just an oversight—it’s a failure that costs lives. Over 2 million people have received STOP THE BLEED® training,2 yet there are more than 1 million EMS providers in the U.S.,3 and not all of them have this certification. While STOP THE BLEED® training is open to civilians, law enforcement, and military personnel, there’s no guarantee that every EMS provider is getting this critical, standardized training. Sure, EMTs and medics get some bleeding control education, but the quality is all over the place—cutting-edge in one city, outdated and borderline dangerous in another. These gaps in training? They’re not just a problem. They’re deadly.
EMS is Failing Trauma Patients—Here’s Why
This isn’t just a certification gap—this is a life-or-death skill gap. And it’s killing patients. Thirty to forty percent of all trauma-related deaths are due to hemorrhage,1 with 33% to 56% of those deaths happening before the patient even reaches the hospital. Research proves that proper prehospital hemorrhage control significantly increases survival rates.4 Seconds matter, and yet EMS providers are still being taught hesitation instead of immediate action. The problem isn’t just training—it’s EMS culture. Some agencies still fear tourniquets, worrying about complications that military medicine has already debunked.5 Meanwhile, patients are bleeding out in the back of ambulances because providers weren’t trained to act fast enough.
Because there is no national requirement for STOP THE BLEED® certification, the level of hemorrhage control training varies across agencies and states, leading to inconsistent practices that literally mean the difference between life and death.
Tourniquets Don’t Destroy Limbs
One of the biggest outdated myths still circulating in EMS is that tourniquets cause amputations—leading to hesitation or outright refusal to apply them in the field. This misconception has been repeatedly debunked by military and civilian research. A 2018 study found that less than 1.7% of patients who had a tourniquet applied suffered any limb loss—and those cases were due to the severity of the initial injury, not the tourniquet itself.4 In contrast, patients who didn’t receive early tourniquet use had significantly higher mortality rates due to massive hemorrhage.
Another military study reviewing more than 6,900 tourniquet applications in combat zones found that only 0.4% of survivors required amputation because of the tourniquet, while those who had delayed or no tourniquet use were far more likely to die.6 A patient doesn’t want to lose a limb, but they’re more than 30 times more likely to die from uncontrolled bleeding than to suffer an amputation from a tourniquet. Studies show that the risk of limb loss with a properly applied tourniquet is less than 1.7%, while the chance of death from severe hemorrhage without one is more than 50%.4, 6 The real risk isn’t losing a limb—it’s losing a life. The real danger is hesitation, failing to apply a tourniquet soon enough, and allowing a patient to bleed out from a preventable cause. EMS must move past outdated fears and prioritize what works—rapid hemorrhage control. Because at that point, a preventable death isn’t just an " unfortunate outcome"—it’s willful medical negligence.
Why Bleeding Control Comes First: The Physiology Behind Survival
EMS loves to preach “airway, breathing, circulation” (ABC)—but here’s the physiological reality: without blood, none of it matters. Massive hemorrhage must be stopped first because the entire cardiopulmonary system depends on one thing—circulating oxygen-rich blood. If you don’t control the bleeding before focusing on airway and breathing, you’re setting your patient up for a losing fight.
If you stop the bleeding first, you buy time. Even if the patient goes into cardiac arrest, we can still perform high-quality CPR because there's enough blood volume left for the heart to circulate. The pulmonary system can still function, and oxygen from a bag-valve mask can actually reach hemoglobin in the remaining blood to keep the brain alive.
If you don’t stop the bleeding first, everything else is useless. Airway is pointless—the patient will bleed out before hypoxia even becomes an issue. Breathing is useless—because there’s no hemoglobin left to carry oxygen to the brain. Circulation is a joke—because the heart is pumping nothing. Once the body hits Class IV hemorrhagic shock (40%+ blood loss), cardiac output crashes, and survival drops to near zero.
This is why tactical medicine prioritizes bleeding control over everything. If you don’t fix the tank (blood volume), the engine (heart) and the oxygen supply (lungs) are irrelevant. Massive hemorrhage is the true priority in trauma. If EMS fails to recognize that, we’re not just delaying care—we’re guaranteeing failure.
Fix the bleed first, or nothing else you do will save them.
References
1. American College of Surgeons. (2022). STOP THE BLEED® training statistics.
2. National Registry of Emergency Medical Technicians (NREMT). (2023. Number of EMS providers in the U.S.
3. PubMed. (2021). Study on trauma-related deaths due to hemorrhage.
4. Journal of Trauma and Acute Care Surgery. (2018). Research on prehospital hemorrhage control and survival rates.
5. JEMS. (2020). Military medicine and tourniquet complications.
6. Military Medicine. (2021). Study on tourniquet applications in combat zones.
About the Author
Johnathon Miranda is a 68W combat medic specialist, EMT, and contract medic specialist with certifications in prehospital trauma care, tactical emergency casualty care, and hemorrhage control. Recognized by U.S. Army Special Forces for investigative journalism under Operational Sentinel, he writes to challenge outdated medical thinking and bridge the gap between civilian and battlefield medicine.
