When it comes to bleeding and complaining about it, the primary mantra of emergency medicine applies: There is no justice, and the smallest things waste the most time. The good-natured patient who rips off his foot in a meat grinder seems to bleed less than the anxious aristocrat who nipped off the tip of his finger while slicing the crusts off a Fluffernutter. Certain injuries just never seem to stop bleeding no matter how small they are, and many patients with minor injuries will return to the ER a few hours after discharge complaining of a blood-saturated dressing.

The greatest offenders include finger pad amputations and teeny facial lacerations, usually from very sharp implements (meat slicers, chef’s knives, shaving razors). Many of these wounds are not good candidates for closure with sutures because of loss of tissue or very small size, and since hands and faces are always moving it is very easy for a patient inadvertently to trigger re-bleeding. Systemic anticoagulation and wild gesticulations generally make things worse.

These wounds need time and pressure to manifest a stable clot, but petrolatum gauze and bandages are not the answer. Blood promptly seeps through and causes great psychic distress, and the xeroform macerates the skin and leaves greasy blotches all over the Marth Stewart sheets. A leak-proof seal is what’s needed for these injuries.

Fig. 1 (left) Do not use too much bacitracin ointment, or your dressing will not adhere properly. Fig.2 (center) Apply a Steri-Strip firmly to the edges of the occlusive dressing or you will ruin everything. Fig. 3 (rght) A gauze overlay does almost nothing except calm the patient, which is actually everything.

Have your patient hold firm pressure on the wound while you lay down an occlusive “Tegaderm”-style plastic dressing with the sticky side facing UP. Place a very small dollop of bacitracin ointment onto the center of the dressing, and then a section of absorbable hemostat (let’s call it “Gelfoam”) directly on top of the ointment (Fig. 1).

Have the patient swiftly move the injury site directly on top of the Gelfoam and continue applying pressure. Many people make the mistake of gingerly rolling up the Tegaderm to get a wrinkle-free texture, but beauty is a fool’s errand here: Swiftly fold it up one-half at a time, and then peel off the paper backing.

Keep the wound in a dependent position so any bleeding accumulates in the Gelfoam while you apply benzoin and then Steri-Strips firmly around the margins of the Tegaderm. Let the benzoin DRY first, or your seal will be ineffective (Fig. 2).

This arrangement creates a sort of grotesque, crinkly “hot pocket,” allowing blood to accumulate and congeal while eliminating or greatly reducing spillage.

Your absorbable hemostat will help a clot form and stabilize, and the bacitracin will reduce infection rates while preventing the dressing from tearing the entire wound back open when the patient eventually removes it.

After an additional 10 minutes of pressure, you must now create a reassuring illusion by covering entire effective-but-hideous ensemble with a cosmetic gauze dressing (Fig. 3).

Tell the patient that s/he may change the outer gauze daily if desired, but to leave the Tegaderm/Gelfoam/bacitracin dressing in place for 48-72 hours to allow the clot to stabilize.

After this time, the patient may soak the entire area in warm water and gently peel off the occlusive dressing. Any residual bleeding should be minimal at this point, and easily controlled with a simple standard dressing.

Have a nifty idea you’d like to see on Tricks of the Trade? Email it to me at fisherwhit@gmail.com, and I promise to give you credit if I use it.

Dr. Fisher practices Emergency Medicine in New England and New York.