Because in trauma, every minute without control is a negotiation with death, and death doesn’t bargain.
The Most Important Clock in the Room
We talk a lot about “golden hours.”
Truth is, trauma doesn’t give you 60 minutes. Often, you get 10–20 minutes before physiology collapses.
Time to haemorrhage control is the single biggest determinant of survival.
Not how fancy your sutures are.
Not how elegant the operation was.
It’s how quickly you stop the bleeding, surgically, mechanically, or physiologically.
Every minute of uncontrolled haemorrhage pushes the patient deeper into the Pentagram of Death:
- Coagulopathy
- Acidosis
- Hypothermia
- Hyperkalaemia
- Hypocalcaemia
You cannot transfuse your way out of a hole in a major vessel.
You must find it, and control it.
Everything else is just keeping them alive long enough to do that.
Damage Control Resuscitation (DCR): The Strategy
DCR is what happens when we finally stop lying to ourselves about what saves lives in trauma.
It’s not maximal surgery, it’s minimal physiology loss.
The pillars are simple:
Haemorrhage control first: clamp, pack, tourniquet, REBOA, sutures only if physiology allows
Balanced transfusion: not red cells alone, but plasma and platelets from the start
Normothermia, normocalcaemia, correction of acidosis: not after the fact
Permissive hypotension (in non-TBI cases): “enough to think and enough to pulse”
In other words:
You keep them just alive enough to fix the reason they’re dying.
Red Cells Alone Don’t Work
For decades, we poured unit after unit of RBCs into bleeding trauma patients.
It made the numbers green and the monitors quiet, briefly.
But the problem wasn’t anaemia.
It was coagulation failure.
Diluting what little clotting function they had left was like trying to fix a hole in a bucket by filling it faster.
We “treated the vital signs” while the physiology bled out.
Plasma: Liquid Bandage for the Dying
Plasma isn’t just volume. It’s biology:
- Coagulation factors
- Fibrinogen
- Proteins that actually help you form and sustain a clot
When you give plasma early and in ratio with red cells (1:1 to 1:2), you’re not buying pressure, you’re buying clot stability.
This is why massive transfusion protocols now begin with:
RBCs
Plasma
Platelets
Altogether. Not sequentially.
Not “after eight units.”
Because by the time the coagulopathy shows on labs, it’s already killing them.
Fresh Whole Blood: The Best We Ever Had
We stopped using fresh whole blood for years because we convinced ourselves components were superior.
We weren’t wrong, we were too clean.
But war taught us what textbooks forgot:
Whole blood is nature’s perfect resuscitation.
One bag delivers:
- Red cells
- Platelets
- Plasma
- Coagulation factors
- Physiologic ratios, already correct
- Warm if collected properly
- Functional platelets that haven’t degraded in storage
It’s physiology in a unit.
It’s clot in a bag.
It’s what keeps soldiers alive, and now, increasingly, civilians.
Early whole blood reduces:
Mortality
Product requirements
Coagulopathy
Transfusion complications
It’s not elegant, but trauma isn’t either.
Time Is the Enemy, Not the Injury
In the OR, pride whispers:
“Do the definitive repair now.”
DCR says:
“Pack it. Clamp it. Stop the blood.
Get out and let physiology recover.”
Damage control surgery is not a shortcut, it is the difference between life and death when physiology is falling off the cliff.
Your surgical ego shouldn’t bleed the patient dry.
The Sequence That Wins
When a trauma patient arrives in extremis:
External haemorrhage control (tourniquet, pelvic binder)
Activate MTP: fresh whole blood or 1:1:1
Warm everything >37°C
Correct calcium early
Get them to surgical control:
- Thoracotomy, laparotomy
- Packing, stapling, Pringle, aortic/REBOA control
Stop: temporary closure
ICU resuscitation until lactate, pH, temperature improve
Return to OR later for definitive repair
That’s DCR.
Not sexy. Totally lifesaving.
The Hardest Lesson
The hardest thing in trauma isn’t cutting.
It’s stopping.
We are conditioned to fix.
But in exsanguination, fixing is failing if the body can’t keep up.
Damage control is knowing the difference between saving pride and saving life.
And From the Patient’s Side…
They won’t remember the cold blood on the floor, the shouted numbers, the Pringle, the REBOA, or the rapid-fire transfusion orders.
They won’t know how close they came to falling off the cliff.
But someone will.
Someone pacing that corridor, clutching a phone, praying without words…
They’ll remember every minute.
Because for us, DCR is protocol.
For them, it’s the miracle that brought their person home.
